Bonaventure of Albany Memory Care

Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the facility main kitchen area, and memory care kitchenette were reviewed on 08/04/25 from 10:45 am through 2:30 pm and found the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Kitchen drains
* Floors in walk-in cooler under racks
* Walk in cooler fan cages
* Ceiling vents
* Walk in freezer floors
* Plastic racks in freezer
* Ceiling vents
* Interior of microwaves (main and Kitchenette)
* Industrial can opener and housing
* Interior of combo steamer/convection oven
* Flooring under and around tables in dining room
* Juice machine
* Stainless steal open shelving holding clean equipment
* Flooring corners and edges behind/under/between equipment
* lip/edge of base coving in multiple sections/areas of kitchen
* Blender base in kitchenette
* Interior of toaster in memory care kitchenette
* Interior of cabinets storing clean dishes in kitchenette
* Interior and exterior of insulated meal/food delivery carts

b. The following areas were in need of repair:

* Cracked tile in cove base by threshold between service area and dish washing area
* Corner of wall near kitchenette door with large gouge exposing dry wall.

c. Kitchen staff was observed to not have hair effectively restrained where their very long pony tail was observed to drag across multiple clean and sanitized dishes/surfaces potentially contaminating the dishes/surfaces.

d. Multiple food items were observed in cold and dry food storage spaces in the main kitchen and memory care kitchenette open to potential contamination.

e. Multiple kitchen staff were observed to touch/handle their masks without washing or sanitizing hands and then touch food contact surfaces and/or ready to eat foods or cleaned and sanitized areas. The facility was under a covid 19 outbreak protocol.

f. Staff member washing dishes was observed to enter the kitchen area without cleaning or sanitizing hands. They were then observed to touch their face, clothing, glasses without washing or sanitizing hands as required. They were also observed to handle dirty dishes and the sprayer in the dirty area and proceed to handling/putting away cleaned and sanitized dishes/cooking equipment with the potentially contaminated hands.

g. Multiple food items were observed stored without date prepared or date opened as required.

h. Large metal soup pans/kettles were observed in the walk-in with soup in them. Staff were interviewed regarding cooling practices. Staff were not able to discuss the appropriate cooling methods and time temperature guidelines to ensure food reached appropriate/safe temperatures within acceptable time frames. Staff 2 (Food Service Director) was also not able to demonstrate appropriate knowledge on proper cooling times/thresholds.

i. Staff member was observed with long, painted/decorated nails. The staff member was observed to dish out salad and soups and did not have gloves on as required to protect food from potential contamination.

j. Box containing empty/dirty drink cans were stored in main kitchen without a tight-fitting lid/closed as required to prevent pest attraction/accumulation. Trash can in memory care kitchenette observed with food debris from previous meal and was uncovered. Staff 2 verified neither receptacle had a lid.

k. Multiple staff were observed to handle clean and sanitized dishes excessively touching the food contact surface during handling, transport.

At approximately 1:00 pm, surveyor reviewed above areas with staff 2 (Food Service Director) who acknowledged the items in need of correction. At approximately 1:45pm Staff 2 (Acting Administrator) and Staff 3 (Regional Director) were informed of the compliance concerns and they acknowledged the identified areas.

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

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

This Rule is not met as evidenced by:
Based on observation and interview, it was determined the facility failed to 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:

Observations of the main facility kitchen and memory care kitchenette were completed on 10/31/25, from 10:45 am through 1:00 pm, and the following was identified:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Walk-in cooler fan cages;
* Ceiling vents;
* Plastic racks in walk-in cooler;
* Industrial can opener and housing;
* Interior of cupboards and drawers in kitchenette;
* Interior of microwave in kitchenette;
* Exterior of blender base in kitchenette; and
* Interior and exterior of insulated food transportation/storage cart.

b. Multiple kitchen staff handling food and/or clean equipment were not using effective hair restraints.

c. Staff 2 (Food Service Director) was not able to demonstrate appropriate knowledge on proper cooling times/thresholds.

d. Two whole pies that were for resident’s desserts for the lunch meal were observed on top of the food transportation cart. The pies were not covered or protected from potential contamination during transport to the memory care unit.

e. The cook in main kitchen was observed to handle ready-to-eat foods with bare hands while serving on the tray line for the lunch meal.

At approximately 12:45 pm, the surveyor reviewed the above areas with Staff 2 (Executive Chef), who acknowledged the items in need of correction. At approximately 1:00 pm, Staff 1 (Executive Director) and Staff 3 (Regional Director) were informed of the compliance concerns, and they acknowledged the identified areas.

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

Refer to C 240.

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.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:
Based on 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.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes and entries made to the service plan were dated and initialed, service plans were reflective of residents' needs and/or provided clear direction to staff regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:



1.Resident 1 moved into the facility in 09/2019 with diagnoses including dementia.



The resident's current service plan available to staff, dated 03/09/25, and 01/08/25 through 04/08/25 progress notes and temporary care plans (TCPs) were reviewed, interviews with staff were conducted, and observations of the resident were completed. The following was identified:



a. The resident had multiple changes and entries on the service plan which were not dated and initialed.



b. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas:



*Activities, including ability to participate and modifications required; and

*Number of staff required to assist with repositioning, incontinence care, transfers and evacuation.



The need to ensure all changes and entries to the service plan were dated and initialed, and service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (Assistant ED), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

?2. Resident 2 was admitted to the facility in 02/2025 with diagnoses including dementia.



Observations of the resident, interviews with staff, review of the resident's 03/30/25 service plan, and 02/28/25 through 04/08/25 temporary care plans and progress notes were completed.



The resident’s service plan was not reflective and/or lacked resident specific direction for staff in the following areas:



* Incontinence and toileting assistance;

* Bathing assistance;

* Activities;

* Transfer assistance;

* Mealtime assistance;

* Behaviors related to telling other residents s/he needed them to help care for him/her; and

* Non-drug interventions for pain.



The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Assistant ED), Staff 2 (RN), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25. The staff acknowledged the findings.



3. Resident 3 was admitted to the facility in 08/2021 with diagnoses including dementia.



Observations of the resident, interviews with staff, review of the resident's 02/04/25 service plan and 01/08/25 through 04/08/25 temporary care plans and progress notes were completed.



The resident’s service plan was not reflective and/or lacked resident specific direction for staff in the following areas:



* Incontinence care, brief changes and toileting assistance;

* Dressing, grooming and hygiene assistance;

* Bathing assistance;

* Activities;

* Transfer assistance, ambulation and wheelchair use;

* Mealtime, feeding assistance and food textures;

* Wandering and entering other resident rooms; and

* Aggression and resistance to dressing/undressing and brief changes.



The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Assistant ED), Staff 2 (RN), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25. The staff acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and/or provided clear direction to staff regarding the delivery of services for 2 of 2 sampled residents (#s 2 and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

a. Resident 2 was admitted to the facility in 02/2025 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the resident's 03/30/25 service plan, temporary care plans, and progress notes were completed.

The resident’s service plan was not reflective and/or lacked resident specific direction for staff in the following areas:

* Toileting;
* Bathing;
* Ambulation;
* Dressing; and
* Non-drug interventions for pain.

b. Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the resident's 05/27/25 service plan, temporary care plans, and progress notes were completed.

The resident’s service plan was not reflective and/or lacked resident specific direction for staff in the following area:

* Toileting.

On 06/18/25, the need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 14 (Regional Director of Operations). She acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:
.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and/or provided clear direction to staff regarding the delivery of services for 2 of 2 sampled residents (#s 2 and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

a. Resident 2 was admitted to the facility in 02/2025 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the resident's 03/30/25 service plan, temporary care plans, and progress notes were completed.

The resident’s service plan was not reflective and/or lacked resident specific direction for staff in the following areas:

* Toileting;
* Bathing;
* Ambulation;
* Dressing; and
* Non-drug interventions for pain.

b. Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the resident's 05/27/25 service plan, temporary care plans, and progress notes were completed.

The resident’s service plan was not reflective and/or lacked resident specific direction for staff in the following area:

* Toileting.

On 06/18/25, the need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 14 (Regional Director of Operations). She acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:
.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes in condition had documented progress monitored at least weekly through resolution and provided clear resident-specific directions to staff as needed for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 02/2025 with diagnoses including dementia.



Observations of the resident, interviews with staff, and review of the resident's service plan dated 03/30/25 and progress notes dated 02/28/25 to 04/08/25 were completed.



The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, and/or lacked resident-specific directions to staff in the following areas:



* Falls with and without injury; and

* Emergency room visits.



The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, and provided clear, resident-specific directions to staff was discussed with Staff 1 (Assistant ED), Staff 2 (RN), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25. The staff acknowledged the findings.



2. Resident 3 was admitted to the facility in 08/2021 with diagnoses including dementia.



Observations of the resident, interviews with staff, and review of the resident's service plan dated 02/04/25 and progress notes dated 01/08/25 to 04/08/25 were completed.



The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution and/or lacked resident-specific directions to staff in the following areas:



* Behaviors, increased aggression and anxiety;

* Frequent urination and potential UTI;

* Resident to resident altercation;

* Feeling ill, cough, cold and increased weakness; and

* Medication changes.



The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, and provided clear, resident-specific directions to staff was discussed with Staff 1 (Assistant ED), Staff 2 (RN), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25. The staff acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols related to an unsampled resident who experienced an incontinent episode and for multiple unsampled residents who received meal service. Findings include, but are not limited to:



1. On 04/09/25 at 3:04 pm, an unsampled resident experienced an incontinent episode in the common living and activity room. Staff 10 (MT) escorted the resident to the bathroom. Bodily fluid was observed on the vinyl chair the resident vacated. Two CGs were present in the room and did not attempt to clean the chair. At 3:11 pm, this surveyor approached Staff 11 (CG) and requested she clean the chair so the other residents in the area did not attempt to sit on or clean the chair. She stated she did not know where cleaning supplies were located. The surveyor instructed her to contact the housekeeping or maintenance department. At 3:20 pm, the incident was reviewed with Staff 2 (RN) and Staff 3 (Regional Director of Health Services) who stated they would immediately address the situation and make sure the area was cleaned appropriately.



2. Observations of meal service were conducted from 04/08/25 through 04/10/25 and the following was identified:



* Caregiving staff were observed serving food and feeding a resident without wearing a protective covering over potentially contaminated clothing; and

* Hand hygiene for residents did not occur, despite multiple unsampled residents observed eating with their hands.



The need to maintain effective infection prevention and control protocols was reviewed with Staff 1 (Assistant ED), Staff 3 and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols related to 1 of 2 sampled residents (#2) and one unsampled resident who received meal service. This is repeat citation. Findings include, but are not limited to:

Observations of the lunch meal service on 06/17/25 identified hand hygiene for a sampled resident (#2) and an unsampled resident did not occur, despite the residents being observed eating with their hands.

On 06/18/25, the need to maintain effective infection prevention and control protocols was reviewed with Staff 14 (Regional Director of Operations). She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

?Based on interview and record review, it was determined the facility failed to ensure medications that were administered as a PRN to treat a resident's behavior had written, resident-specific parameters and non-pharmacological interventions were documented as tried with ineffective results prior to administering the medication for 1 of 1 sampled resident (#1) who was prescribed and administered PRN medication to treat a behavior. Findings include, but are not limited to:



Resident 1 was admitted to the facility in 09/2019 with diagnoses including dementia.



Resident 1's MARs, dated from 03/01/25 through 04/08/25 and physician’s orders were reviewed, and the following was identified:



The resident had three PRN psychotropic medications which were prescribed to treat agitation and/or anxiety:



*Lorazepam 0.5 mg every four hours;

*Risperidone 0.25 mg once per day; and

*Haldol 5 mg every four hours.



The symptom presentation for the three medications was described as “yelling, cursing, getting into staff space.” The medications lacked clear, resident-specific parameters for administration.



The resident was administered lorazepam (for anxiety) on 04/07/25. There was no documented evidence that non-pharmacological interventions were tried with ineffective results prior to administering the medication.



The need to include resident-specific parameters for PRN medications which addressed behavior, and to document non-drug interventions were tried with ineffective results prior to administering PRN medication for behavior, was reviewed with Staff 1 (Assistant ED), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to employ a full-time administrator scheduled to be on site in the facility at least 40 hours per week. Findings include, but are not limited to:



Survey entered the facility on 04/08/25 at 8:45 am and requested to speak with the administrator. Staff 1 (Assistant ED) stated that she did not know who currently held the license as administrator for the facility. On 04/08/25 at 12:55 pm Staff 1 confirmed the facility did not have an administrator and did not have an approved exception for an administrator designee.



The need to employ a full-time administrator was reviewed with Staff 1, Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

OAR 411-054-0065 (1-3) Administrator Qualification and Requirements

(1) FULL-TIME ADMINISTRATOR. Each licensed residential care and assisted living facility must employ a full-time administrator. The administrator must be scheduled to be on-site in the facility at least 40 hours per week. Each individual serving as an administrator of a residential care or assisted living facility must soon obtain an administrator ' s license. This new licensing program will be phased in over a two-year period; by January 1, 2022, in order to work as an administrator, individuals must Obtain a full "Residential Care Facility Administrator" license from the Health Licensing Office, Oregon Health Authority, as required by OAR chapter 853. Until January 1, 2022, there are three different options available to administrators. These three options are outlined in sections (2), (3) and (4) below:

Stat. Auth.: ORS 410.070, 443.450
Stats. Implemented: ORS 443.400 - 443.455, 443.991

This Rule is not met as evidenced by:

?Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual care plan and service plan for 3 of 3 sampled residents (#s 1, 2 and 3) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to:

The facility's ABST was reviewed during the survey 04/08/25 through 04/10/25.

Review of Residents 1, 2 and 3’s ABST revealed multiple ADLs were not reflective of the residents' evaluated care needs.

The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was reviewed with Staff 1 (Assistant Executive Director), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was completed prior to a resident moving into the facility, updated and reviewed no less than quarterly at the same time the service plan was updated and/or with a significant change of condition for 3 of 3 sampled residents (#s 1, 2 and 3) and multiple unsampled residents. Findings include, but are not limited to:

The facility’s ABST data was retrieved at 7:00 am on 04/08/25 and reviewed during the survey 04/08/25 through 04/10/25. The following was identified:



a. Resident 1’s ABST evaluation was not updated and reviewed at least quarterly with his/her service plan update on 03/09/25, or with significant changes of condition.

b. Resident 2, who moved into the facility 02/28/25, and four unsampled residents, who moved into the facility 04/08/25, 03/12/25, 03/01/25 and 02/02/25 respectively, did not have an ABST evaluation completed prior to moving into the facility.

c. Resident 3’s ABST evaluation was not updated and reviewed with his/her service plan update.



The need to ensure residents’ ABST evaluations were completed prior to move-in and updated with significant changes of condition and no less than quarterly with the service plan update was reviewed with Staff 1 (Assistant ED), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was completed prior to an unsampled resident moving into the facility and updated and reviewed no less than quarterly for multiple unsampled residents. Additionally, the facility failed to accurately capture care time that staff were providing for 1 of 2 sampled residents (#2) whose ABST was reviewed. This is a repeat citation. Findings include, but are not limited to:

The facility’s ABST data was retrieved at 9:15 am on 06/17/25 and reviewed during the survey from 06/17/25 through 06/18/25. The following was identified:


* An unsampled resident, who moved into the facility on 06/12/25, lacked an ABST evaluation completed prior to moving into the facility;
* 11 unsampled residents’ ABSTs were not updated at least quarterly; and
* Review of Resident 2’s ABST revealed multiple ADLs were not accurately capturing care time that staff were providing.

On 06/18/25, the need to ensure residents’ ABST evaluations were completed prior to move-in, updated no less than quarterly, and accurately captured care time staff were providing was reviewed with Staff 14 (Regional Director of Operations). She acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:

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

Refer to deficiencies in this report.

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.

This Rule is not met as evidenced by:

? Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:



Observations of the facility on 04/08/25 and 04/09/25 showed the following areas to be in need of cleaning or repair:



* Multiple carpet stains were noted in the hallways and common areas. The stains varied in size and included white, red and black stains. Carpet stains were noted in the memory care director’s office as well;

* Multiple scuffs, gouges and scratches were noted to the laminate flooring in the dining room. Scratches were several inches in length at the minimum;

* Ceiling lights in the dining room and hallway had numerous dead insects and debris gathered in the light fixtures;

* Strong odors of stale urine and a sour smell were noted in the common area bathroom and the hallways near the entrances to the memory care unit;

* The common area bathroom had brown stains along the base of the toilet and on the nearby tile;

* Spills, scrapes, splatters and debris were noted in/on the drawers, cupboards, walls and windowsills in the dining room. The curtains in the dining room had multiple spills and splatters with black/brown/white discolorations;

* Room 6 had dark carpet stains, missing and/or discolored caulking along the shower edges and around the toilet base;

* Room 21 had missing and/or discolored caulking at the shower edge and at the base of the toilet. Large cracks in the ceiling and at the wall corner were noted. The cracks were pulling apart creating a small gap;

* A dusty vent was located in the common area on the lower wall; and

* Multiple wall corners throughout the facility had chunks of missing plaster.



The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Assistant ED) on 04/09/25. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility on 06/17/25 through 06/18/25 showed the following areas in need of cleaning or repair:

* Multiple carpet stains were noted in the hallways and common area. The stains varied in size and included white and red stains. Carpet stains were noted in the memory care director’s office as well;

* Ceiling lights in the dining room and common area had numerous dead insects and debris gathered in the light fixtures; and

* Room 6 had missing and/or discolored caulking along the shower edges and around the toilet base.

On 06/17/25, the areas in need of cleaning and/or repair were shown to and discussed with Staff 14 (Regional Director of Operations). She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

?Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:



On 04/08/25, observations of the memory care unit showed resident one-bedroom apartments contained wall heaters. The heaters were located where residents could potentially come into incidental contact with them.



The wall heaters located in the bedrooms of the four one-bedroom apartments in the memory care unit were tested on 04/08/25. The surface temperatures exceeded 120 degrees. Staff 1 (Assistant ED) and Staff 3 (Regional Director of Health Services) indicated they would have the heaters disabled.



Staff 1 and Staff 12 (Maintenance) did additional temperature checks with the surveyor on 04/10/25, after new grates were installed. Staff 12 indicated extenders would be put in place to gain another one to two inches between the grate and the wall heater to ensure all temperatures consistently remained under 120 degrees.



The need to ensure all wall heaters and/or grates did not exceed 120 degrees was discussed with Staff 1, 3 and 12 on 4/10/25. The staff acknowledged the findings.

OAR 411-054-0200 (8) Heating and Ventilation

(8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction.
(a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit.
(A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours.
(B) During times of extreme summer heat, fans must be made available when air conditioning is not provided.
(b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside.
(c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit.
(d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to:


Refer to: C295, C350, C513 and C540.

OAR 411-057-0140(2) Administration Compliance

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

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

Refer to C295, C363, and C513.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

? Based on 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: C260, C270 and C330

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

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

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C260.

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

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

This Rule is not met as evidenced by:

?Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 1 of 3 sampled residents (#1) whose records were reviewed. Findings include, but are not limited to:



Resident 1’s service plan dated 03/09/25 and temporary care plans dated 03/09/25 through 04/08/25 were reviewed. The service plan was found to be lacking information and staff instructions related to an individualized nutrition and hydration plan, including preferences and appropriate snack and meal options.



The need to develop an individualized nutrition and hydration plan for each resident and include it in the service plan was reviewed with Staff 1 (Assistant ED), Staff 3 (Regional Director of Health Services) and Staff 4 (Regional RN Consultant) on 04/10/25 at 2:45pm. They acknowledged the findings.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration

(c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 1 of 2 sampled residents (#5) whose records were reviewed. Findings include, but are not limited to:

Resident 5’s service plan dated 05/27/25 and temporary care plans were reviewed. The service plan was found to be lacking information and staff instructions related to an individualized nutrition and hydration plan, including preferences and appropriate snack and meal options.

On 06/18/25, the need to develop an individualized nutrition and hydration plan for each resident and include it in the service plan was reviewed with Staff 14 (Regional Director of Operations). She acknowledged the findings.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration

(c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 08/06/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 08/06/24, conducted 10/10/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen was reviewed on 08/06/24 from 10:55 am through 1:45 pm and the following was identified: a. An accumulation of food spills, splatters, dirt, dust, and/or black matter was visible on or underneath the following: * Cart holding clean plates; * Industrial can opener and housing;* Top of range; * Front and sides of Alto-shaam warmer/steamer; * Vents over the tray-line and between tray-line and dishwashing area; * Wall behind warewasher and near rinse sink; * Top of warewasher; and * Drains in dishwashing area.b. The following areas were in need of repair or replacement: * Toaster on tray-line with worn and peeling front panel and knobs; * Cutting boards on make-line heavily scored and stained; * Muffin pan with significant visible damage and wear; * Plastic carafes which were scored and cloudy; and* Sections of caulking by sink near warewasher cracked/missing or with black debris.c. Multiple cooking items found on the floor including tongs and muffin pan. d. Multiple food items in the fridge and/or freezer were found to be open or not sealed appropriately to protect from potential contamination. e. Kitchen staff were observed to not wash cantaloupe prior to slicing as a ready to eat item to serve to residents. f. One kitchen staff was observed to not have hair restrained as required. g. Thawing protein under running water without the protein fully submerged. The surveyor toured the kitchen areas described above at 1:50 pm with Staff 4 (Dietary Services Manager), and at 2:00 pm with Staff 2 (Assisted Living Director) and Staff 3 (Memory Care Director). The need to ensure food sanitation rules were followed as above was reviewed with Staff 1 (Assistant Executive Director), Staff 2, Staff 3, Staff 4 and Staff 5 (Regional Director of Operations) on 08/06/24 at 2:20 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have policy and procedures in place for exclusion of food service workers when sick or ill with potential or actual contagious food related illness. Findings include, but are not limited by: On 08/06/24, Staff 1 (Assistant Executive Director) was asked to provide policy and procedure for when employee's who prepared food were sick and had illnesses or symptoms that may be related to a potentially contagious pathogen. Staff 1 stated she had spoken with Staff 5 (Regional Director of Operations) who was in the process of attempting to find the information. During the exit interview at 2:20 pm, Staff 5 reported she had not been able to locate the policy yet but would have it shortly. She agreed to email the information to the surveyor by 2:00 pm on 08/07/24. No policy and procedure was conveyed to the surveyor by 2:00 pm on 08/07/24. The need to have infection a prevention policy and procedure was reviewed via phone with Staff 1 at 2:11 pm on 08/07/24. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240 and C295.

The findings of the kitchen inspection, conducted 7/6/23, 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 re-visit to the kitchen inspection survey of 07/06/23, conducted 10/16/23, 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 observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen was conducted on 07/06/23 from 10:10 am through 2:30 pm and the following was noted: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Drains throughout kitchen;* Reach in milk cooler;* Reach in deli cooler;* Walk in cooler and freezer floors;* Plastic racks in freezer;* Ceiling vents;* Interior of Ice Machine;* Interior of microwave;* Blender base;* Industrial can opener;* Large vertical racks stored in Walk in cooler;* Caulking around the perimeter of dish machine and beverage counter;* Janitor closet walls, floors; and* Floors under and in between equipment/corners and edges. b. The following areas were in need of repair: * Robocoupe stand cracked, the base was cracked with an approximate two inch piece missing at the base of the bowl;* Pipe under the dishwasher was leaking;* Hole behind kitchen door entrance with wiring exposed; and* Leak under hand washing sink.c. Tomato slicer, table top mixer were stored uncovered not protected from potential contamination. d. Multiple kitchen staff preparing and/or serving food did not have hair and/or facial hair effectively restrained as required.e. Multiple plastic spatulas were found in poor repair being heavily scored, stained with chunks missing. A black utility cart used to deliver room trays to memory care unit was heat damaged leaving deep gouges and scoring. f. Box containing empty/dirty pop and beer cans were stored in dry storage next to food items. g. Cooked ready to eat salmon found stored directly under raw beef products;At approximately 11:30 am to 12:30 pm, the Memory Care Kitchenette was observed and needed cleaning of the drains under the sink and under the steamtable. The reach in refrigerator was found with black mold like substance on the back of the shelf. The microwave, stove top and oven were found with dried on food debris. There was a layer of dust found on the top of the counter directly over the steam table. The floor was dirty underneath the steam table. A box of juice was found stored on the floor. There were three plates of food sitting on top of the counter without means of keeping food hot. When staff checked the temperature before service it was at 122 degrees F or below. Staff were not aware of the correct temperature food needed to be reheated before service to residents. Staff did not sanitize thermometer before or between temping the food. Staff 3 (Memory Care Administrator) acknowledged the areas of concern. At approximately 2:00 pm, surveyors reviewed above areas with staff 1 (Executive Director) and Staff 2 (Dining services manager) and they acknowledged the identified areas.

Based on observation, record review and interviews it was determined the facility failed to ensure 4 of 25 sampled staff (# 4, 5, 6 and 7) reviewed for food handlers certificates had current cards at the time of survey. Findings include, but are not limited to:On 7/6/23 the facility was asked to provide verification that staff who prepared food had current food handlers cards. Documentation provided by the facility noted Staff 4, 5, 6 and 7 (kitchen staff) did not have food handlers cards. Staff 1 acknowledged the missing documentation.

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.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 01/13/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review it was confirmed the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include: During separate interviews on 01/13/2023, Staff #1-2 (S1 and S2) both stated that they were aware of some staff members not wiping residents when providing assistance with toileting. S2 and S3 stated that they both went through in-service training to properly provide assistance to residents. A review of the in-service training for residents' care centered around toileting shows all staff received re-training on how to provide the correct care. On 01/13/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: In-service for the proper way to provide assistance with toileting was provided to all staff.

The findings of the kitchen inspection, conducted 09/07/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 9/7/22, conducted 12/20/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 09/07/22, the main kitchen for the facility was observed and the following deficiencies were identified: a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:* Walk in freezer floor;* Inside cabinets and under the sink of the beverage station; * Sides and the top of a fryer;* Inside and around a flat top grill; and* Inside and around the oven and stove top.b. The following areas needed repair:* Ice Machine; and* Sandwich and serving cutting boards;c. Ice-cream containers inside a walk-in freezer were uncovered.d. Multiple trash cans were observed uncovered when not in use.On 09/07/22, the areas which required cleaning and repair were observed and discussed with Staff 1 (Assistant Executive Director), Staff 2 (Memory Care Director), and Staff 3 (Dining Services Manager). They acknowledged the findings.

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

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 07/26/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the re-licensure survey, conducted 11/15/21 through 11/17/21, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first revisit to the re-licensure survey of 11/17/21, conducted 02/14/22 through 02/15/22, are documented in this report. It was determined the facility was in substantial compliance with OARS 411 Division 54 for Residential Care and Assisted Living Facilities, OARS 411 Division 57 for Memory Care Communities and OARS 411 Division 004 for Home and Community Based Regulations.

Based on interview and record review, it was determined the facility failed to ensure falls with injury and resident to resident altercations were promptly investigated to rule out abuse and reported to the local SPD office as required for 2 of 3 sampled residents (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in July 2021 with diagnoses including dementia. The resident's service plan dated 09/17/21 and interviews with care staff between 11/15/21 and 11/17/21 indicated the resident could ambulate on his/her own and utilized a walker. The resident was unable to consistently direct his/her own care and had a history of falls. Review of incident investigations and progress notes from 08/27/21 through 11/15/21 showed the following: * A progress note dated 08/27/21 indicated the resident was found on the floor with a large football size bruise to the middle of his/her back. No investigation of the incident was completed. * A progress note dated 10/01/21 indicted the resident was found on the floor in front of his/her room. The resident complained of shoulder pain and was sent to the emergency room for evaluation. No injuries were found. No investigation of the incident was completed. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. The staff acknowledged the findings. The facility reported the incidents to the local SPD office on 11/17/21. Confirmation of the reports were provided prior to survey exit.2. Resident 1 was admitted to the facility in September 2017 with diagnoses including dementia. The resident's service plan dated 10/18/21 and interviews with care staff between 11/15/21 and 11/17/21 indicated the resident was dependent on staff for care, had a recent neck fracture in September and had frequent falls. The resident was unable to consistently direct his/her own care and had a history of falls. Review of incident investigations and progress notes from 08/27/21 through 11/15/21 showed the following: * A progress note dated 10/15/21 indicated the resident was shoved by another resident. There were no injuries noted. The incident was not reported to the local SPD office. * A progress note dated 11/08/21 indicted the resident had a non-injury fall. A large rug burn to the back was found on the resident later the same day. No investigation of the incident was completed. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and reported to the local SPD office as needed, was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. The staff acknowledged the findings. The facility reported the resident to resident altercation to the local SPD office on 11/17/21. Confirmation of the reports were provided prior to survey exit.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:1. On 11/15/21 at 9:30 am, the facility's main kitchen was observed to need cleaning or repair in the following areas:* Floors throughout the kitchen, including dry storage, walk-in refrigerator, freezer and underneath the beverage station had black matter buildup and food debris in corners, around perimeter edges, under equipment, inside floor drains, and in between tile grout;* The juice dispenser had a metal shelf with chipped paint, and rust had developed around the rim where the shelf attached to the machine;* Shelving throughout the kitchen, including the walk-in refrigerator and freezer, and shelving in the dry storage had food spills, splatters, dirt, dust, and debris; * Pipes behind multiple appliances had grease, dirt, and debris on them;* Caulking around the stainless-steel edge of the dishwashing area was black;* Ceiling vents had an accumulation of lint and dust on the grates; and* Chipped paint and black smears on the kitchen doors and frames.The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 2 (Regional Director of Operations) and Staff 8 (ED) on 11/17/21. The findings were acknowledged.2. Observations of the kitchenette located in the memory care unit on 11/15/21 revealed the following areas were in need of cleaning and repair:* The drain underneath the sink had black/brown accumulation and debris and the pipe above the drain had brown matter around the edges of the pipe and hanging down over the drain;* The stove had food debris in the burners, the oven had debris on the bottom of the oven and spills on the door;* The walls in the kitchenette had multiple chips, dings, splatters and spills;* The refrigerator and freezer unit had food debris, spills and splatters to the lower shelf and doors;* The microwave had splatters and spills to the inside of the unit and on the door;* The dry storage area had cobwebs along the corners, food debris under the shelving units, individual dead insects under the shelves and a large pile of dead insects at the inner corner near the door of the storage; and* The wall near the refrigerator had a large hole, approximately 12 inches long and two inches wide with chunks of dry wall hanging within the hole.The areas in need of cleaning and repair were discussed with and shown to Staff 1 (MC Administrator) on 11/15/21. Staff 1 acknowledged the findings and the dead insects were cleaned up right away.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to:During the re-licensure survey conducted 11/15/21 through 11/17/21, there was a lack of scheduled and unscheduled activities provided for residents living in the memory care community.On entrance to the memory care unit on 11/15/21 there was no monthly activity calendar posted and no daily lists indicating what activities were going to be offered throughout the day. A dry erase easel was located in the common area which indicated the date was 11/15/21 and it was health care month. The board remained unchanged for the entirety of the survey.Multiple continuous observations of the memory care unit on day shift and swing shift between 11/15/21 and 11/17/21 showed a lack of group activities provided for the residents. Approximately 6-8 residents were gathered in the common area at one time throughout the day. The residents were observed sitting in the common area both awake and asleep, additional residents were observed wandering the halls back and forth with minimal interaction by staff and the remaining residents were in their apartments asleep in chairs/beds, watching TV or looking out the window. A movie or television show was running on the TV in the common area throughout the day.Staff interviews conducted between 11/15/21 and 11/17/21 revealed the person assigned to activities was new to the position and was only able to work on activities a few days a week because she was frequently pulled to work the floor. The care staff were generally aware they should conduct activities with the residents but indicated there was not enough time and they were not sure what exactly to do. In interview on 11/15/21 and 11/16/21 Staff 1 (MC Administrator) indicated the memory care unit did not have an activity calendar and there was nothing posted or provided to residents. Staff 1 stated the new activity staff worked as strictly activity staff about three days a week with the goal they would be five full days. The staff member was working as a medication technician frequently and Staff 1 was not able to get her full time to activities quite yet. Staff 1 further indicated they had a list of suggested activities to do with the residents, but not an actual plan/calendar in place. The lack of an activity program and calendar was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. Staff 3 indicated the memory care unit should have its own calendar and she would assist Staff 1 to get it in place. Staff 3 further stated the activity staff should not be pulled to work other positions and that would stop immediately. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff and/or was consistently followed by staff for 1 of 2 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in September 2017 with diagnoses including dementia. Observations of the resident and interviews with staff from 11/15/21 to 11/17/21 and review of the service plan dated 10/18/21, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas: * Transfer assistance and the number of staff needed;* Incontinence care and toileting; * Neck brace application and showering and dressing needs related to the brace;* Wheelchair use;* Meal assistance, health shakes and diet texture;* Behaviors related to resident to resident altercations;* Falls and safety interventions including fall mat, scoop mattress, low bed and side rails; and* Bowel tracking, snack tracking and health shakes. The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were followed was discussed with Staff 1 (MC Administrator) and Staff 2 (Regional Director of Operations) on 11/17/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in September 2017 with diagnoses including dementia. Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 11/03/21 included the following orders:* Oxycodone HCL 100 mg/5 ml (30 ml), give 0.25 ml (5 mg) by mouth twice a day; and* Oxycodone HCL 100 mg/5 ml (30 ml), give 0.25 ml (5 mg) by mouth every 30 minutes as needed for pain or shortness of breath.The resident's Controlled Substance Disposition logs and MARS, reviewed from 10/01/21 through 11/15/21 showed the following:* On 10/15/21 three PRN doses of Oxycodone were recorded on the MAR but only two doses were documented on the disposition log;* On 10/16/21 three PRN doses of Oxycodone were recorded on the MAR but only two doses were documented on the disposition log;* On 10/24/21 the disposition log showed a PRN dose of Oxycodone was signed out at 6:30 pm, but the MAR did not reflect the dose as given until 8:22 pm;* On 10/25/21 the disposition log showed a PRN dose of Oxycodone was signed out at 7:30 pm, but the MAR showed the dose was administered at 5:03 pm; and* On 11/10/21 two PRN doses of Oxycodone were signed as given on the MAR, but only one dose was documented on the disposition log. Comparison of the medication bottles to the disposition logs, showed the amount of medication left was reflected accurately on the log. The need to ensure narcotic disposition logs accurately reflected the medications administered and the time they were administered was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physicians orders were available in the residents' records and were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in July 2021 with diagnoses including dementia. The resident's 7/28/21 signed physician orders and 10/01/21 to 11/15/21 MARs showed the following:* An order for Eliquis (blood thinner) 5 mg tablet, take by mouth twice daily.The medication was documented on the MARs. There was no indication the medication was being given and no discontinuation order was located in the resident's record. The need to ensure orders were available in the resident's record for all prescribed medications and were administered as ordered by the prescriber was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. The staff acknowledged the findings and indicated the physician would be contacted for clarification.2. Resident 2 was admitted to the facility in September 2017 with diagnoses including dementia.The resident's 11/03/21 signed physician orders and 10/01/21 to 11/15/21 MARs showed the following:* An order for Oxycodone HCL 100 mg/5 ml (30 ml), give 0.25 ml (5 mg) by mouth twice a day. The order indicated it originated on 10/03/21.The October 2021 MAR showed the medication was given only one time per day, at 1:00 am, until 10/30/21 when the order was changed to reflect an 8:00 am and 8:00 pm administration.* An order for Tylenol 500 mg by mouth every four hours as needed for pain.The Tylenol was not reflected on the 11/01/21 to 11/15/21 MAR.The need to ensure orders were available in the resident's record for all prescribed medications and were administered as ordered by the prescriber was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. The staff acknowledged the findings and indicated the physician would be contacted for clarification.

Based on observation, interview and record review, it was determined the facility failed to ensure a thorough assessment, with all required components was completed by a PT, OT or RN for assistive devices with potentially restraining qualities for 1 of 1 sampled resident (#2) reviewed who had supportive devices. Findings include, but are not limited to:Resident 2 was admitted to the facility in September 2017 with diagnoses including vascular dementia.During the acuity interview on 11/15/21, Staff 15 (RN) identified the resident as having side rails on his/her bed.The resident's most recent service plan dated 10/18/21 contained no information on the use of side rails.An order from hospice dated 11/9/21 indicated the resident "may have side rails for stimulation enhancement (tactile) and (visual), ½ rails."A temporary service plan dated 11/13/21 indicated the resident had an injury fall out of bed, and staff requested a hospital bed from hospice. The temporary service plan indicated the resident may have side rails for stimulation enhancement (tactile) and (visual). An unsigned, supporting device evaluation dated 11/15/21, indicated the reason for use was for stimulation enhancement (tactile and visual). The resident's cognitive awareness of the device and functional ability to use the device stated "stimulation enhancement." Under the section titled Less Restrictive Alternatives Considered, it was documented "Hospice order."Observations of the resident's room on 11/15/21 and of the resident while in bed on 11/16/21, showed two half side rails were attached to the top of the resident's bed. The side rail located on the right side was loose when pulled on and had a small 1-2 inch gap between the rail and mattress.Interviews with staff between 11/15/21 and 11/17/21 showed inconsistent knowledge around the use of the side rails and what staff were to watch for. The staff indicated the side rails were new for the resident and were in place for less than a week, but they were unaware of an exact date. Interviews with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) were conducted on 11/16/21. Staff 1 indicated the side rails had been in place for a short time. They were unaware of the reason for use listed by hospice and listed on the evaluation of "stimulation enhancement." Staff 3 indicated they would take a further look at the hospice order and intent of the side rails. Staff 1 indicated the resident would sometimes yank/pull on the rails and shake them which loosened them. Staff 1 stated she would have maintenance take a look at the rails. The need to complete a thorough assessment of supportive devices with restraining qualities and their appropriateness for use was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. The staff acknowledged the findings.

Based on interview and record review, it was determined 2 of 3 sampled, newly hired direct care staff (#s 4 and 5) failed to complete First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:A review of the facility's training records on 11/16/21 and again on 11/17/21 revealed: Staff 4 (CG) hired on 09/24/21, and Staff 5 (MT/CG) hired on 09/05/21 did not have documentation of first aid and abdominal thrust training completion within the required 30 days of hire.On 11/17/21, the need to ensure First Aid and abdominal thrust training was completed within the required timeframe was discussed with Staff 2 (Regional Director of Operations), Staff 8 (ED) and Staff 15 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety documentation reflected all required fire drill components. Findings include, but are not limited to:Fire drill records were reviewed from April 2021 to October 2021. The following deficiencies were identified:* There was no documented evidence the facility was conducting fire drills every other month on alternating shifts for the memory care community; and * The evacuation/drill documentation did not contain information on the escape route used, problems encountered, evacuation time period needed, staff members on duty and participating in the memory care and the number of occupants evacuated. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Chief Operating Officer) and Staff 13 (Maintenance) on 11/16/21. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:Fire and life safety records, reviewed between April 2021 through October 2021, revealed the facility lacked documented evidence of the following:* Alternate exit routes were used during fire drills; and* Staff interviewed were not aware of the designated point of safety.The need to ensure alternate exit routes were used during fire drills and all staff were aware of the designated point of safety was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director), Staff 3 (Chief Operating Officer) and Staff 13 (Maintenance) on 11/16/21. The staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. Findings include, but are not limited to:Observations of the secure outdoor area on 11/15/21, revealed there were multiple drop-offs of 2-4 inches along pathway edges.The need to ensure pathways were free of safety hazards was discussed with Staff 1 (MC Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/15/21 and 11/16/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:Observations of the facility on 11/15/21 and 11/16/21 showed the following areas in need of cleaning or repair:* Multiple walls, doors and door frames in the dining room and hallways had, scrapes, splatters/drips and chips;* Multiple chairs in the dining room and common area had scrapes, chips and dings to the arms and lower legs and one bench seat had a large tear on the seat;* Window sills in the dining room had large pieces of food debris, dead insects, cobwebs and spills;* The dining room floor had numerous long black streaks, scratches and gouges ranging from a few inches to a few feet in length;* The common area bathroom had a brown substance on the toilet bowel, missing sections of the caulking around the base of the toilet and caulking that was in place was dark brown in color;* Multiple handrails had spills and/or debris inside the ravine between the rail and the wall; and* Two sections of handrail had a brown substance on the top and inner side of the rail. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (MC Administrator) on 11/15/21 and 11/16/21. She acknowledged the findings.

Based on observation and interview, the facility failed to ensure residents who lived in the facility had a key to their units per evaluated need. Findings include, but are not limited to:Observations of the memory care unit on 11/15/21 showed 16 of the 22 resident rooms did not have locking door knobs on their apartments. In an interview on 11/15/21 Staff 1 (MC Administrator) indicated the only rooms with locking door knobs were those residents who could manage a key and could unlock the door on their own. Staff 1 indicated in some cases family may request a lock to help keep other residents out of the room. She was unaware all rooms should have the ability to lock.The need to ensure all resident apartments had locking door knobs, residents were evaluated for their ability to use a key and to ensure a key was provided for those residents who could operate the door lock was discussed with Staff 1, Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 11/16/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C231, C240, C372, C420, C422, C510, C513 and H1518.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly hired staff (#5) completed all required pre-service and competency training prior to providing care and services independently and 1 of 1 sampled direct care staff (#7) completed a total of 16 hours of in-service training annually, including 10 hours related to provisions of care in CBC. Findings include, but are not limited to: Review of the facility's training records on 11/16/21 and 11/17/21 revealed: a. Staff 5 (MT/CG) hired on 09/05/21, lacked documented evidence training and demonstrated competency had been completed for all required components within the first 30 days of hire or before independently providing care and services, for topics including: * Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms; * 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; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; * Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: identify and address pain; provide food and fluid; prevent wandering and elopement; and use a person-centered approach; * Environmental factors that are important to residents well-being (e.g., noise, staff interactions, lighting, room temperature, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident and the resident's service plan; and * The use of supportive devices with restraining qualities in memory care communities. b. Staff 7 (MT) was hired on 2/13/19. Review of the facility training records revealed Staff 7 did not complete the 10 hours of annual training related to provision of care in CBC. The need to ensure newly hired staff completed all required pre-service and competency training prior to providing care and services independently and veteran staff completed a total of 16 hours of in-service training annually, including 10 hours related to provision of care in CBC was discussed with Staff 2 (Regional Director of Operations), Staff 8 (ED) and Staff 15 (RN) on 11/17/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C242, C260, C302, C303 and C340.