Windsong at Eola Hills

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 in accordance with the Oregon Fire Code and that fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed from 08/2025 through 02/2026, showed fire drill documentation was lacking in the following areas: * The escape route used; * Number of occupants evacuated; and * Evidence of alternate routes used. Additionally, the records reviewed did not show fire and life safety training was provided to staff on alternate months from fire drills. On 02/19/26 at 01:20 pm Staff 1 (ED) and Staff 5 (Maintenance Director) confirmed that all required elements were not included on their current fire drill documentation records and life safety training had not been completed as required. The need to ensure all required components were addressed and documented for each fire drill, and that drills were conducted on alternate months from fire and life safety training, was discussed with Staff 1 and Staff 5 on 02/19/26.

Fire drills and Life Safety training will be completed on schedule per the OAR. Life safety Binder and Fire drill binder will be organized according to month due and monthly calendar schedules will be completed as reminders of due dates. (Maintenance Director) will hold all trainings on fire and life safety during new hire orientation every Tuesday and as needed. Maintenance Director will ensure that every current employee has had fire and life safety training. Fire drill form updated to include required questions pertaining to OAR which include *the escape route used; *Number of occupants evacuated; and *Evidence of alternate routes used. Fire and Life Safety is on an alternate month schedule in our TELS system to provide reminders and due dates to our Maintenance director.

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 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission, and re-instruct at least annually, on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire, and failed to maintain a written record of fire safety training, including content of the training sessions and the residents attending. Findings include, but are not limited to: Review of fire drill and fire and life safety records from 11/01/25 through 02/17/26 revealed there was no documented evidence of resident instruction within 24 hours of admission or annual fire safety re-instruction. On 02/18/25 at 1:15 pm, Staff 1 (ED) confirmed the facility did not have a system for instructing residents within 24 hours of admission or re-instructing residents at least annually on fire and life safety expectations. The need to instruct residents within 24 hours of admission and re-instruct at least annually on fire and life safety procedures was discussed with Staff 1 and Staff 5 (Maintenance Director) on 02/19/25 at 1:20 pm. They acknowledged the findings.

All residents and their POA’s who currently reside at Windsong will have facility fire and life safety procedures explained and documented. RCC’s will review this quarterly with resident care plan meetings to ensure completion. All new residents will have fire and life safety training within 24 hours of admission from our Community relations director. Move in packets will contain our life and fire safety form for Community relations director to go over.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were in a locked storage unit and exterior pathways were maintained in good repair. Findings include, but are not limited to: During a tour of the MCC on 02/17/26 at 12:45 pm, the following was identified: * Cleaning chemicals and disinfectants were observed accessible to the residents in unlocked cupboards within the dining room kitchenettes in both Aspen and Cedar units of the MCC; and * The interior and exterior courtyard pathways had multiple drop-offs along pathway edges, measuring up to approximately two inches in depth. The drop-offs presented a potential trip and fall hazard to residents using the pathways. The need to ensure all chemicals and other toxic materials were in a locked storage unit and exterior pathways were maintained in good repair was discussed with Staff 1 (ED) and Staff 4 (Resident Care Coordinator) on 02/19/26 at 3:50 pm. They acknowledged the findings.

Courtyard pathway edges that measured up to two inches in depth will be filled in with Mulch by Maintenance Director and monitored Monthly. All chemicals and other Toxic materials were removed immediately. Cleaning chemicals are now stored in locked housekeeping closets. Housekeeping will ensure that after using chemicals, they will return them to locked closets directly after.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

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 C420, C422, and C510.

The issue identified during survey was reviewed by the Administrator immediately upon notification. All documentation and procedures related to the cited concern were reviewed to ensure compliance with Oregon Administrative Rules for Residential Care Facilities.The Administrator has reviewed the applicable Oregon Administrative Rules and facility policies to ensure administrative compliance. Staff and management were re-educated on regulatory requirements and facility policy to ensure ongoing adherence to state regulations.The Administrator or designee will conduct periodic reviews of relevant documentation and practices to ensure compliance with Oregon Administrative Rules. Any concerns will be addressed immediately through retraining or policy clarification.

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

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

Based on interview and record review, it was determined the facility failed to ensure staff training requirements were met related to pre-service orientation for 3 of 3 newly hired staff (#s 11, 12, and 16), dementia training for 4 of 4 newly hired (#s 11, 12, 16, and 7), and demonstration of competency in job duties within 30 days of hire for 3 of 3 newly hired staff (#s 11, 12, and 16). Findings include, but are not limited to: Training records were reviewed on 02/18/26 at 11:20 am with Staff 6 (Business Office Manager). The following was identified: 1. There was no documented evidence that Staff 11 (MT), Staff 12 (CG), Staff 16 (CG), and Staff 7 (Cook), hired 12/18/25, 11/23/25, 11/18/25, and 01/12/26, respectively, had completed one or more of the following pre-service orientation and/or dementia training: * Resident rights and values of CBC care; * Fire safety and emergency procedures; * Family support and the role the family may have in the care of the resident; and * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan. 2. There was no documented evidence Staff 11 (MT), Staff 12 (CG), and Staff 16 (CG), hired 12/18/25, 11/23/25, and 11/18/25, respectively, demonstrated competency in one or more of the following areas within 30 days of hire: * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. The need to ensure staff training requirements were completed within the requisite time periods was discussed with Staff 1 (ED) and Staff 6 on 02/18/26. They acknowledged the findings.

Training program through Oregon Care Partners has been established with the required training courses such as *Resident rights and values of CBC care; *Fire safety and emergency procedures. *Family support and the role the family may have in the care of the resident; and *How to provide personal care to a resident with Changes associated with normal aging. * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. Staff who have not completed them have been assigned the training needed. BOM and ED will monitor completion of these training courses by using our monthly audit form. BOM updated Residents Rights forms have been reviewed and signed with staff. Resident rights forms have been added to our new hire orientation packets

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

OAR 411-057-0160(g) Outside Area (g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e).

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Findings include, but are not limited to: During a tour of the secured interior and exterior courtyards of the Aspen and Cedar units on 02/17/26 at approximately 1:00 pm, it was observed that the doors allowing entry to and return from the courtyards in Cedar and Aspen units were locked. Residents were unable to access the secured courtyards or return indoors without staff assistance. Interviews conducted with multiple care staff on 02/18/26 indicated the courtyard doors in both Aspen and Cedar remained locked, and staff opened the doors for the residents when they requested to go outside. The need to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (ED) and Staff 4 (Resident Care Coordinator) on 02/19/26 at 3:50 pm. They acknowledged the findings.

Interior and exterior doors to the secured courtyards have been unlocked to allow residents to enter and return without staff assistance. Interior and exterior doors will only be locked when there are unsafe weather conditions, and a sign will be posted by Maintenance Director. Maintenance will check doors daily to ensure they are unlocked and if needed lock due to unsafe weather, signage will be posted.

OAR 411-057-0160(g) Outside Area (g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e).

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. Facility did not ensure residents with modified textured diets received correct textures. Findings include, but are not limited to: Observation of the main facility kitchen and the unit kitchenettes were reviewed on 08/20/25 from 11:15 am through 1:45 pm and revealed the following deficient practices: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Kitchen drain under ice machine * Ceiling vents above steam table area * Open shelving in prep area; * Sides of fryer and grill top; * Metal racks storing clean dishes and service supplies; * Walk in freezer floor; * Dry storage floor * Metal rack in walk in * Large can rack in dry storage * Cedar unit kitchenette oven * Cedar unit cupboards and drawers * Aspen unit kitchenette reach in freezer * Walk in ceiling. b. Multiple food items/packages/containers found in walk in not dated when opened. Item found past manufactures use by date. c. Facility was using a quaternary ammonia surface sanitizer but did not have the appropriate chemical testing strips to validate correct concentration for chemicals to effectively sanitize surfaces. d. Multiple staff beverages and food items were observed stored in walk in cooler next to and above/on food designated for resident use causing potential contamination issues. e. Kitchen staff was observed to serve multiple residents with “soft and bite size” diet orders items that were not bite size. Staff was not able to demonstrate appropriate knowledge of appropriate items and/or size for standardized bite size diets. Staff did not know bread items typically not appropriate for this diet type unless approved by SLP (speech therapist) and those items would need to be bite size. Staff was observed to served multiple residents with large vegetable pieces including broccoli stems and/or large broccoli florets. Staff served multiple residents on soft and bite size diets whole roles. Staff was not aware of appropriate validating/testing measures for minced and moist and puree textures to ensure they met those diet texture specifications. Staff acknowledged very limited training on these diets were provided. f. Meal service single use disposable items were noted stored uncovered with the food contact surfaces exposed/not protected from contamination. g. Multiple scoop plates were observed heavily stained/scored and in need of replacement. At 1:30 pm Staff 1 (Executive Director) was informed of above areas in need of correction, and they acknowledged the identified areas.

• Dinning Services Manager Immediately re-trained all kitchen staff on IDDSI (International Dysphagia Diet Standardisation Initiative) guidelines, including proper texture modifications, approved food items, and portion sizing for bite-sized diets. • Removed inappropriate bread items from texture-modified diet line-up unless approved by a speech therapist. • RN to consult with Speech therapist to review and update dietary guidelines for residents requiring texture modification. • All kitchen staff will receive annual and ongoing quarterly training on IDDSI guidelines. • DSM will provide Visual guides and portion reference posters in the kitchen and dietary prep areas. • Dietary Manager/designee will conduct weekly meal audits to verify proper food textures and resident diet compliance. • DSM and kitchen staff will preform a full deep-clean of all kitchen areas, neighborhood kitchenettes, shelving, vents, drains, and appliances was completed immediately following the survey. • All expired food items were removed and discarded. • Implemented a written daily, weekly, and monthly cleaning schedule with assigned staff responsibilities and supervisory sign-off. • Kitchenettes in memory care neighborhoods will be placed on the same cleaning and inspection schedule as the main kitchen. • Dietary Manager and Environmental Services Supervisor will perform weekly sanitation audits using a standardized checklist. • Monthly unannounced kitchen inspections will be completed by the Executive Director/designee. • All undated or expired items were discarded immediately. • Staff were re-educated on the requirement that all opened items must be labeled and dated. Weekly audits of food storage areas by Dietary Manager. • Proper quaternary ammonia test strips were obtained immediately. • Staff trained on proper testing technique and acceptable sanitizer ranges. • All staff food/beverages were removed from resident food areas immediately. • Staff re-educated that personal food and drink must be kept in designated breakroom refrigerators only.

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, and failed to ensure meals were served according to established menus. This is a repeat citation. Findings include, but are not limited to: Observations of the main facility kitchen and the unit kitchenettes were completed on 12/02/25 from 10:30 am through 2:00 pm and revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, white billowy matter, and grease was visible on or underneath the following: * Kitchen drains under ice machine, steam line, and prep area; * Open shelving storing spices; * Plastic “shelf liners” on metal racks storing clean dishes and service supplies; * Walk-in freezer floor; * Metal racks in walk-in; * Fan cage in walk-in cooler; * Large can rack in dry storage; * Movable baking rack stored in walk-in; * Metal water hose and spigots near stove; * Countertop mixer; * Cedar unit kitchenette oven; * Cedar unit cupboards and drawers; * Cedar unit reach-in refrigerator; and * Aspen unit kitchenette oven interior. b. Food items/packages/containers found in walk-in not were not dated when opened. Items found past manufacturer’s use by date. A rotting head of iceberg lettuce was cut and wrapped in foodservice plastic without a date. Hot dogs were observed in a pan dated 11/20, past the use by date for the opened product. c. During the meal observation, the menu items were from the day before according to the week-at-a-glance menu provided to residents and families. No notification of the menu change was provided to the residents. Staff 2 (Dining Services Manager) acknowledged she did not know the process for finding and generating daily menus yet and was due to receive training soon in this area. The lunch menu items posted at the table stated that the vegetable was to be carrots; however, the vegetable served was corn. Staff 2 stated typically items that were changed would be communicated to residents but did not believe the vegetable change had been communicated for that meal. Staff 2 acknowledged the substitution was not of similar nutritional value and was not aware that this was a requirement. e. Spent/used cooking oil was observed stored in empty uncovered cans under the hand washing sink with potential to attract insects and pests. At 1:30 pm Staff 1 (Executive Director) and Staff 2 (Dining Services Manager) were informed of above the areas in need of correction, and they acknowledged the identified areas.

A. All open shelving, metal racks, plastic shelf liners, and storage surfaces were scrubbed, sanitized, and reorganized to prevent debris accumulation. Walk-in freezer floor and metal racks were deep-cleaned, and sanitized. Walk-in cooler fan cage was fully cleaned to remove dust accumulation. Large dry-storage can rack and movable baking rack were removed, cleaned, sanitized. Metal water hose and spigots near the stove were cleaned and sanitized to remove grease buildup. Countertop mixer was fully disassembled, cleaned, and sanitized. Cedar unit kitchenette oven, cupboards, drawers, and reach-in refrigerator were cleaned to remove spills, stains, dust, and debris. Aspen unit kitchenette oven interior was fully cleaned and degreased. Stephanie Morton Dinning Services Manager/cooks/dietary aides. a weekly deep-clean checklist that includes all racks, shelving, fan guards, equipment surfaces, and unit kitchenettes. Stephanie Morton, Cooks,and Dietary Aides. B.Food items/packages/containers in walk-in were all dated and any expired foods were thrown away. Dietary aides now have a task list to check through walk-in daily to ensure all open dates are in place as well as checking for expired food items. Dietary Aides, DSM, Cooks C. when Substitutions are needed for meal changes, Cooks/dietary aides will write on menu to notify family, residents and staff. Dietary aides, RA's, Cooks E. Grease/oil that was uncovered was immedietly covered. Grease/oil will be kept in a closed container to prevent insects/pests. Stephanie Morton

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.

• Dinning Services Manager Immediately re-trained all kitchen staff on IDDSI (International Dysphagia Diet Standardisation Initiative) guidelines, including proper texture modifications, approved food items, and portion sizing for bite-sized diets. • Removed inappropriate bread items from texture-modified diet line-up unless approved by a speech therapist. • RN to consult with Speech therapist to review and update dietary guidelines for residents requiring texture modification immedietly following survey. • All kitchen staff will receive annual and ongoing quarterly training from DSM on IDDSI guidelines. • Visual guides and portion reference posters are now posted in the kitchen and dietary prep areas. • Dietary Manager/designee will conduct weekly meal audits to verify proper food textures and resident diet compliance. • DSM and all kitchen staff will preform a full deep-clean of all kitchen areas, neighborhood kitchenettes, shelving, vents, drains, and appliances immediately following the survey. • All expired food items were removed and discarded. • DSM will Implement a written daily, weekly, and monthly cleaning schedule with assigned staff responsibilities and supervisory sign-off. • DSM will ensure that Kitchenettes in memory care neighborhoods will be placed on the same cleaning and inspection schedule as the main kitchen. • Dietary Manager will perform weekly sanitation audits using a standardized checklist which will be turned into Executive director for sign off. • Monthly unannounced kitchen inspections will be completed by the Executive Director/designee. • All undated or expired items were discarded immediately. • Staff were re-educated on the requirement that all opened items must be labeled and dated. Weekly audits of food storage areas by Dietary Manager. Open date stickers we provided and will be in a designated area so that they are available at all times. • Proper quaternary ammonia test strips were obtained immediately. • DSM trained Staff on proper testing technique and acceptable sanitizer ranges. • All staff food/beverages were removed from resident food areas immediately. Signage placed of refridgerator door that states "no staff food or drink". • DSM/Executive Director re-educated that personal food and drink must be kept in designated breakroom refrigerators only.

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. This is a repeat citation. Findings include, but are not limited to: Refer to C240 and C455

A. All open shelving, metal racks, plastic shelf liners, and storage surfaces were scrubbed, sanitized, and reorganized to prevent debris accumulation. Walk-in freezer floor and metal racks were deep-cleaned, and sanitized. Walk-in cooler fan cage was fully cleaned to remove dust accumulation. Large dry-storage can rack and movable baking rack were removed, cleaned, sanitized. Metal water hose and spigots near the stove were cleaned and sanitized to remove grease buildup. Countertop mixer was fully disassembled, cleaned, and sanitized. Cedar unit kitchenette oven, cupboards, drawers, and reach-in refrigerator were cleaned to remove spills, stains, dust, and debris. Aspen unit kitchenette oven interior was fully cleaned and degreased. Stephanie Morton Dinning Services Manager/cooks/dietary aides. a weekly deep-clean checklist that includes all racks, shelving, fan guards, equipment surfaces, and unit kitchenettes. Stephanie Morton, Cooks,and Dietary Aides. B.Food items/packages/containers in walk-in were all dated and any expired foods were thrown away. Dietary aides now have a task list to check through walk-in daily to ensure all open dates are in place as well as checking for expired food items. Dietary Aides, DSM, Cooks C. when Substitutions are needed for meal changes, Cooks/dietary aides will write on menu to notify family, residents and staff. Dietary aides, RA's, Cooks E. Grease/oil that was uncovered was immedietly covered. Grease/oil will be kept in a closed container to prevent insects/pests. Stephanie Morton

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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

Based on interview, observation and review of records, 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, and Z142.

A. All open shelving, metal racks, plastic shelf liners, and storage surfaces were scrubbed, sanitized, and reorganized to prevent debris accumulation. Walk-in freezer floor and metal racks were deep-cleaned, and sanitized. Walk-in cooler fan cage was fully cleaned to remove dust accumulation. Large dry-storage can rack and movable baking rack were removed, cleaned, sanitized. Metal water hose and spigots near the stove were cleaned and sanitized to remove grease buildup. Countertop mixer was fully disassembled, cleaned, and sanitized. Cedar unit kitchenette oven, cupboards, drawers, and reach-in refrigerator were cleaned to remove spills, stains, dust, and debris. Aspen unit kitchenette oven interior was fully cleaned and degreased. Stephanie Morton Dinning Services Manager/cooks/dietary aides. a weekly deep-clean checklist that includes all racks, shelving, fan guards, equipment surfaces, and unit kitchenettes. Stephanie Morton, Cooks,and Dietary Aides. B.Food items/packages/containers in walk-in were all dated and any expired foods were thrown away. Dietary aides now have a task list to check through walk-in daily to ensure all open dates are in place as well as checking for expired food items. Dietary Aides, DSM, Cooks C. when Substitutions are needed for meal changes, Cooks/dietary aides will write on menu to notify family, residents and staff. 12/2/25 Dietary aides, RA's, Cooks E. Grease/oil that was uncovered was immedietly covered. Grease/oil will be kept in a closed container to prevent insects/pests. 12/2/25 Stephanie Morton

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

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 main facility kitchen and the unit kitchenettes were reviewed on 07/18/24 from 10:20 am through 2:00 pm and revealed the following deficient practices: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Kitchen drain under prep area; * Ceiling vents and light fixtures; * Removable hood vents; * Open shelving in prep area; * Counter top mixer; * Table holding slicer; * Large can opener base and housing; * Industrial slicer; * Rack shelving in walk in cooler; * Interior of reach in deli cooler; * Sides of fryer and grill top; * Metal racks storing clean dishes and service supplies; * Walk in cooler floor; * Unit kitchenette ovens; * Unit kitchenette reach in refrigerators; and * Walk in ceiling. b. The following areas needed repair: * Reach in cooler door seal broken/missing; * Large accumulation of dust/dirt/debris on the walk in cooler fans and cage. * Reach in refrigerator in south kitchenette reading at 62 degrees. * Metal racks in reach in cooler next to tray line with rusted racks. c. Multiple food items/packages/containers found in walk in, reach in deli fridge and reach in cooler near the line with food items not dated, labeled, or uncovered and exposed to potential contamination. d. Multiple kitchen staff observed to prepare foods or handle clean dishes/equipment without hair or facial hair effectively restrained. e. Reach in refrigerator in North unit did not have a thermometer to monitor that food was stored at appropriate temperatures. A container of Ensure for a resident and a container of cream cheese along with beverages were stored in this refrigerator. f. Facility was using a chlorine based surface sanitizer but did not have the appropriate chemical testing strips to validate correct concentration for chemicals to effectively sanitize surfaces. g. Kitchen staff not washing hands when going from washing dirty dishes to handling clean dishes. Staff was observed to exit kitchen and did not wash hands upon returning to kitchen. At 1:30 pm Staff 1 (Executive Director) and Staff 2 (Dietary Manager) were informed of above areas in need of correction and they acknowledged the identified areas.

A) The following areas will be added to the weekly cleaning task list: * Kitchen drain under prep area; * Ceiling vents and light fixtures; * Removable hood vents; * Open shelving in prep area; * Counter top mixer; * Table holding slicer; * Large can opener base and housing; * Industrial slicer; * Rack shelving in walk in cooler; * Interior of reach in deli cooler; * Sides of fryer and grill top; * Metal racks storing clean dishes and service supplies; * Walk in cooler floor; * Unit kitchenette ovens; * Unit kitchenette reach in refrigerators; and * Walk in ceiling. DSD (Dining Services Manager) is responsible to ensure task lists are turned in and completed weekly. ED to conduct audit monthly. B) * Reach in cooler door seal will be replaced * Large accumulation of dust/dirt/debris on the walk in cooler fans and cage.- Added to TELs for monthly cleaning * Reach in refrigerator in south kitchenette reading at 62 degrees. * Metal racks in reach in cooler next to tray line with rusted racks will be replaced C) Multiple food items/packages/containers found in walk in, reach in deli fridge and reach in cooler near the line with food items not dated, labeled, or uncovered and exposed to potential contamination-          Dietary team to receive in-service on proper storage and dating of items in kitchen. DSD to conduct audit weekly and ED to audit monthly. D) Multiple kitchen staff observed to prepare foods or handle clean dishes/equipment without hair or facial hair effectively restrained.        Dietary team to receive in-service regard proper hair restraints. DSD to ensure team members are following proper hair restraints at all times. e. Reach in refrigerator in North unit did not have a thermometer to monitor that food was stored at appropriate temperatures. A container of Ensure for a resident and a container of cream cheese along with beverages were stored in this refrigerator.         Thermometer to be purchased and installed in North kitchenette refrigerator. Staff to be in-serviced that personal items are not stored in resident refrigerators at next staff meeting as well as appropriate food storage of resident items. f. Facility was using a chlorine based surface sanitizer but did not have the appropriate chemical testing strips to validate correct concentration for chemicals to effectively sanitize surfaces.     Proper chemical strips ordered. g. Kitchen staff not washing hands when going from washing dirty dishes to handling clean dishes. Staff was observed to exit kitchen and did not wash hands upon returning to kitchen.        Dietary staff will be in-serviced on appropriate handwashing procedures. DSD to ensure observations of handwashing and instruct team to conduct as needed.

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 main facility kitchen and the unit kitchenettes were reviewed on 09/27/24 from 12:30 pm through 2:30 pm and revealed the following deficient practices: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Ceiling vents and light fixtures; * Open shelving in prep area; * Large can opener base and housing; * Rack shelving in walk in cooler; * Flooring under metal racks in walk in cooler; * Flooring in freezer; * Sides of fryer and grill top; * Flooring beside/under fryer; * Metal shelving next to stove/grill; * Walk in ceiling and cooling fans/fan cages; * Fan blades and cages throughout kitchen areas. * Unit kitchenette reach in refrigerators; and * Unit kitchenette ovens. b. The following areas needed repair: * Reach in cooler door seal broken/missing; and * Large accumulation of dust/dirt/debris on the walk in cooler fans and cage. c. Salad dressing containers in reach in cooler used for salad bar did not contain labels/dates and were stored greater than 24 hrs. At 2:00 pm Staff 1 (Executive Director) was informed of above areas in need of continued correction and they acknowledged the identified areas.

The following areas to be cleaned by dietary staff: * Ceiling Vents * Rack shelving in walk in cooler *Flooring under racks in walk-in cooler *Flooring in freezer *Metal shelving next stove/grill *Walk in cooling fans and cages *Fan blades and cages Light covers to be replaced. Fryer and surrounding area to be cleaned by cook after each use vs current weekly schedule. Housekeeping team reminded to clean kitchenettes weekly at Housekeeping meeting 10/9. ED to inspect weekly. Large can opener base has been replaced. Reach in fridge door seal to be replaced. All foods will be stored with date if being stored greater than 24 hours.

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 main facility kitchen and the unit kitchenettes on 09/27/24 from 1:30 pm through 3:00 pm noted the following: An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Bottom shelves in prep area; * Large can opener; * Rack shelving in walk in cooler; * Flooring under metal racks in walk in cooler; * Sides of fryer/steamer and grill top next to fryer; * Flooring beside/under/behind fryer; * Walk in cooler ceiling and light fixture; and * Fan blades and cage above main food prep area. At 1:45 pm Staff 1 (Regional Director of Operations)  and Staff 2 (Dietary manager) were informed of above areas in need of continued correction and they acknowledged the identified areas.

The bottom shelves in prep area were cleaned as well as the large can opener were cleaned and sanitized Rack shelving and flooring under metal racks in the walk-in cooler were powerwashed and put back in place on 12/17/24.  This task was added to the monthly sanitation checklist. The fan cover in the walk-in cooler was removed, the fan cleaned on 12/6/24. The fryer and grill were pulled out to clean the flooring underneath and the sides of the fryer and grill top.  This was completed on 12/23/24.  This deep cleaning task was added to the monthly sanitation checklist. Sanitation checklists were updated to reflect a more comprehensive approach.  Kitchen staff were trained to this updated checklist and routines the week of 12/23/24.

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 C 240.

see C 240

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

Refer to C240

Based on 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.

Based on interview and observations, 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 review of records, 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.

Sanitation checklists will be reviewed weekly by the Dining Services Director and submitted to the Executive Director. The Executive Director will spot audit kitchen and kitchenettes weekly, referencing the cleaning checklists. Regional Director will review the status of the kitchen at least quarterly to ensure proper maintenance and sanitation.

The findings of the kitchen inspection, conducted 07/18/24, 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 revisit to the kitchen inspection of 07/18/24, conducted 09/27/24, 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 07/18/24, conducted 11/26/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the third revisit to the kitchen inspection of 09/27/24, conducted 01/31/25, 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, Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.

2. Resident 4 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's disease. The resident's clinical record from 07/31/23 through 10/30/23, including progress notes, service plan and temporary service plans were reviewed, and interviews with staff were conducted. The following was identified: * On 08/14/23 the progress notes indicated that the hospice aide had reported a skin discoloration to the resident's right leg. The incident was not investigated to rule out abuse and/or neglect, nor was it reported to the local SPD office. * On 08/21/23 the progress notes indicated the resident had a skin tear to the left knuckle.  The incident was not investigated to rule out abuse and/or neglect, nor was it reported to the local SPD office. The surveyor requested Staff 2 (RN) report the incidents to the local SPD on 10/31/23 and received confirmation the facility reported the incidents on 10/31/23. The need to investigate injuries of unknown cause to rule out abuse and/or neglect, and to report the incidents to the local SPD office if abuse and/or neglect could not be ruled out was discussed with Staff 1 (ED) and Staff 2 on 11/01/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to report physical injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injuries were not the result of abuse for 2 of 4 sampled residents (#s 2 and 4) with injuries of unknown cause. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia, asthma, anxiety and shortness of breath. The Service Plan dated 07/31/23 indicated the resident "is not oriented to time, place, date, situations and is only oriented to self, [his/her spouse] and familiar faces such as family and friends." A review of the resident's clinical record between 07/31/23 and 10/29/23, and family and staff interviews identified the following: * A Progress Note entry dated 07/31/23 noted: "Being put on alert for skin tear to L [left] leg below knee."; * A Progress Note entry dated 08/13/23 noted: "Resident is also being placed on alert for skin tear to left outer knee."; * A Progress Note entry dated 08/16/23 noted: "right wrist skin tear ....Placing on RN skin checks."; and * A Progress Note entry dated 08/30/23 noted: " ...also added new skin tear alert for resident: skin tear on back of L [left] calf." The incidents on 07/31/23, 08/13/23, 08/16/23 and 08/30/23 represented injuries of unknown cause. There was no documented evidence the facility immediately investigated the injuries to rule out abuse, nor reported them to the local SPD office as suspected abuse. In an interview with Staff 1 (ED) on 11/01/23, she acknowledged the four incidents of injuries of unknown cause were not reported immediately to the local SPD office. On 11/01/23, Staff 3 (RCC) provided documentation that she self-reported the incidents to the local SPD office. The need to ensure resident incidents were immediately investigated by the facility to reasonably conclude and document that the physical injuries was not the result of abuse, and reported to the local SPD office as needed was discussed with Staff 1, Staff 2 (RN), and Staff 3 on 11/01/23 at 12:45 pm. They acknowledged the findings. No further information was provided.

Incidents pertaining to resident's 2 and 4 were investigated and reported to APS as due to time lapse unable to rule out abuse and neglect. Incident report completed prior to survey exit. Resident Care Coordinators (RCCs) are responsible for conducting second checks on all orders and outside provider notes daily. While conducting second checks, RCC's will identify if incident reports are in place for new skin issues and will follow facility processes. If not, RCC will follow up with med tech to ensure process is completed in a timely fashion. Health Services Director (HSD) is responsible for conducting third check of orders during working days and will verify that process has been completed by MT/RCC. RCC's and HSD will also complete Oregon Care Partners Abuse Reporting and Investigation class to review the investigative process and reportable events.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: Resident 5 was admitted to the facility on 10/219/23 with diagnoses including Alzheimer's dementia. The resident's new move-in evaluation was completed on 10/13/23.  The following elements were not addressed in the move-in evaluation: * Personality, including how the person copes with change or challenging situations; * Complex medication regimen; and * Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting and room temperature. The need to complete move-in evaluations that addressed all required elements was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 11/01/23. The staff acknowledged the findings.

The Functional Evaluation tool that is used by the facility will be reviewed and edited to include the same components as is on the service plan to include "personality, including how the person copes with change or challenging situations, complex medication regimen, and environmental factors that impact the resident's behavior including, but not limited to, noise, lighting, and room temperature." All residents' current functional evaluations will be reviewed by either RCC, HSD, or ED and components added once tool is updated. Moving forward, components will be added to the functional evaluation tool which cannot be completed with missing information. This will be reviewed by RCC and/or HSD during initial move in and per service plan schedule/with significant change of condition to ensure all necessary compenents are met.

2. Resident 4 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's disease. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 10/23/23, temporary service plans, and progress notes dated 07/31/23 to 10/30/23 were completed. The resident's service plan was not reflective, lacked resident specific direction for staff, and/or was not implemented by staff in the following areas: * Meal assistance and adaptive equipment; * Activity needs, physical limitations and abilities and level of participation; * Assistance needed for evacuation; * Current behaviors; * Non-skid mat next to bed; * Pacing and wandering; * Bedtime needs/sleep habits; * Grooming and hygiene assistance; and * Barrier cream. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 11/01/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services, and/or were implemented for 2 of 4 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia, asthma, anxiety and shortness of breath. Observations were made of the resident's care on 10/30/23 and 10/31/23. Interviews with facility staff and the resident's family were conducted. The current service plan dated 07/31/23 was reviewed. Resident 2's service plan was not implemented and lacked clear instructions to staff in the following areas: * Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety; and * Use of barrier cream with toileting changes. The need to ensure the service plan was implemented and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 11/01/23. They acknowledged the findings. No further information was provided.

RCC will update resident 2 and 4's service plans to reflect current needs and remove historical information that is no longer relevant that may be unclear for staff reviewing service plans. RCCs, HSD, and ED will review all current resident service plans and update accordingly to reflect current plan of care. Service plans will be reviewed per the regulation at initial move in, 30 day review, quarterly, and upon significant changes in condition by RCCs. HSD will be responsible for reviewing service plans to ensure they reflect current plan of care once completed by RCCs. If descrpancies are noted, HSD will bring to RCCs to correct. ED will conduct final review once corrections have been made.

2. Resident 4 moved into the facility in 10/2021 with diagnoses including Alzheimer's dementia. The resident's service plan, temporary service plans, progress notes dated 07/31/23 through 10/30/23, RN assessment dated 08/01/23 and the ABST report was reviewed and revealed the resident had a significant change of condition in 08/2023 and required increased assistance in mobility, transfers and ADL tasks. Resident 4 was observed during survey on multiple occasions receiving two person assist with bed mobility, transfers and wheelchair positioning. The ABST report for Resident 4 had not been updated quarterly since 10/19/22, was not updated after the significant change of condition, and failed to reflect his/her current care needs and level of assistance in the following areas: * Repositioning in bed/chair; and * Transfers. The need to ensure the ABST tool was updated quarterly and following a resident's significant change of condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 11/01/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated no less than quarterly and with changes of condition. Findings include, but are not limited to: 1. On 11/01/23, the facility ABST was reviewed with Staff 1 (ED). Multiple sampled and unsampled residents lacked documented evidence their ABST had been reviewed and updated quarterly. On 11/01/23, the need to ensure resident ABST's were updated quarterly was discussed with Staff 1 (ED). She acknowledged the findings.

Residents 2 and 4 will be reviewed by RCCs on the ABST once service plans are updated as aforementioned. RCC's will audit all service plans for current residents and update ABST accordingly. When RCC's have completed service plans and they have been reviewed by HSD, ED will conduct final review and compare service plan to ABST to ensure all needs are reflected. ED will pull ABST report monthly to ensure residents are all updated in accordance with aforementioned service plan schedules.

Based on observation and interview, it was determined the facility failed to ensure an exit door alarm or other acceptable system was provided for security purposes and to alert staff when residents exited the MCC. Findings include, but are not limited to: The facility was toured 10/30/23 through 11/01/23. The four exit doors leading to the secure courtyard areas in the north and south hall units did not have working door alarms or other acceptable system that alerted staff when a resident exited the neighborhood. Staff 1 (ED) reported there was an audible alarm on each door. However, when the doors were opened there was no audible sound or other system to alert staff of a resident exiting to the courtyards. The need to provide an alarm or other system on the exit doors for each unit was reviewed with Staff 1 on 11/01/23. She acknowledged the findings.

New audible operating system for interior courtyards will be ordered and installed by Maintenance Director. (MD) Maintenance Director will be responsible for ensuring functional operation of alert system weekly. This task has been added to weekly TELs task list. If not working properly, MD will take the necessary steps to correct. ED will conduct audit monthly to ensure devices are operational.

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 231, C 361, C 555.

Refer to C231, C361, and C555

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 16 and 17) completed all required pre-service training prior to beginning job duties independently, and 1 of 2 sampled long-term direct care staff (#15) completed a total of 16 hours of annual in-service training, including six hours of dementia care training. Findings include, but are not limited to: Training records were reviewed on 10/31/23, and the following was identified: Staff 15 (Resident Assistant) was hired 04/20/21, Staff 16 (Resident Assistant) was hired 09/27/23, and Staff 17 (Resident Assistant) 08/22/23. a. There was no documented evidence Staff 16 and Staff 17 completed the required pre-service training prior to providing personal care independently in the use of supportive devices with restraining qualities in memory care communities. b. There was no documented evidence Staff 15 completed the required annual in-service training, including six hours of dementia care training. The need to ensure newly hired direct care staff completed all pre-service training topics prior to beginning any job duties, and long-term direct care staff completed a total of 16 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 11/01/23. They acknowledged the findings. No further information was provided.

ED will review Relias platform and identify a course that meets the description of the use of supportive devices with restraining qualities in memory care communities. This coarse will be added to the Relias new hire onboarding module. Current staff will be inserviced on supportive devices with restraining qualities at staff meeting and/or one on one in-service as applicable. New hires will be expected to complete all Relias training modules prior to being permitted to train on the floor. Business Office Manager BOM will pull Relias transcript once new hires indicate completion to ensure all classes completed before being permitted to train on floor. Ongoing dementia CEUs: BOM will conduct audit of all staff that have been employed longer than 1 year to identify which staff have not completed 6 dementia CEU's. BOM will provide list of staff not currently meeting this rule to RCC. RCC will be responsible for ensuring staff are scheduled to complete CEUs to meet this requirement. BOM will conduct monthly audit to identify which staff are in need of CEUs. BOM will provide list to RCC for RCC to schedule completion of monthly CEUs. For staff that fail to meet their annual CEU's, BOM will notify RCC. RCC and/or ED will remove staff from schedule until CEUs are completed.

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

Refer to C252 and C260

The findings of the re-licensure survey, conducted 10/30/23 through 11/01/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the re-licensure survey of 11/01/23, conducted 02/05/24 through 02/06/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Division 004 for Home and Community Based Services.

Based on observation, interview and record review it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-0000.  Findings include, but are not limited to: On 01/04/23 at 10:35 am, the facility kitchen was observed to need cleaning in the following areas: * Bottom shelf, fans and outside of doors of the reach in refrigerator; * Floors in the walk in refrigerator and freezer; * Blue container lids in the dry storage area; * Food bins containing oatmeal, flour and panko crumbs; * Shelves below coffee/juice counter; * Lower shelf containing cutting boards; * Surfaces (sides/front/doors) and wall behind steamer, deep fat fryer, stove and grill; * Vents within the hood above the stove/grill/fryer; * Sliding clear doors under steam table storing dishes; * Top of pole holding whisks next to the steam table; * Sandwich refrigerator between the cutting board and door closure area; * Fans operating above handwashing sink and prep area; * Wall and ceiling surrounding the fan and sprinkler head in prep area; * Ceiling vents in prep area and beverage counter; * Dishwashing area: wall above and below the spray sink; drain and floor under the dishwasher; and *Floors throughout the kitchen: underneath counters, deep fat fryer, stove/grill, dry storage, prep area, three compartment sink, ice machine and beverage area. The following food items were improperly stored: * Individual servings of ice cream were uncovered in the walk-in freezer and  a sheet pan of cake/brownies on a rolling cart in walk in refrigerator were uncovered. The facility failed to ensure the dishmachine was operating according to the data plate rinse temperature of 180 degrees F: * Several observations on 01/04/23 at 10:45 am of the rinse temperature gauge on top of the dishmachine showed the temperature registered between 140 and 150 degrees F. * Interview with Staff 5 (dishwasher) indicated the gauge did not work and stated the temperature was not monitored. * Staff 1 (Executive Director) was informed and they contacted Staff 3 (Kitchen Manager) and learned temperatures were taken and recorded manually with a thermometer placed in the dishmachine water after the rinse cycle ran. * No rinse temperatures were recorded on the temperature logs. * Staff 4 (Cook) took a temperature of the water at 11:10 am which read 156 degrees F. * Maintenance director was immediately notified and service vendor was contacted for immediate repairs. The above areas were discussed with Staff 1 (Executive Director) and Staff 2 (Cook) on 01/04/23. The findings were acknowledged.

Dining Services Director (DSD) will ensure items requiring cleaning are on the daily and weekly cleaning checklists for dining staff. Deep cleaning will be completed to address all items listed in citation. DSD will review cleaning checklists and inspect daily on working days. Executive Director (ED) will conduct weekly audits to ensure cleaning checklists are completed in their entirety as well as visual inspection of kitchen. Dishwasher has been inspected and repair parts ordered. Repair will be completed once parts are received. DSD will review wash and rinse temperatures daily on working days and will notify ED if out of required parameters. ED will review dishwasher temperatures weekly with DSD.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-0000.  This is a repeat citation. Findings include, but are not limited to: On 4/11/23 at 11:30 am, the facility kitchen was observed to need cleaning in the following areas: * Fan blades and cages;   * Bulk food bin lids; * Surfaces (sides/front/doors) and wall behind steamer, deep fat fryer, stove and grill; * Bottom of pole holding whisks next to the steam table; * Sandwich refrigerator around edges and in-between divider areas; * Wall and ceiling surrounding the fan and sprinkler head in prep area; * Lower shelf where cutting boards were stored; * Open shelving under steam table where serving pans were stored; * Dishwashing area: wall above and below the spray sink; drain and floor under the dishwasher; and * Floors throughout the kitchen: underneath counters, deep fat fryer, stove/grill, dry storage, prep area, three compartment sink, ice machine and beverage area. * Floors underneath shelving in walk in cooler and freezer; * Rolling baking rack stored in walk in cooler; and * Walls behind equipment. The facility failed to ensure the dish machine was operating according to the data plate rinse temperature of 180 degrees F. * Several observations of the rinse temperature gauge on top of the dish machine showed the temperature of the rinse did not reach 180 degrees F. Records of dish wash temperatures reviewed from 04/01/23 through 04/11/23 documented a range of temperatures for morning, lunch and dinner of 156-176 degrees F, with no recorded temperature readings of 180 degrees F for the final sanitizing rinse.  Staff 1 (Executive Director) acknowledged the dishwasher had not been reaching 180 degrees but had thought it needed to be between 160 and 180 degrees F. S/he acknowledged the facility had been working with a vendor on multiple occasions to get the rinse cycle temperature higher. During this survey the highest the temperature would reach was 178 degrees F per the dial on the machine. The data plate on the dish machine did confirm that the minimum rise cycle temp should be 180 degrees F. The above areas were discussed with Staff 1 (Executive Director) and Staff 2 (Kitchen Manager) on 4/11/23. The findings were acknowledged.

DSD will conduct deep cleaning party with dietary staff  where all equipment will be pulled and floors and walls deep cleaned. Items listed are on weekly cleaning list. (fan blades, deli bar, whisk holder, etc) ED to create inspection checklist and conduct audits weekly after deep cleaning. If found unsatisfactory, ED will inspect daily on working days until completed. Vendor will be contacted again to repair the dishwasher to obtain a minimum rinse temperature of 180 degrees.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-0000.  This is a repeat citation. Findings include, but are not limited to: On 06/02/23 at 1:00 pm, the facility kitchen was observed to need cleaning and repair in the following areas: * Surfaces (sides/front/doors) and wall behind steamer, deep fat fryer, stove and grill; * Wall and ceiling in the prep area located in the back of the kitchen had built up dust debris; * Wall above the spray sink in the dishwashing area had built up black matter; * Floors underneath deep fat fryer, stove/grill, and walk in refrigerator and freezer had built up black matter; * Sandwich refrigerator and reach in refrigerator had individual food items that were not properly stored, labeled and dated; * The hand washing sink faucet handle was broken and wouldn't turn off; and * The facility failed to ensure the dish machine was operating according to the data plate rinse temperature of 180 degrees F. Several observations of the rinse temperature gauge on top of the dish machine showed the temperature of the rinse did not reach 180 degrees F. Staff 1 (Executive Director) acknowledged the facility had been working with a vendor on multiple occasions to get the rinse cycle temperature higher. During this survey, Staff 1 and the surveyor ran the dish machine nine consecutive times. The highest the temperature would reach was 176-178 degrees F per the dial on the machine. The data plate on the dish machine did confirm that the minimum rise cycle temp should be 180 degrees F. Staff 1 and Staff 2 (Dietary Manager) stated they would call the vendor again for repair and directed kitchen staff to use the three compartment sink for sanitizing dishes and kitchen equipment. The above areas were discussed with Staff 1 and Staff 2 on 06/02/23. The findings were acknowledged.

Staff will use 3 sink method until dishwasher is either repaired again or replaced. Dietary staff will continue to log daily temperatures once machine repaired/replaced. DSD will review daily on working days and report any temperatures out of parameters to ED. Areas in which cleanliness was a concern have been addressed. Moving forward, ED will conduct bi-weekly audits of kitchen as well as ensuring all stored foods are covered, labeled, and dated.

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 C 240.

Reference C240

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 follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C240.

Refer to C240

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

Refer to C240

Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. 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 01/04/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 1/4/23, conducted 4/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 01/04/23, conducted 06/02/23, 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 revisit to the kitchen inspection of 1/4/23, conducted 8/9/23, 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.

Based on interview and record review, it was determined the facility failed to protect residents from abuse, failed to immediately notify the local SPD office of any incident of abuse or suspected abuse and failed to promptly investigate all reports of abuse or suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse, for 4 of 5 sampled residents (#s 1, 2, 3, and 4) who experienced injuries of unknown cause, physical altercations, sexual touching and an unwitnessed falls with injury. The facility failed to promptly investigate and report when Resident 3 was involved in an incident of suspected sexual abuse with another resident on two occasions. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in March 2021 with a diagnosis including Alzheimer's dementia. Resident 3's current service plan dated 08/26/21, stated Resident 3 had late stage dementia, was confused often, required cues, reminders and redirection from staff and was dependent on staff's assistance for most ADL care. a. A temporary service plan dated 09/21/21, indicated staff observed an unsampled resident trying to touch Resident 3. The incident was not investigated until 09/27/21 and reported the unsampled resident had his/her hands on top of Resident 3's pants "trying to get under them". The report provided conflicting information and stated abuse had been ruled out because it was possible the unsampled resident was trying to hold Resident 3's hand and touched Resident 3's pants instead. Staff 18 (CG), who completed the temporary service plan on 09/21/21, was interviewed via phone on 12/15/21 and stated the unsampled resident had his/her hand on top of Resident 3's pants near the waist band and was trying to lift Resident 3's shirt. An incident report dated 09/22/21, indicated staff observed the same unsampled resident "with [ his/her] hands down Residents 3's pants touching [Resident 3's] private parts." The facility failed to promptly investigate the incident on 09/21/21. On 09/22/21 the unsampled resident involved in the incident the day prior was observed with his/her hands down Resident 3's pants. There was no documented evidence the incidents were reported to local SPD office. b. Resident 3's service plan dated 08/26/21, stated Resident 3 required assistance of one staff member for ambulation. Review of Resident 3's incident reports indicated the resident was a high fall risk, and had experienced five unwitnessed falls between   07/16/21 and 10/20/21. Two of the falls resulted in injury. In an incident report dated 09/05/21, staff documented Resident 3 was found on the ground in the facility's outdoor courtyard. Resident 3 was sent to the Emergency Room (ER) for evaluation and treatment of left side drooping and weakness. The resident returned from the ER with a diagnosis of a scalp contusion. The investigation completed on 09/05/21 sated staff were following the service plan and abuse was ruled out because the resident stated no one had hurt him/her. However, the resident's service plans indicated staff were to provide one person assist with ambulation and further stated the resident had late stage dementia and was often confused. There was no documented evidence the facility reported the unwitnessed fall with injury to the local SPD office. An incident report dated 10/20/21, stated staff found Resident 3 down on the floor in the dining room. The resident was sent to the ER for evaluation and treatment of complaints of severe hip pain. The incident report did not indicate the facility had investigated the incident to rule out abuse or suspected abuse, and there was no documented evidence the facility reported the incident to the local SPD office. c. An incident report dated 06/19/21, stated Resident 3 was involved in a physical altercation with another resident where the other resident put his/her hands on Resident 3's neck and pushed Resident 3 down. There was no documented evidence the facility reported the incident to the local SPD office. An incident report dated 08/15/21, stated Resident 3 was involved in a physical altercation with another resident where the other resident hit Resident 3's face with an open hand. There was no documented evidence the facility reported the incident to the local SPD office The need to ensure  incidents of abuse or suspected abuse were promptly investigated and reported to the local SPD office was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings and reported all required incidents to the local SPD office, per the survey team's request. Confirmation of the reports were provided to the survey team prior to survey exit.   2. Resident 2 was admitted to the facility in October 2014 with a diagnosis including dementia. Resident 2's service plan dated 10/05/21, stated the resident was "wheelchair bound"  and required full assistance from staff for all transfers and ADL's. A progress note dated 10/12/21, stated staff discovered a bruise on Resident 2's upper left arm and a temporary service plan dated 10/13/21, stated staff discovered a bruise on Resident 2's right hip. There was no documented evidence the facility investigated the incidents to determine if abuse or suspected abuse could be ruled or reported the incidents to the local SPD office. The need to ensure injuries of unknown cause were promptly investigated and reported to the local SPD office was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings and reported all required incidents to the local SPD office, per the survey team's request. Confirmation of the reports were provided to the survey team prior to survey exit. 3. Resident 4 was admitted to the memory care community in February 2019 with diagnoses including dementia and transient ischemic attack. Review of the resident's progress notes, incident reports and interim service plans identified the following deficiencies: The facility failed to immediately report three incidents of abuse to the local SPD office, involving resident to resident altercations. These were listed as: * 09/14/21- Resident 4 was involved in an unwitnessed altercation with another resident; * 11/14/21- staff witnessed Resident 4 gripping another resident's arm, while scratching and trying to hit [him/her]; and * 11/18/21- staff observed Resident 4 grab another resident's arm and "smack [him/her] across the face four times". There was no documented evidence the facility reported these three incidents to the local SPD office. On 12/15/21 the need to ensure incidents of abuse or suspected abuse were promptly reported to the local SPD office was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. At survey's request, the facility reported the incidents to the local SPD office. Confirmation of the reports were provided to survey prior to exit. 4. Resident 1 was admitted to the facility in October 2021 with diagnoses including history of Cerebrovascular accident. An incident report dated 10/26/21 stated Resident 1 was involved in a physical altercation with another resident where the other resident hit Resident 1 two to three times in the upper arm. There was no documented evidence the facility reported the incident to the local SPD office. On 12/16/21, the need to ensure incidents of abuse or suspected abuse were promptly investigated and reported to the local SPD office was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. The facility reported the incidents to the local SPD office per the survey team's request. Confirmation of the reports were provided to the survey team prior to survey exit.

All staff will complete Abuse Reporting and Investigation from Oregon Care Partners. Abuse reporting and investigation will also be covered at the all staff meeting Staff will be trained to notify ED/LN/RCC of suspected abuse/neglect immediately. Incident reports will be reviewed by RCC/LN/ED within 24 hours of notification per state guidelines.  Incidents where abuse and neglect cannot be ruled out, i.e. unwitnessed falls with injury, injuries of unknown origin, res to res altercations, inappropriate contact, will be reported immediately to APS. Consultant to monitor monthly during visits.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required components and were updated with changes as appropriate within the first 30 days for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Resident 1 was admitted to the facility in October 2021. Resident 1's move-in evaluation failed to address the following required components: * List of current diagnoses; * List of medications and PRN use; * Visits to health practitioner(s), ER, hospital, and/or NF in the past year; * Effective non-drug interventions (related to mental health issues); * Personality including how the person copes with change or challenging situations; * Ability to manage medications; * Transportation; * List of treatments; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, and room temperature. There was no documented evidence the facility updated the resident move-in evaluation within the first 30 days. On 12/16/21, the need to ensure new move-in evaluations included all required components and were updated within the first 30 days was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Res 1 will have 30 day evaluation completed. New resident move in eval will be reviewed by ED prior to admission to ensure all components included. ED will continue to review eval/service plan due dates weekly with RCC/LN to ensure they are completed timely. Move-in eval tool will be reviewed to ensure all required components are included per OAR Consultant to review monthly at visits.

3. Resident 3 was admitted to the facility in March 2021 with diagnoses including Alzheimer's dementia. Resident 3's current service plan dated 08/26/21, was reviewed on 12/13/21. The service plan had not been updated quarterly and was not updated when the resident experienced a significant change in condition related to a severe weight lost on 07/30/21. The need to ensure service plans were updated quarterly and/or updated when the resident had a significant change in condition was discussed with Staff 1 (ED) and Staff 2 (Regional  Director of Operations) on 12/16/21. They acknowledged the findings. 2. Resident 4 was admitted to the memory care community in February 2019 with diagnoses including dementia and transient ischemic attack (TIA). Review of Resident 4's service plan, dated 08/12/21, progress notes, incidents reports and staff interviews identified the following deficiencies: a. The service plan was not reflective of the resident's current status or lacked direction to staff in the following areas: * Challenging or volatile behavior patterns; * Non-drug interventions; and * Multiple resident to resident altercations. b. The facility failed to update the service plan quarterly, as the rule required. On 12/16/21 the need to ensure service plans were reflective of residents' current status, provided instructions to staff and were updated quarterly was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, were reviewed and updated quarterly and/or when a resident experienced a significant change in conditionand, or were followed for 3 of 5 sampled residents (#s 1, 3, and 4). Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in October 2021 with diagnoses including history of Cerebrovascular accident. Resident 1's service plan, progress notes, incidents reports and staff interviews identified the service plan was not reflective of the resident's current status or lacked direction to staff in the following areas: *Shaving assistance; and *Transfer assistance. On 12/16/21, the need to ensure service plan's were reflective of resident needs and were being followed was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

An audit of all service plans will be conducted, to include residents 1,3, and 4 by RCC/LN to ensure all components are included as well as updated timely. ED will review weekly with RCC/LN to ensure completion as well as that all components are included ED will review service plan due dates weekly with LN/RCC to ensure completion within 30 days for new residents, 90 days for existing residents, and with significant changes of condition. LN/RCC will review 24 hour report/incident reports daily to monitor for significant changes in condition. Service plans will be updated to reflect the significant changes per state guidelines. ED will review updated service plans for completion.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated and referred to the RN for further assessment as indicated, necessary actions/interventions were determined, documented and communicated to staff and the residents' condition, including effectiveness of interventions, was monitored weekly through resolution for 3 of 5 sampled residents (#s 2, 3, and 4) who had documented changes of condition. Resident 2 experienced pressure wounds which went untreated and worsened over time. Resident 3 experienced a severe weight loss, continued to lose weight over time, and displayed repetitive intrusive wandering behaviors which placed the resident at risk of injury. Resident 4 displayed repetitive episodes of physical aggression towards other residents, which placed the residents at risk of injury. Findings include but are not limited to: 1. Resident 2 was admitted to the facility in October 2014 with diagnoses including dementia. Resident 2's service plan dated 10/05/21 stated the resident was "wheelchair bound"  and required full assistance from staff for all transfers and ADLs. a. Progress notes (10/05/21 -12/13/21), MARs/TARs  (10/01/21 - 12/13/21) and temporary service plans were reviewed and indicated the following information related to a wound on Resident 2's coccyx area: *10/12/21- A temporary service plan stated Resident 2 had a "small pressure sore on right buttocks/hip. Apply A&D ointment as needed." There was no documented evidence staff had administered the treatment per review of the October 2021 MAR/TAR and progress notes; * 10/22/21- A progress note stated the facility received orders for "calmoseptine topical paste for residents pressure wound on buttocks." There was no documented evidence staff had administered the treatment, per review of the October and November 2021 MAR/TAR and progress notes; * 11/27/21- A temporary service plan noted the resident now had an "open wound on his/her coccyx". * 11/28/21- An RN progress note indicated the resident had an "open area" on his/her coccyx which measured 1cm x 1cm. The note stated the facility was to notify hospice and the resident was placed on alert for weekly skin checks. * 12/2/21- Staff 3 completed an assessment and documented the coccyx wound measured 1.2 cm x 1 cm. Staff 3 contacted the resident's hospice provider and requested they provide an evaluation and wound care orders. *12/3/21- A progress note stated Resident 2's hospice provider assessed the wound as a "stage III wound on coccyx" and initiated wound care orders. The facility's failure to evaluate and monitor the wound on the resident's coccyx and failure to administer treatments as prescribed resulted in worsening of the wound. The resident's coccyx wound was observed by the survey team's RN and Staff 3 (LPN) on 12/16/21. The skin impairment documentation completed by Staff 3 on 12/16/21 indicated the wound had worsened and measured 3 cm x 2.5 cm. The survey team's RN stated the wound was at a minimum a stage III pressure wound. b. Progress notes (10/05/21 -12/13/21), MARs/TARs  (10/01/21 - 12/13/21) and temporary service plans were reviewed and indicated the following information related to wounds on Resident 2's left hip, right hip and right heel: * 10/28/21- A progress note indicated staff identified a skin abrasion on Resident 2's left hip; * 11/05/21- Dressing changes for "left hip pressure sore" were initiated on the MAR; * 11/12/21- A temporary service plan stated Resident 2 had "pressure sores" on the right and left hip and right heel; * 11/28/21- An LN progress note stated the resident had a 4 cm x 3 cm blister on the right heel, there was no mention of the hip "pressure sores"; and * A progress note and skin assessments, completed by Staff 3, dated 12/02/21 indicated the blister on the residents right heel remained intact, the wound on the resident's right hip had resolved but the wound on the left hip measured 4 cm x 2.4 cm, with the open area of the wound measuring 2 cm x 1.5 cm. Staff 3 contacted the resident's hospice provider and requested an evaluation and wound care orders. The facility continued to provide dressing changes as directed. The facility failed to refer the resident to the RN for further assessment when the resident's left hip abrasion (identified on 10/28/21) had not resolved and two additional "pressure sores" were documented by staff on 11/12/21. There was no documented evidence the facility monitored the left hip "pressure sore" between 10/28/21 - 12/02/21, the right heel "pressure sore" between 11/12/21 -11/28/21, and the right hip "pressure sore" between 11/12/ 21 - 12/02/21. The facility's failure to monitor the wound on Resident 2's left hip between 10/28/21 -12/02/21 resulted in worsening of the wound. The left hip wound was observed by the survey team's RN and Staff 3 (LPN) on 12/16/21. The skin impairment documentation completed by Staff 3 indicated the wound on the left hip had worsened and measured 4 cm x 3 cm, with the open area of the wound measuring 3 cm x 2.5 cm.   The need to ensure residents who experienced changes of condition were referred to the RN for further evaluation, monitored at least weekly through condition resolution and necessary interventions were determined and documented was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings. 2.  Resident 3 was admitted to the facility in March 2021 with a diagnosis including Alzheimer's dementia. a. Resident 3's weight records dated 06/30/21 through 12/13/21 indicated the following: On 06/30/21 Resident 3's weight was documented as 170.2 pounds and on 07/30/21 Resident 3's weight was documented as 161.2 pounds. This indicated Resident 3 experienced a severe weight loss of  9 pounds or 5.28% of total body weight within 30 days. The resident continued to experience weight fluctuations over the next several months. On 12/15/21 the resident weighed 156.6 pounds which represented a  weight loss of 13 pounds, or 8% of total body weight over six months. There was no documented evidence the facility identified, evaluated, determined interventions and monitored the resident's severe weight loss between 07/30/21 and 08/27/21, or referred the resident to the RN for assessment when the resident experienced a significant change of condition. On 08/27/21, a temporary service plan instructed staff to provide Resident 3 with an adaptive lipped plate. There was no evidence the facility monitored the use of or effectiveness of the adaptive device in reducing further weight loss 08/27/21 - 12/13/21. No other weight loss interventions were noted in the residents chart. The need to ensure resident changes of condition were identified and evaluated, interventions were determined, documented and monitored weekly and residents with significant changes of condition were referred to the facility RN for assessment was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings. b. Resident 3's current service plan dated 08/26/21, stated the resident had late stage dementia, was confused often, had a history of falls and had a history of wandering. The following interventions were included in the 08/26/21 service plan: When the resident is observed wandering throughout facility: * Staff were to offer food/drink; * Staff to conduct safety checks each shift; * Hold the resident's hand; * Offer toileting; * Put music on while encouraging the resident to sit in a chair, and * Redirect the resident by walking him/her to dining or living room. In an incident report dated 10/09/21, staff documented Resident 3 experienced an unwitnessed fall and was found sitting on the floor of another resident's room. No injury was noted. The temporary service plan did not include new interventions to address the resident's fall or intrusive wandering. An incident report dated 11/15/21, stated Resident 3 experienced an unwitnessed fall and staff found the resident on the floor in an unoccupied room. The temporary service plan included interventions to lock the doors of unoccupied rooms. There was no documented evidence interventions to address the resident's behavior of wandering into other rooms were developed. An incident report dated 11/25/21 stated staff found Resident 3 on the floor of another resident's room. No injury was noted. The temporary service plan did not include new interventions to address the resident's fall or intrusive wandering behaviors. An incident report dated 12/01/21 stated staff responded to a scream coming from another resident's room. Staff found Resident 3 on the floor in the other residents room. The resident in that room stated "I pushed the intruder down". Resident 3 sustained "a small scratch on [his/her] vertebra and a scratch on [his/her] back going along the right side." The facility failed to determine, document and monitor interventions for effectiveness when Resident 3 displayed repetitive intrusive wandering behaviors which placed Resident 3 at risk for injury. On 12/01/21 Resident 3 wandered into another residents room and was injured. The facility's failure to determine, document and monitor interventions for effectiveness when Resident 3 experienced a change in behavior and unwitnessed falls was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings. 3. Resident 4 was admitted to the memory care community in February 2019 with diagnoses including dementia and transient ischemic attack (TIA). Review of Resident 4's progress notes, interim service plans, incident reports and staff interviews indicated the resident had six physical altercations with other residents between 09/13/21 and 12/13/21. The incidents were listed as follows: * 09/14/21- Resident 4 was in an unwitnessed altercation with another resident. An interim service plan stated staff should re-direct the two residents from each other; * 09/26/21- Staff witnessed Resident 4 being struck in the face by another resident, who stated Resident 4 had "hit [him/her] first". An interim service plan stated Resident 4 was to be re-directed to the dining room, Montessori room when observed near the other resident; * 09/28/21- Staff witnessed Resident 4 being "punched repeatedly in the head", by the same resident as the previous incident. An interim service plan instructed staff to "re-direct Resident to his room or other common area"; * 11/14/21- Resident 4 was seen by staff gripping another resident's forearm, while scratching and trying to hit the resident. An interim service plan stated "if these two residents are up on [night] shift and near each other, they will be supervised"; * 11/18/21- Staff witnessed Resident 4 grab another resident's arm and "smack [him/her] across the face four times". An interim service plan stated staff should observe for other residents in Resident 4's path, as s/he self-propels in wheel chair, directing Resident 4 around other residents when necessary; and * 12/02/21- Staff observed Resident 4 holding onto another resident's blouse and wrist, and "tugging [him/her] back and forth". An interim service plan instructed staff to "intervene if the two residents are seen together, and are having any issues". In each of these instances an interim service plan was developed and Resident 4 was put on "alert charting".  However, the service plans did not provide new interventions and the facility failed to monitor the  previous interventions for effectiveness. On 12/07/21 the facility RN sent a fax to Resident 4's physician requesting a medication review, diagnostic lab work, and PT/OT evaluation. On 12/07/21 an order was obtained to increase Resident 4's Risperidone (an antipsychotic) to twice daily, for behaviors. The medication was started on 12/07/21 and there were no further incidents documented through survey entrance date of 12/13/21. However, the facility's failure to implement new interventions and monitor those for effectiveness contributed to a prolonged pattern of physical aggression, which put Resident 4 and other residents at risk for harm. On 12/17/21 the need to develop new behavior interventions and monitor those for effectiveness was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

All staff to be trained on abuse reporting and investigation through Oregon Care Partners and all staff meeting. Res 2,3,4 will have change of condition completed. MA's will receive in-service on weight and skin policies. MA will complete incident report and notify LN/RCC/ED of any changes in behavior or skin integrity. RCC/LN will implement appropriate interventions for behaviors and monitor effectiveness. LN will complete weekly skin assessments and implement appropriate interventions, notify appropriate outside agencies i.e. HH, Hospice,PCP RN/LN/RCC will review weights weekly.  Should a resident experience significant weight loss/gain-RN/ED will be notified immediately.  Interventions will be implemented and PCP notified. Interventions for residents experiencing significant weight loss/gain will be monitored for effectiveness weekly by RN/LN/RCC Consultant to review COCs monthly at visits.

Based on observation, interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, to include findings, resident status and interventions, for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes of condition. Resident 3 experienced severe and ongoing weight loss and Resident 2 experienced multiple pressure wounds that worsened over time. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in October 2014 with diagnoses including dementia. Resident 2's service plan dated 10/05/21, sated the resident was "wheelchair bound" and required full assistance from staff for all transfers and ADLs. a. On 11/27/21, a temporary service plan noted the resident had an "open wound on his/her coccyx". * 11/28/21- An RN progress note indicated the resident had an "open area" on his/her coccyx which measured 1 cm x 1 cm. The note stated the facility was to notify hospice and the resident was placed on alert for weekly skin checks. There was no documented evidence the RN completed an assessment of the residents wound to include residents status, interventions made as a result of an assessment, or that the residents service plan had been updated. A thorough RN assessment was not completed until 12/02/21. The resident's coccyx wound was observed by the survey team's RN and Staff 3 (LPN) on 12/16/21. The skin impairment documentation completed by Staff 3 on 12/16/21 indicated the wound had worsened and measured 3 cm x 2,5 cm. The survey team's RN stated the wound was at a minimum a stage III pressure wound. On 12/16/21 Staff 1 (ED) stated the facility had recently undergone a change in the RN position and the facility was not able to locate or access previous RN assessments. The facility's failure to ensure a timely and thorough RN assessment was completed resulted in worsening of the resident's coccyx wound. Refer to C270 example 1a. b. Progress notes (10/05/21-12/13/21), MARs/TARs  (10/01/21-12/13/21) and temporary service plans were reviewed and indicated the following information related to wounds on Resident 2's left hip, right hip and right heel: * 10/28/21- A progress note indicated staff identified a skin abrasion on Resident 2's left hip; * 11/12/21- A temporary service plan stated Resident 2 had "pressure sores" on the right and left hip and right heel; There was no documented evidence the pressure sores were assessed by the facility's RN until 12/02/21. The left hip wound was observed by the survey team's RN and Staff 3 (LPN) on 12/16/21. The skin impairment documentation completed by Staff 3 indicated the wound on the left hip had worsened and measured 4 cm x 3 cm, with the open area of the wound measuring 3 cm x 2.5 cm. On 12/16/21 Staff 1 (ED) stated the facility had recently undergone a change in the RN position and the facility was not able to locate or access previous RN assessments. The facility's failure to ensure a timely RN assessment was completed on 11/12/21 when staff reported the resident's left hip abrasion (identified on 10/28/21) had not resolved and two additional "pressure sores" were identified by staff, resulted in the resident's left hip wound worsening. Refer to C270 example 1b. The need to ensure a significant change of condition assessment was completed by the RN, to include findings, resident status and interventions, in a timely manner was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings. 2. Resident 3 was admitted to the facility in March 2021 with a diagnoses including Alzheimer's dementia. Resident 3's weight records dated 06/30/21-12/13/21 indicated the following: On 06/30/21 Resident 3's weight was documented as 170.2 pounds and on 07/30/21 Resident 3's weight was documented as 161.2 pounds. Resident 3 experienced a severe weight loss of  9 pounds or 5.28% of total body weight over 30 days, which indicated a significant change in the residents condition. There was no documented evidence the weight loss was assessed by an RN and the resident continued to experience weight fluctuations over the next several months. On 12/15/21 the resident weighed 156.6 pounds which represents a 13 pound or 8% loss of total body weight from 06/30/21-12/15/21. The need to ensure an RN assessment was completed when resident's experienced significant changes in condition was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings.

Refer to C270

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (#1) who had documented medication refusals. Findings include, but are not limited to: Resident 1's clinical records and MARs/TARs were reviewed during the survey and identified multiple medication and treatment refusals between 12/01/21 and 12/13/21. There was no documented evidence the facility notified the physician when the resident refused consent to orders. On 12/16/21 the failure to notify physicians of the documented medication and treatments refusals was reviewed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Res 1's med refusals have been reported to MD.  Med refusal protocol will be reviewed and revised. All MA's will receive training on procedure for resident refusal of medications. MA's will notify MD of any missed medication via fax per facility protocol. RCC/LN will review MARs weekly to ensure PCP's are notified any medication refusals. Med refusals will also be monitored by reviewing med omissions during 24 hour chart review.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 sampled newly-hired direct care staff (#s 7 and 8) had documented evidence of completion of First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed during survey. The facility did not have documentation that Staff 7 (CG) and Staff 8 (MA), hired 08/06/21 and 10/01/21 respectively, completed the required First Aid and abdominal thrust training within 30 days of hire. The need to ensure newly-hired direct care staff completed First Aid and abdominal thrust training with in 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings .

Care staff 7 and 8 have obtained first aid/abdominal thrust. BOM will conduct audit of employee files. BOM will ensure any existing direct care staff employed longer than 30 days has current First Aid/Abdominal Thrust. BOM will review new employee files weekly after orientation to ensure completion. Should a direct care staff fail to complete the first aid/abdominal thrust training within 30 days of hire, they will be removed from the schedule until complete. BOM will review findings with RCC/LN/ED weekly to ensure compliance. RDO to audit monthly during visits.

Based on interview and record review it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternating months from fire drills and failed to ensure fire drills included all required documentation components. Findings include, but are not limited to: Fire and life safety records for June 2021 through November 2021 were reviewed on 12/15/21 and showed the facility failed to conduct fire and life safety trainings on alternate months and failed to consistantly document the following required fire drill components: *Escape route used; *Problems encountered; *Evacuation time-period needed; *Staff members on duty and participating; and *Number of occupants evacuated. In an interview with Staff 1 (ED) on 12/16/21, they reported there was no documented staff training records related to fire and life safety from June 2021 through December 2021. On 12/16/21, the need to ensure fire and life safety training was provided to staff on alternate months of fire drills and fire drills had documented evidence of all required components was discussed with Staff 1 and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Maintenance Director (MD) will conduct fire and life safety training on alternate months of fire drills at the monthly all staff meetings. A sign in sheet will be kept to track attendance of employees attending. ED will review All Staff Inservices monthly with MD to ensure compliance. RDO to review Fire and Life Safety records quarterly.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code. Findings include, but are not limited to: Fire and life safety records for June 2021 through November 2021 were reviewed and lacked the following components: *Alternating evacuation routes during fire drills; and *Documentation resident evacuation levels were determined and met. On 12/16/21, the need to ensure fire and life safety training included all required components was discussed with  Staff 1(ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

MD will conduct fire drills in accordance with state guidelines on alternating months of fire and life safety training. MD will complete the fire drill in its entirety utilizing the records on TELs system. ED will review fire drills monthly with MD to ensure they encompass all components to include alternating evacuation routes and ensure resident evacuation levels are determined and met. RDO to review fire drill records quarterly.

Based on observation and interview, it was determined the facility failed to ensure the door that exited to an interior courtyard was equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: Observations during the survey revealed exit doors, including doors to the enclosed courtyards, had no alarm or other acceptable system to alert staff when residents entered or exited. On 12/14/21, the failure to ensure doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (ED) and Staff 11 (Maintenance Director). They acknowledged the findings.

RDO and ED will contact customer support to ensure that chimes are working on all exterior doors leading to interior courtyards. During times of inclement weather outlined in community policy, doors will be kept locked to ensure the safety of residents. MD will inspect door alarms leading to interior courtyards monthly via TELs and alert ED of any malfunctions.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to  C 231, C 372, C 420, C 422 and C 555.

Refer to C 231, C 372, C 420, C 422 and C 555

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired direct care staff (#s 7, 8, 10 and 14) completed all required competency training within 30 days of hire and 2 of 3 sampled veteran staff (#s 16 and 17) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to: 1. Training records for Staff 7 (CG) hired 08/06/21, Staff 8 (MA) hired 10/01/21, Staff 10 (CG) hired 09/14/21 and Staff 14 (CG) hired 06/30/21, were reviewed during survey. The following deficiencies were identified: a. There was no documented evidence Staff 7, 8 and 14 had had completed competency training, in all required topics, within 30 days of hire. b. There was no documented evidence Staff 10 had completed competency training within 30 days of hire on the following topics: * Changes associated with normal aging;    * Identification, documentation and reporting of changes of condition; and    * Conditions that require assessment, treatment, observation and reporting.       c. There was no documented evidence Staff 8 (MA) completed competency training within 30 days of hire related to demonstrating ability to perform safe medication and treatment administration unsupervised. * On 12/15/21, Staff 2 (Regional Director of Operations) stated the facility had recently undergone a change in management and believed Staff 8 had completed the required training but the records had not been maintained by the previous management. Per the survey team's request, the facility removed Staff 8 from his/her medication administration duties and provided the staff member with the appropriate training prior to returning Staff 8 to medication administration duties. 2. Training records for Staff 16 (CG) hired on 08/20/19 and Staff 17 (CG) hired on 05/23/19, were reviewed during survey. The following deficiencies were identified: There was no documented evidence Staff 16 (CG) and Staff 17 (CG) had completed six hours of annual dementia related training. Additionally, there was no documented evidence Staff 16 completed the required 10 hours of annual training related to provision of care. The need to ensure newly-hired direct care staff completed competencies in all required topics within 30 days of hire, and veteran staff completed 16 hours of in-service training annually, including 6 hours of dementia care training, was reviewed with Staff 1 (ED) and Staff 2 on 12/16/21. They acknowledged the findings.

BOM will conduct audit of all direct care staff files. Any staff missing their 30 day competencies will be required to complete with a trainer/RCC/LN. BOM will notify RCC/LN of any direct care staff that have not completed the required CEU's. Direct care staff will be assigned the appropriate CEU's and are expected to complete the required amount. BOM will audit employees files monthly and review with ED any outstanding matters. All direct care staff will receive Montessori (dementia specific) training. BOM will continue to review staff training records weekly and review with RCC/ED any outstanding items.  Direct care staff that fail to meet these requirements will be removed from the schedule until their completion.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 270, C 280, and C 305

Refer to C 252, C 260, C 270, C 280, and C 305

3. Resident 3 was admitted to the memory care community in March 2014 with diagnoses including Alzheimer's dementia. Review of Resident 3's service plan dated 08/26/2021 and an undated activity evaluation indicated the following: Resident 3's activity evaluation and activity service plan failed to address the following required elements: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; and * Adaptations necessary for the resident to participate. On 12/16/21 the lack of an individualized activity plan that was reflective of the resident's current status, addressed all required components and was available during the resident's waking hours was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. Resident 4 was admitted to the memory care community in February 2019 with diagnoses including dementia and transient ischemic attack (TIA). Review of Resident 4's service plan, dated 08/12/2021 indicated the following: a. The resident's service plan lacked an individualized plan for meaningful activities that promoted the physical and emotional well-being of the resident, were person-directed and available during the resident's waking hours. b. Resident 4's activity evaluation failed to address following required elements: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities for behavior interventions. On 12/16/21 the lack of an individualized activity plan that was reflective of the resident's current status, addressed all required components and was available during the resident's waking hours was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the memory care community in October 2021 with diagnoses including history of CVA (cerebrovascular accident). Review of Resident 1's service plan offered some information about the resident's interests, the facility had not fully evaluated the resident's: *Current abilities and skills; *Physical abilities and limitations; *Adaptations necessary for the resident to participate; and *Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities. On 12/16/21, the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Activities Associate and Marketing Director will audit "My Life Stories" for all residents and ensure any missing are completed. "My Life Stories" will be given to RCC/LN to incorporate into service plans. RCC/LN will include this in their service plan audit. Service plans will be reviewed with ED to ensure compliance. Refer to C260

2. Resident 3 was admitted to the facility in March 2014. Resident 3's current service plan dated 08/26/21, stated Resident 3 had late stage dementia, was confused often, had a history of falls and had a history of wandering. Review of Resident 3's service plan dated 08/26/21 and temporary service plans indicated Resident 3's behaviors of intrusive wandering were not evaluated and included on the service plan. Refer to C 270 example 1 b. The need to ensure behavioral symptoms which negatively impacted the resident and others in the community were evaluated and included on the service plan was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 12/16/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident and others in the memory care community, update the resident's service plan, or initiate outside consultation or acute care when indicated, for 2 of 3 sampled residents (#s 3 and 4) whose service plans were reviewed. Resident 3 displayed repetitive intrusive wandering behaviors which placed the resident at risk of injury. Resident 4 displayed repetitive episodes of physical aggression towards other residents, which placed the resident and others at risk of injury. Findings include, but are not limited to: 1. Resident 4 was admitted to the memory care community in February 2019 with diagnoses including dementia and transient ischemic attack (TIA). Review of Resident 4's progress notes, interim service plans, and incident reports identified three resident to resident altercations where Resident 4 was the aggressor, and one episode where the aggressor was undetermined. These incidents were listed as follows: * 09/14/21- resident 4 was involved in an unwitnessed altercation with another resident; * 11/14/21- staff witnessed Resident 4 gripping another resident's arm, while scratching and trying to hit [him/her]; * 11/18/21- staff observed Resident 4 grab another resident's arm and "smack [him/her] across the face four times"; and * 12/02/21- Staff observed Resident 4 holding onto another resident's blouse and wrist, and "tugging [him/her] back and forth". In an interview on 12/14/21, Staff 9 (MA) stated Resident 4 had "been involved in several resident to resident altercations, and had even assaulted staff members on a few occasions." When asked about safety measures to manage those behaviors, Staff 9 said "we just keep a close eye on [him/her], and try to redirect [him/her] if a conflict arises". Resident 4 was observed on multiple days and in various settings during the survey. The resident was seen self-propelling in his/her wheel chair in the hall, eating or reading in the dining room, or watching TV. At none of these times was Resident 4 observed displaying any aggressive, disruptive or threatening behaviors. The facility's failure to evaluate the negative behaviors, and to implement changes to Resident 4's service plan put the resident and others at risk of harm. On 12/14/21 at approximately 3:00 pm, survey requested an immediate plan of correction to address the resident's behaviors. The plan was received and accepted at 4:41 pm, and the situation was abated. On 12/16/21 the need for evaluation and service planning for behavioral symptoms which negatively impact the resident and others was discussed with Staff 1 and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Refer to C270

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to: The MCC was toured on 12/14/21. Resident rooms 32, 37, and 43 lacked any individualized identification to assist residents in recognizing their room. The need to ensure each resident room was identified for the resident was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Activities Associate and Marketing Director will conduct a visual audit of resident doors and shadow boxes to ensure room are individually identified. Activities Associate and Marketing Director will work with families to individualize any doors/rooms that do not meet this criteria. Activities and Marketing will notify ED when occupied doors/rooms are individually identifiable. ED will conduct visual audit to ensure completion. Activity associate will consult with families of new residents to ensure rooms/doors are individually identifiable prior to move in. Should family not be available/unable to assist, Activity Associate will utilize My Life Story to create identifiable doors. ED will review with AA weekly for completion. RDO will monitor monthly during visits.

The findings of the re-licensure survey conducted 12/13/21 through 12/17/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day A situation was identified where there was a failure of the facility to comply with the Department's rules that caused residents serious harm. An immediate plan of correction was requested in the following area: OAR 411-057-0160 Behaviors. 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 12/17/2021, conducted 04/26/22 through 04/27/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.