Farmington Square Gresham

OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law.

Based on observation and interview, it was determined the facility failed to ensure the required postings were in a routinely accessible and conspicuous location to residents and visitors and were available for inspection at all times. Findings include, but are not limited to: The facility was toured on 03/17/25, and it consisted of five separate and distinct cottages. The following postings were not posted in each of the cottages as required: * Copy of most recent re-licensure survey, including all revisits and POC; * The Ombudsman Notification Poster; * The LGBTQIA2S+ Rights and Protections; and * The LGBTQIA2S+ Nondiscrimination Notice. The need to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.

1. The most recent survey, Ombudsman Notification Poster, Resident Rights including LGBTQIA2S+ Rights and Protections along with the Nondiscrimination Notice, and most recent licensing survey have been posted in the community. 2. The Executive Director will receive additional training on required postings in the community. 3. The Executive Director or Designee will audit postings monthly to verify they are current and posted in the appropriate locations. 4. The Executive Director will be responsible for ensuring compliance.

OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law.

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

Based on observation and interview, it was determined the facility failed to ensure medical and other records were kept confidential. Findings include, but are not limited to: During the relicensure survey from 03/17/25 through 03/20/25 observations were made of a printer and fax machine used to communicate resident health information to and from the facility located in a resident use laundry room. Multiple unsampled resident's confidential information was observed on the fax machine and/or printer during the survey. On 03/17/25, observations of medical and/or other records were left on a counter next to the fax machine while two residents were in the laundry room. The documents were gathered and given to Staff 2 (General Manager) who stated she would discuss the concern with Staff 1 (ED). On 03/19/25 and 03/20/25 additional documents were observed on the printer and/or fax machine throughout each day. The findings were reviewed with Staff 1 and Staff 2 on 03/20/25 at approximately 11:54 am. They acknowledged the findings.

1. The fax machine and copy machine will be relocated to an area that is not accessible to residents. 2. See Number One. 3. Daily until relocation is completed. 4. The Executive Director will be responsible for ensuring compliance.

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

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation and interview, it was determined the facility failed to designate an individual to be the facility’s “Infection Control Specialist”, and to establish and maintain infection preventions and control protocols to provide a safe, sanitary and comfortable environment for 1 of 1 resident (#7), whose records were reviewed. Findings include, but are not limited to: a. In an interview on 03/20/25, Staff 1 (ED) acknowledged the facility did not 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. b. Resident 7 was admitted to the facility in 03/2023 with diagnoses including dementia, aphasia, dysphagia, retention of urine and multiple sclerosis. During the acuity interview on 03/17/24, Resident 7 was reported to require a high degree of care, including a soft mechanical texture diet requiring assistance with meals. During the survey from 03/17/25 through 03/20/25, the surveyor obtained permission and observed the facility staff provide personal care and feeding to Resident 7. The resident was noted to require total care assistance from staff. On multiple instances, direct care staff donned gloves without first performing hand hygiene, did not change single use gloves between tasks, and performed feeding without wearing a protective barrier over clothing to prevent the potential for cross contamination. On 03/17/25 at 12:49 pm, Staff 31 (MT) was observed to drop a tube of prescription cream on the floor, the MT proceeded to pick up and administer the medication to the resident without changing gloves prior to administering the cream. c. On 03/17/25 and 03/18/25 during lunch service, the survey team observed staff transporting meals within Barlow cottage from the kitchenette to residents’ rooms without proper plate covering. Additionally, the survey team observed an uncovered tray of brownies that were taken into a resident’s room. d. Observations of lunch service on 03/18/25 and 03/19/25, revealed multiple direct care staff in Diamond cottage served food and provided direct feeding to residents having donned gloves without first performing hand hygiene and without donning a protective barrier over potentially contaminated clothing. The need to ensure the facility designated an individual to be the facility’s “Infection Control Specialist” and to establish and maintain effective infection prevention and control protocols was reviewed with Staff 1, Staff 2 (General Manager), Staff 4 (RN), Staff 7 (LPN), Staff 8 (Wellness Director), Staff 10 (Wellness Director), and Staff 40 (Operations Specialist) on 03/20/25 at 11:04 am and again at 11:54 am. They acknowledged the findings.

infection control, designated person, handwashing and glove use, covering food, aprons designated person in place, additional training for care staff and dining 1. The community has designated an infection control speciailist. 2. The Dining Services Staff and Direct Care Staff will receive additional training on hand washing, proper plate covering when delivering meals, and wearing aprons when serving meals or assistng residents with direct feeding. 3. The Executive Director will be responsible for ensuring compliance.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

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

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code. Findings include, but are not limited to: Review of fire drill and fire and life safety records for 09/2024 through 02/2025 identified the following: * The facility was not evacuating residents from the simulated fire area; therefore, there was no documentation of: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. * Additionally, the facility failed to document the staff members on duty and participating in the drill in two of the three drills completed. On 03/19/25 at 12:00 pm, Staff 6 (Maintenance Director), confirmed residents were not evacuated or relocated during fire drills. On 03/19/25 at 12:00 pm, the need to ensure fire drills were conducted in accordance with the Oregon Fire Code was discussed with Staff 1 (ED), Staff 2 (General Manager), Staff 3 (Business Office Manager), Staff 6 and Staff 40 (Operations Specialist). They acknowledged the findings.

1. The Community completed a fire drill that included resident evacuation and documentation. 2. The Maintenance Director and Executive Director will receive additional training on the Fire and Life Safety Training and Drills Flowchart and the Fire and Life Safety Ass Staff In-Service & Training Documentation. 3. Completion of Drills and Documentation will be reviewed monthly per the QA - Maintenance Review Schedule. 4. The Executive Director will be responsible for ensuring compliance.

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

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

Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: Review of fire drill and fire and life safety records for 09/2024 through 02/2025 revealed no documented evidence of annual fire safety re-instruction for residents. On 03/19/25 at 12:00 pm, Staff 1 (ED) confirmed the facility did not have a system for re-instructing residents, at least annually, on fire and life safety expectations. On 03/19/25 at 12:00 pm, the need to re-instruct residents, at least annually, on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire per the OFC requirements was discussed with Staff 1, Staff 2 (General Manager), Staff 3 (Business Office Manager), Staff 6 (Maintenance Director) and Staff 40 (Operations Specialist). They acknowledged the findings.

1.The Community will complete the Fire and Life Safety Annual Resident Safety Training for all Residents. 2. The Maintenance Director and Executive Director will receive additional training on Resident Safety Training. 3. Fire and Life Safety Annual Resident Safety Training Documentation will be reviewed annualy per the QA - Maintenance Review Schedule. 4. The Executive Director will be responsible for ensuring compliance.

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

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

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the RCF common use areas, entrance and exit ways were made of hard, smooth material, were accessible and maintained in good repair and all chemicals and other toxic materials were safely stored in a locked storage. Findings include, but are not limited to: During a tour of the facility from 03/17/25 through 03/19/25. The facility consisted of five separate and distinct cottages and the following was identified: a. Three of the cottages had interior courtyards, Astor, Barlow, and Crown. Astor and Barlow had patios attached to some resident rooms. All the courtyards and patios did not have a threshold that was accessible for residents who used wheelchairs or walkers. Additionally, the wooden ramp access to the back courtyard in the Crown cottage was not in good repair. During an interview on 03/18/25 at 1:38 pm, Resident 1 reported s/he had difficulty getting over the front entrance threshold of the Barlow cottage in his/her wheelchair. b. Cleaning chemicals and disinfectants were found unlocked in housekeeping closets in the Astor cottage and Crown memory care cottage. The closets were easily accessible to residents. Upon reinspection on 03/18/25 and 03/19/25, the housekeeping closet was found unlocked in Astor. The need to ensure all exterior pathways and accesses to the RCF common use areas, entrance and exit ways were made of hard, smooth material, were accessible and maintained in good repair and all chemicals and other toxic materials were safely stored in a locked storage was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.

1. Thresholds have been installed on doors to allow residents with wheelchairs or walkers to have access. The housekeeping door handles have been changed to one that automatically locks. 2. The Housekeeping and Direct Care Staff will receive additional training on keeping housekeeping closets locked at all times. 3. Thresholds and self-locking door handles will be reviewed quarterly per the QA - Building Inspection. 4. The Executive Director will be responsible for ensuring compliance.

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

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

Based on observation and interview, it was determined the facility failed to ensure when an electronic code must be entered to use an exit door, it was clearly posted for residents, visitors and staff use and all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 03/17/25. The facility consisted of five separate and distinct cottages, two ALF and three MCC units. The following was identified: a. The main entrance to Barlow, the enhanced ALF, had a code for entry and it was not clearly posted for resident use. During survey, it was identified not all residents knew the code. b. The following areas were in need of repair: * In Astor, the sink in the staff/visitor bathroom was separating from the wall with a large crack present; * In Barlow, the mirror in the resident’s shower room was broken, and the inside laundry room door was lacking trim; * In Crown, the call light cord was missing, and the shower head holder was broken in the resident’s main shower room; and * In Crown, resident room 44, the shower head holder and window blinds were broken; and * In Diamond, the paint was lifting off the wall above the door trim near the common area. The lack of electronic code to an exit door being clearly posted for residents, visitors and staff use and ensuring all interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.

1. The access code posted for Barlow. All Common areas will receive repairs as indicated in the SOD. 2. The Maintenance Director and Executive Director will received additional training on the QA Quarterly Building Inspection. 3. Common areas will be reviewed quarterly per the QA - Building Inspection. 4. The Executive Director will be responsible for ensuring compliance.

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

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

Based on observation and interview, it was determined the facility failed to ensure residents' rights of privacy and dignity for multiple sampled and unsampled residents whose medical information was maintained in the facility. Findings include, but are not limited to: Refer to C 200.

Refer to C 200.

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

OAR411-004-0020(1)(e) Optimize Settings: Independence, Activities (1) Residential and non-residential HCB settings must have all of the following qualities: (e) The setting optimizes, but does not regiment, individual initiative, autonomy, self-direction and independence in making life choices including, but not limited to: daily activities, physical environment, and with whom the individual chooses to interact.

Based on observation and interview, it was determined the facility failed to ensure the setting optimized, but did not regiment, individual initiative, autonomy, self-direction and independence in making life choices for multiple sampled and unsampled residents who resided in the Barlow cottage. Findings include but are not limited to: Refer to C 513a.

Refer to C 513a.

OAR411-004-0020(1)(e) Optimize Settings: Independence, Activities (1) Residential and non-residential HCB settings must have all of the following qualities: (e) The setting optimizes, but does not regiment, individual initiative, autonomy, self-direction and independence in making life choices including, but not limited to: daily activities, physical environment, and with whom the individual chooses to interact.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual.

Based on observation and interview, it was determined the facility failed to ensure the setting was physically accessible to individuals. Findings include, but are not limited to: Refer to C 510a.

Refer to C 510a.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

Based on observation and interview, it was determined the facility failed to ensure each individual resident had privacy in his/her own unit for multiple sampled and unsampled residents who resided in the MCC cottages. Findings include, but are not limited to: During the re-licensure survey, dated 03/17/25 through 03/20/25, the environment was toured and interviews with staff and residents were completed. The following were revealed: a. Multiple residents who resided in the Diamond and Emerald cottages shared an apartment. The bathrooms in the shared apartments were observed to lack a locking mechanism that would ensure privacy to the resident in his/her own unit. On 03/19/25 at 10:00 am, Staff 40 (Operations Specialist) confirmed the bathroom doors of shared units did not have the ability to be locked. b. The doors of resident apartments in the Crown, Diamond, and Emerald cottages were observed to have lever-type handles. These handles had a keyed locking mechanism on the exterior of the door; however, the interior handle had no mechanism that would allow a resident to lock the door from inside the room to ensure privacy. On 03/20/25, Staff 14 (MT/CG), Staff 20 (CG), and Staff 21 (MT) confirmed the doors in Crown, Diamond, and Emerald cannot be locked from the inside. The need to ensure residents were provided with individual privacy in their own unit was discussed with Staff 1 (ED), Staff 2 (General Manager), Staff 4 (RN), Staff 7 (LPN), Staff 8 (Wellness Director), and Staff 40 on 03/20/25 at 11:18 am. They acknowledged the findings.

1. The door handles on the bathrooms of shared suites have been changed replaced with handles that have a locking mechanism. 2. The Executive Director and Maintenance Director will receive additional training on handles with locking mechanisms to ensure provacy to the resident. 3. Door hanles will be reviewed quarterly per the QA - Quarterly Building Inspection. 4. The Executive Director will be responsible for ensuring compliance.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Based on interview and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access their unit for multiple sampled and unsampled residents. Findings include, but are not limited to: During the re-licensure survey, dated 03/17/25 through 03/20/25, resident service plans were reviewed and interviews with residents, family members, and staff were completed. Interviews with Resident 2 and 7 confirmed they were not provided keys to their apartments. Follow-up interviews with Resident 2 and 5’s family members confirmed no key was provided to the resident or the resident’s family. On 03/20/25 at 8:38 am, Resident 2 stated s/he wanted a key for his/her apartment. The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1, Staff 2 (General Manager), Staff 4 (RN), Staff 7 (LPN), Staff 8 (Wellness Director), and Staff 40 (Operations Specialist) on 03/20/25 at 11:18 am. They acknowledged the findings.

1. door handles in the Memory Care will be replaced with handles that have a locking mechanism. Each Resident or Responsible Party will receive a key to the apartment and the service plan will be updated. 2. The Executive Director will receive additional training on providing a key at time of move-in for all residents and documenting on the service plan. 3. The key status will be reviewed with each routine service plan update. 4. The Executive Director will be responsible for ensuring compliance.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted.

Based on observation and interview, the facility failed to post the LGBTQIA2S+ Rights and Protections and the LGBTQIA2S+ Nondiscrimination Notice. Findings include, but are not limited to: Refer to C152

Refer to C 152.

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted.

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

Based on observation, interview, and record review it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 152, C 200, C 295, C 420, C 422, C 510, C 513.

Refer to C152, C 200, C 295, C 420, C 422, C 510, C513.

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

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room.

Based on observation and interview, it was determined the facility failed to ensure residents who resided in the memory care cottages had individually identified residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to: The facility’s three memory care cottages, Crown, Diamond and Emerald were toured on 03/17/25. Multiple resident rooms in each cottage lacked any individualized identification to assist residents in recognizing their room. On 3/17/25 at 11:40 am, an unsampled resident was observed going into multiple resident rooms and was asking caregivers where his/her room was. Upon further observation, the resident’s room lacked an individual identifier to assist the resident in recognizing his/her room. The need to ensure each resident room was individually identified to assist residents in recognizing their room was discussed with Staff 1 (ED), Staff 2 (General Manager) and Staff 40 (Operations Specialist) on 03/18/25 at 10:00 am. They acknowledged the findings.

1. All memory care apartments now have an individual identifier to assist the resident with recognizing his/her apartment. 2. The Executive Director and Life Enrichment Director will receive additional training on individual identifiers for each memory care resident. 3. Individual Identifiers will be reviewed upon move-in and quarterly per the QA - Quarterly Building Inspection. 4. The Executive Director will be responsible for ensuring compliance.

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room.

Based on interview and record review, conducted during a site visit on 02/20/25, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled Resident (# 4) was substantiated. Findings include, but are not limited to: Resident 4's service plan, dated 02/01/24, indicated Resident 4 required one to two medication passes per day and the facility was responsible for the service. Resident 4's Incident Report, dated 04/16/24 indicated Resident 4 was administered Resident 3's morning medications. Resident 4's Progress notes, dated 04/01/24 through 04/30/24, indicated s/he was placed on alert charting for the medication error and did not have an adverse reaction to the incorrect medication. The facility's self-report, dated 04/16/24, indicated Resident 4 had received his/her roommate's morning medications by mistake. Staff 1 (Executive Director) stated s/he recalled the medication error and Resident 4 received his/her roommate's medication by accident. Staff 1 further stated the staff member who administered the incorrect medication no longer works at the facility. Resident 4 was no longer in the building and could not be observed or interviewed. It was determined the facility's failure to carry out medication and treatment orders as prescribed for Resident 4. The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (General Manager).   The facility's plan of correction: The facility provided the staff member additional training on proper medication administration and how to avoid medication errors in the future. The staff member who administered the incorrect medication no longer works at the facility. Based on interview and record review, conducted during a site visit on 02/20/25, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 1) was substantiated. Findings include, but are not limited to: Resident 1's service plan, dated 06/30/24, indicated Resident 1 required three to four medication passes per day and the facility was responsible for the service. The facility's self-report, dated 07/09/24, indicated Resident 1 received his/her roommate's medications. Resident 1's primary care physician ordered Resident 1 to be sent to the hospital for monitoring. Resident 1's progress notes, dated 07/01/24 through 07/31/24, indicated Resident 1 was put on alert charting to monitor for any adverse reactions due to the medication error after s/he returned from the hospital. Staff 2 (Regional Manager) stated s/he was the former Executive Director of this facility and remembered the medication error with Resident 1. A staff member had given Resident 1 his/her roommate's medications. It was determined the facility's failure to carry out medication and treatment orders as prescribed for Resident 1 was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2.   The facility's plan of correction: The facility provided the staff member additional training on proper medication administration. The facility implemented for staff to take the resident's medication box with them when administering medications. The medication box has a photo of the resident on it. If the resident does not have a photo uploaded to their system, staff are not allowed to pre-pop or pour a resident's medication and must pop it right after verifying the resident's identity and administer the medication.

Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled Residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager).

Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager). Based on observation, interview, and record review, conducted during a site visit on 02/20/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 6 of 9 sampled Residents (#s 7, 8, 9, 10, 11, and 12). The facility utilized the ODHS ABST and had a census of 82. Five out of 82 residents (Residents 7, 8, 9, 10, and 11) were not updated in the ABST as outlined in OAR, and Resident 12 was missing from the tool. Staff 1 (Executive Director) stated s/he was responsible for updating the ABST and oversaw the facility's staffing plan. When staffing shortages happened, the facility's Wellness Directors assisted with care needs on the floor. Staff 1 further stated Resident 12 resided in the building. The facility's posted staffing schedule indicated on day shift, there were five Med Techs (MTs) and eight and ½ Caregivers (CGs) scheduled, on evening shift, there were five MTs and six CGs scheduled, and on night shift, five MTs and two CGs scheduled. On 02/20/25, there were 14 direct care staff observed working the floor on day shift. The facility's staff schedule, dated 02/01/25 through 02/28/25, indicated during 02/14/25 through 02/20/25, the facility was staffed to their posted staffing plan 100% of the time. On 02/20/25, resident needs were observed to be met. It was determined the facility's failure to fully implement and update an ABST was substantiated for Residents 7, 8, 9, 10, 11, and 12. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (General Manager).

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 02/20/25.  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 living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health HS: Hours of sleep LPN: Licensed Practical Nurse MT:            Medication Technician or Med Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse SP: Service plan SPT: Service Planning Team TAR: Treatment Administration Record

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

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 01/15/25 at 10:30 am, the facility kitchenettes (Astor, Barlow, ,Crown and, Diamond) dishwashers were observed with Staff 1 (Director of Dining Services) and it was determined the facility did not have a system in place to check the temperatures and chlorine levels routinely to ensure appropriate temperatures and chlorine levels. Surveyor and Staff 1 checked temperatures in each kitchenette, all met minimum temperature of 120 degrees, except in Crown (90 to 115 degrees). Chlorine levels were also checked in each kitchenette, all met minimum levels. The areas of concern were observed and discussed with Staff 1 and discussed with Staff 2 (Executive Director) and Staff 3 (Regional Director of Operations) on 01/15/25. The findings were acknowledged.

1. The dishmachine temperatures have been obtained and corrected as needed. 2. The Dining Services Staff and Dining Services Director will receive additional training on obtaining and documenting temperatures daily. The Dish Machine Temp & PPM Log will be placed in each kitchenette (Astor, Barlow, Crown, Diamond). 3. The Dining Services Director will review weekly per the QA - Storage and Sanitation Audit. 4. The Executive Director will be responsible for ensuring compliance.

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

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

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

Refer to C 240.

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

Based on interview and record review, conducted during a site visit on 01/02/24, it was confirmed that the facility failed to ensure that prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training for 3 of 3 sampled staff (#4, 5 & 6) staff whose training records were reviewed. Findings include, but are not limited to the following: In an interview on 01/02/24, Staff 1 (Administrator) stated staff complete dementia training as part of the facility's orientation program and the facility uses a Memory Care Orientation and Training Checklist. A review of Staff 4 (Med Tech), Staff 5 (Med Tech) and Staff 6s' (Caregiver) training records indicated 1 of 3 (# 6) staff did not have a completed Memory Care Orientation and Training Checklists. Training records for 3 of 3 staff lacked training in the following areas: * 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; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and * Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: · Identify and address pain; · Provide food and fluids; · Prevent wandering and elopement; and · Use a person-centered approach. In an email correspondence on 01/11/24, Staff 1 stated the facility primarily uses Relias for pre-orientation memory care training and the checklist is done in addition to the online training. The facility failed to ensure that prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 2 (Life Enrichment Director). Facility Verbal Plan of Correction: Administrator and life enrichment director will complete an audit of staff training records to determine if other staff are missing pre-service dementia training and review OAR to ensure staff and facility is complying with pre-service training requirements.

Based on observation and interview, conducted during a site visit on 01/02/24, it was confirmed the facility failed to have a secured janitor closet for storing supplies and equipment; and have the capacity for locked storage of chemicals and equipment. Findings include, but are not limited to the following: In a walkthrough of Emerald house at 11:05 am on 01/02/24, the laundry room  'Out' door was observed to be partially ajar. Laundry detergent, laundry chemicals and cleaning chemicals were observed in the unlocked laundry room. In a walkthrough of Astor house at 1:39 pm on 01/02/24, the housekeeping closet was observed to be unlocked with a housekeeping cart and multiple chemicals present. At 1:41 pm, the laundry room was observed to be unlocked with laundry detergent and chemicals present. In an interview on 01/02/24, Staff 7 (med tech) stated the laundry room door lock in Emerald house is broken and maintenance is supposed to come fix it. S/he stated chemicals that staff use for cleaning get stored in the janitors closed which is locked. The facility failed to have a secured janitor closet for storing supplies and equipment; and have the capacity for locked storage of chemicals and equipment. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 2 (Life Enrichment Director). Facility Verbal Plan of Correction: The administrator will ensure maintenance fixes the broken lock on the laundry room door by the end of the day and they will have an in service to ensure staff know to keep chemical storage locked.

Based on observation, interview, and record review, it was determined the facility failed to ensure proper food preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility kitchen was toured on 10/02/23, observations of the five facility kitchens, including food storage areas, food preparation, food service, and interviews with staff were conducted during the annual kitchen inspection. a. Emerald House, the main kitchen, was toured at 10:05 am and identified the following: * The exit door to the outside was fully opened, without a screen and allowed for the entry of pests; * Multiple trash cans lacked covers; * Air conditioning unit mounted above the ware washing area had brown splatters and debris buildup; * Ice machine interior lid and air vents had a buildup of debris; * The dry food storage area had less than a week supply of dry goods; * Interviews with multiple staff identified on multiple days throughout the week the kitchen doesn't have the ingredients to prepare and serve what was on the menu; * Interviews with staff also identified that there had been times that the kitchen didn't provide a written menu for residents; * Interior shelf walls of the steam table and prep table had a large area of brown matter; * Bottom shelf of the stainless-steel table to the right of the grill was covered in black matter and had a five gallon bucket of used food grease that had not been discarded; * Buildup of food debris and grease behind and underneath the stovetop, oven and grill; * Food splatter and debris buildup on the conveyor toaster and microwave; * Drawer underneath the toaster and drink counter had dirty serving utensils and debris that had fallen into the drawer; * Disposable food containers stored on the prep counter contained food splatter on them; * Drains beneath bakery table and underneath the sink next to bakery table had a buildup of food waste; * The walk-in freezer had food and debris on the floor; * The exhaust fan cage blowing into the walk-in refrigerator had dust and debris; * The walk-in refrigerator had multiple leftover food items that were beyond the discard date and continued to be stored on the refrigerator shelves; * Ready to eat meat products were improperly stored and shelved with produce and on the upper shelves; * Meat was wrapped in clear wrap or covered with parchment paper without a label or date; * Under counter reach-in Continental refrigerator had multiple food items that were uncovered, unlabeled and not dated; * Staff lacked knowledge of how to use sanitation test strips; * Staff lacked good infection control related to use of aprons, hair restraints and hand hygiene between dirty and clean tasks; * Multiple staff interviewed lacked knowledge of signs and symptoms of foodborne illness, transmission and prevention of foodborne illnesses including cross contamination and safe food handling processes; * Staff failed to take food temperatures for all food prior to transporting the food to the warmer for hot holding; and * Staff failed to ensure serving carts were clean and disinfected prior to placing plates and glasses for meal service to the dining room. b. Crown House kitchenette was toured at 12:05 pm and identified the following: * Splatters, spills, debris, drips were noted on the inside and outside of the microwave and toaster; * Staff were not using sanitation test strips for the stationary rack dishwasher; * The upright refrigerator was missing the temperature gauge; and * All staff failed to have verification of a valid Oregon Food Handler card. c. Barlow House kitchenette was toured at approximately 12:26 pm and identified the following: * Splatters, spills, debris, drips were noted on the inside and outside of the microwave and toaster; * The drain and surrounding floor under the single compartment sink had black/brown matter; * Drain underneath the two-compartment sink had a buildup of debris; * Floors throughout the kitchen was visibly soiled with dirt buildup, grass clippings, leaves and food debris; and * The backsplash by the two-compartment sink was pulling away from the wall. * Shelving used to store clean dishes had chipped laminate and was an unclean surface; and * Gouges on cupboard doors rendering the surface uncleanable. d. Diamond House kitchenette was toured at 12:37 pm and identified the following: * Splatters, spills, debris noted on the toaster, interior /exterior of the microwave and drain under the three compartment sink; * Multiple ceiling vents had buildup dust and debris; * Multiple leftover food items were not dated or labeled in the upright refrigerator; * Staff lacked knowledge and proper use of the three-compartment sink for sanitation of dishes; * There was inoperable stainless-steel reach in refrigerator left discarded in the back of the kitchen; and * All staff failed to have verification of a valid Oregon Food Handler card. e. Astor House kitchenette was toured at approximately 12:56 pm and the following was identified: * The upright refrigerator was missing the temperature gauge; * There was a two-inch hole in the floor near the center island prep table; * There was no soap dispenser for hand hygiene; * There were no sanitation test strips for the stationary rack dishwasher; and * There were splatters and food debris on the interior and exterior of the microwave and toaster. The above findings were discussed with Staff 1 (Administrator) and Staff 2 (Dining Services Director) on 10/02/23 at 1:10 pm. They acknowledged the findings.

1. Each kitchen will receive a deep clean. The sink, shelving, and cabinets in Barlow will be repaired. An audit will be completed to ensure all applicible employees have a Food Handlers Card on file. 2. The Dining Services Director will receive additional training on Menu creation using the contracted platform and developing the shopping list from the menu. The Dining Services Director, Cooks, and Dining Services Aides will receive additional trainng on infection control, handwahing, signs and symptoms of foodborne illness, food temperatures, and use of test strips for kitchen equipment. 3. The Dining Services Director will review all areas weekly per the Dining Services - Quality Assurance Review Schedule. 4. The Executive Director will be responsible for ensuring compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the five facility kitchens, including food storage areas and food preparation on 12/06/23 revealed: 1. Emerald House, the facility's main kitchen, was toured at 1:37 pm. a. An accumulation of food spills, splatters, loose food debris, grease, dirt, dust and garbage was observed on, in or underneath the following: * Heated serving carts; * Ice machine vents; * Interior ice machine mechanism had black matter; * Shelving below the steam table and the prep table; * Stove; * Grill; * Oven; * Microwave; * Drawer underneath the toaster; * Exhaust fan cage in the walk-in refrigerator; and * Drains throughout the kitchen. b. Observations of the walk-in refrigerator, reach-in refrigerator and dry pantry revealed the following foods were not covered, dated, and/or labeled appropriately: * Rice; * Gelatin dessert; * Liquid egg; * Low fat cottage cheese; * Unidentified sauces; * Salsa; and * Creamy dressing. c. Staff were observed not testing newly mixed sanitation solution prior to use. d. Staff lacked good infection control related to the use of beard restraints, hand hygiene between dirty and clean tasks, and glove use. 2. Diamond House kitchenette was toured at 2:57 pm. The following was revealed: * The microwave had food splatter. The interior surfaces of the microwave were peeling which resulted in an uncleanable surface; * An open gallon of milk was not dated; and * A frayed rag was in the freezer. 3. Astor House kitchenette was toured at 3:03 pm. The following was revealed: * The microwave had food splatter. The interior surfaces of the microwave were peeling which resulted in an uncleanable surface; and * An open container of half and half was beyond the discard date. 4. Barlow House kitchenette was toured at 3:10 pm. The following was revealed: Splatters, spills, debris and drips were noted on the inside and outside of the microwave and toaster. 5. Crown House kitchenette was toured at 3:22 pm. The following was revealed: Splatters, spills, debris and drips were noted on the inside and outside of the microwave and toaster. The primary kitchen and kitchenettes were toured with Staff 4 (Dining Services Director) on 12/06/23, he acknowledged the findings. Photographs and a discussion of findings occurred with Staff 1 (ED) on 12/06/23 at 3:53 pm and was finalized at 4:24 pm. She acknowledged the findings.

1. The identified areas will receive a deep cleaning, the cleaning schedule will be updated and customized per individual cottage kitchen,the microwave in Astor and Diamond will be replaced. 2. Dining Services staff will receive additional training on the Cleaning Schedule, Dating and Labeling Food, Hand Hygiene, Glove use, Proper use of Beard Restraints, and Proper use of Sanitization Solution including testing prior to use. 3. Review will be completed weekly per the QA - Dining Services Review Schedule. 4. The Executive Director will be responsible to ensure compliance

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

Refer to C240

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

Refer to C240

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

Refer to C240

The findings of the kitchen inspection, conducted 10/02/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection survey of 10/02/23, conducted 12/06/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 10/02/23, conducted 01/24/24, 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 interview and record review, conducted during a site visit on 01/02/24, it was confirmed the facility failed to carry out medication orders as prescribed for 2 of 2 sampled residents (#'s 3 and 7). Findings include the following: a. A review of Resident 3's MAR from April 2022 and his/her physician orders dated 01/02/24 which indicated resident was not administered Metoprolol 25 mg from 04/15/22 - 04/20/22 due to the medication not being available. From 04/04/22 - 04/06/22 resident did not receive Tamsulosin 0.4 mg due to medication not being available. In an interview on 01/02/24, Staff 1 (Executive Director) there had been issues with getting Resident 3's medications ordered and delivered timely years ago, but it has since been resolved. b. A review of Resident 7's MAR from May 2022 and his/her physician orders dated 05/31/22 indicated multiple medications not documented on from 05/07/22 - 05/08/22 with no indication if medications were given or not. The facility failed to carry out medication orders as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 01/02/24. Facility Verbal Plan of Correction: The Executive Director had already taken steps to correct medication ordering issues with Resident 3, Resident 7 was no longer a resident.

Based on observation, interview and record review, conducted during a site visit on 09/21/23 and 09/22/23, it was confirmed the facility failed to ensure implementation of services for 1 of 1 sampled resident (# 6). Findings include, but are not limited to: On 09/21/23, Resident 6's room was observed resident recliner seat contained dark-brown staining. Resident 6's service plan, dated 09/05/23, indicated s/he required total assistance for toileting three to four times per day and housekeeping to be done two times weekly. Resident 6's service plan also indicated resident was a 2-person transfer with gait belt and s/he requires total assistance at all meals and adaptive utensils. During an interview on 09/22/23, Staff 8 (Housekeeping) stated housekeeping had not been done in  "Emerald"  house in at least a week, and s/he will find used incontinence briefs under resident beds or furniture. During an interview on 09/22/23, Staff 9 (Caregiver) stated  how s/he and Staff 10 (Caregiver) transferred Resident 6 into his/her wheelchair. S/he stated each staff placed a hand in each armpit to lift resident out of bed. On 09/22/23 at 11:14 am, two staff were observed to enter resident 6's room, incontinence care was performed and resident was dressed and transferred into his/her wheelchair without the use of a gait belt. On 09/22/23 Resident 6 was observed in the dining room at 11:52 am with a plate of food and no adaptive utensils and no staff present providing assistance. On 09/22/23 at 12:13 pm Staff 9 was observed providing feeding assistance to Resident 6. It was determined the facility failed to ensure implementation of services. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) on 09/22/23. Verbal plan of correction: Staff 1 will review Resident 6's evaluation as s/he is a new admit to the facility and his/her initial assessment may no longer be accurate to his/her current care needs. Staff 1 will follow-up with staff regarding use of gait belt and ensure his/her service plan is updated and reflective of resident's needs. Based on interview and record review, conducted during a site visit on 09/21/23 and 09/22/23, it was confirmed the facility failed to ensure implementation of services for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: Resident 2's service plan, dated 09/14/23, indicated s/he required total assistance for showers 3-4 times per week, and standby to total assistance for dressing. During an interview on 09/22/23, Staff 3 (Med Tech) stated Resident 2 was scheduled for and received showers two times per week. During an interview on 09/22/23, Staff 1 (Executive Director) stated Resident 2 should get two showers per week but is service planned for up to four a week if s/he asked for them. On 09/22/23 staff were observed to assist Resident 2 with his/her shower. When staff assisted Resident 2 to the dining room after his/her shower, s/he was observed to be in the same clothing that s/he was wearing prior to his/her shower. It was determined the facility failed to ensure implementation of services for bathing and dressing. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 09/22/23. Verbal plan of correction: Staff 1 would adjust Resident 2's service plan to accurately reflect the services Resident 2 received and would work with the family to ensure changes were acceptable.

The findings of the on-site investigation, conducted 09/21/23 through 09/22/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on observation, interview and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the five facility kitchens, including food storage areas, food preparation, and food service, on 08/08/22 revealed: a. Emerald House, the main kitchen, was toured at 9:45 am: * The walk-in freezer had food and debris on the floor; * The walk-in refrigerator had metal storage racks that were covered in areas with a white residue; * The exhaust fan cage blowing into the walk-in refrigerator had dust and debris; * A bowl of pasta dated 07/06/22 continued to be stored on the shelf instead of being discarded; * Meat was wrapped in clear wrap without a label or date; and * Scoops were left in the dry goods bins, which included flour, sugar, polenta and oats. b. Diamond House kitchenette was toured at 10:08 am: * Splatters, spills, debris, drips and items not dated or labeled were noted: - On shelving below the hand washing sink; - On shelving in the refrigerator; - A container of rice was not labeled or dated; - A container of white substance was not dated or labeled; - Breakfast plates including eggs, toast and bacon were observed on the counter; - The front of the oven; and - Food debris in the drawer under the microwave. c. Barlow House kitchenette was toured at approximately 10:15 am: * Splatters, spills, debris, drips and items not dated or labeled were noted in the following areas: - Cupboards and shelves with food crumbs; - The drain and surrounding floor under the sink had black/brown matter; - Shelving used to store clean dishes had chipped laminate and was an unclean surface; - Broken cupboard doors; - Shelving in the refrigerator had dried food debris; and - There was uncovered, unlabeled food in the drawers of the refrigerator. d. Crown House kitchenette was toured at 10:30 am: * Splatters, spills, debris, drips and items not dated or labeled were noted in the following areas: - The island used to prep and store food had dried food residue and was sticky to the touch; - Drawers and cupboards throughout the kitchenette had food spills and dried liquid and were sticky to the touch; - Shelving in the refrigerator; - There was a broken cupboard and drawer; - The drain and surrounding floor under the sink had black/brown matter; and - The flooring throughout the kitchen had cracks in the linoleum and created a non-cleanable surface. e. Astor House kitchenette was toured at approximately 10:45 am: * The flooring and drain under the sink had black/brown matter; and * Cupboards and shelving that stored clean dishes and silverware had dried food debris. The Emerald, Diamond and Barlow kitchens were toured with Staff 1 (Administrator) on 08/08/22 at 11:10 am, who verified the findings.  The Crown and Astor House kitchens were discussed with Staff 1 at 11:15 am.  Staff 1 stated she was in the process of hiring a dietary manager.

1. The kitchens and equipment will receive a deep clean, and repairs completed as necessary. 2. The Dining Services staff will receive additional training on  the kitchen Cleaning Schedule policy and procedure as well as the Food, Supplies and Equipment Storage policy and procedure. 3. The Dining Services Director will review this area weekly per the Quality Assurance - Dining Review Schedule. 4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

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

Refer to C 240.

The findings of the kitchen inspection, conducted 08/08/22, 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 first revisit to the kitchen inspection survey of 08/08/22, conducted 12/29/22, 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 and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview and record review, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors, available for inspection and accurate. Findings include, but are not limited to: A tour of the facility conducted on 10/28/21 identified the following: * The most recent survey with plan of correction was not posted and available for view; * There was no posting of the facility staffing plan; and * The designee in charge had not been posted to reflect who was in charge. The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 10/29/21. They acknowledged the findings.

1.  The most recent survey with plan of correction is available for view and a sign has been posted to guide to the location.  The facility staffing plan has been posted in each house.  The designeee in charge, upon Administrator absence, has been posted. 2.  The Executive Director and Assistant Executive Director received additional training on the Quality Assurance Master Review Schedule; Survey Compliance, that address this rule. 3.  The Executive Director will review this area monthly per the Quality Assurance Master Review Schedule to ensure correction. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to document evidence of an immediate investigation which reasonably concluded resident incidents were not the result of abuse or neglect and included an administrator's review for 1 of 1 sampled resident (#5) with unwitnessed falls. Findings include, but are not limited to: Resident 5 was admitted to the memory care unit in 2019 with diagnoses including dementia and had multiple unwitnessed falls. During an interview with Staff 5 (Wellness Director) s/he stated Resident 5 was dependent on staff for most ADL care and required assistance of at least one person for transfers. A review of Resident 5's incident reports and progress notes dated 07/28/21 through 10/26/21 revealed s/he had 19 unwitnessed falls. The incident reports did not contain the dates or the names of the person(s) completing the reports, or a way to verify when the investigations had been completed in order to immediately rule out abuse and neglect. The reports also lacked verification the incidents had been reviewed by the Administrator. During an interview with Staff 1 (Administrator) on 10/28/21, the process for reporting and investigating incidents was discussed. Staff 1 verified the incident reports did not include documentation of the dates and names of persons who completed the investigations as well as the date and review of the Administrator. The need to ensure investigations contained the required documentation was discussed with Staff 1 and Staff 2 (Operations Specialist) on 10/28/21. They acknowledged the findings and Staff 1 stated the electronic system would be modified to show the dates and signatures of those involved in performing investigations.

1.  The community electronic system has been modified to show dates and signatures of the person involved in completing the investigation and the date, signature and review of the Administrator. 2. The electronic system has been tested to ensure dates and signatures are captured appropriately to address this rule. 3. The Executive Director will review incident reports daily per the Quality Assurance Master Review Schedule; Daily Stand Up to ensure correction. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs, provided instructions for staff as to what, when and how services would be provided and were followed for 2 of 6 sampled residents (#s 5 and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the memory care in 2019 with diagnoses including normal pressure hydrocephalus and dementia. During observations and interviews on 10/28/21, caregivers reported Resident 5 needed help with most ADL care, experienced multiple falls, had a catheter, was able to feed him/herself and was receiving Hospice support services. The service plan, dated 10/25/21, and ISP's (Interim Service Plan) were reviewed and were not reflective of the resident's needs in the following areas: * Level of assistance needed for grooming; * Ability to manage glasses; * Recent, gradual weight loss; * Current activity plan; and * Attending meals in the dining room versus in bed. The service plan did not provide clear direction to staff in the following areas: * Fall interventions to follow to prevent falls; * Level of transfer assistance needed; and * Use of side rails and call system. The need for service plans to be reflective of resident's needs and provide clear direction for staff to follow was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 10/29/21. They acknowledged the findings. 2. Resident 7 was admitted to the memory care in May 2021 with diagnoses including Alzheimer's disease with late onset and chronic lower back pain. Observations of the resident, interviews with the resident and staff, review of the service plan, dated 08/30/21, and interim service plans (ISP's) showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff, did not provide clear direction to staff, and was not accurate in the following areas: * Daily weights and use of Ted hose were not accurate; * Weight loss interventions, meal assistance due to weight loss, and chronic pain management, including non-pharmacological interventions for pain lacked clear instructions to staff; and * Meal monitoring was not consistently followed. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and was followed was discussed with Staff 1 (Administrator) and Staff 2 (Operation Specialist) on 11/01/21. They acknowledged the findings.

1. The Service Plan for resident #5 and #7 have been updated and remaining resident's service plan will be reviewed to ensure each service plan is refective of resident needs and provides clear instruction to staff. 2.  The Executive Director, Assistant Executive Director  and the Wellness team (Wellness Directors and Wellness LN's), received additional training on the Service Plan policy and procedure and the Service Plan guide that address this rule. All staff will receive additional training on delivery of service. 3.  The Executive Director and Wellness Team will review this area weekly per their individual Quality Assurance Review Schedules; Service Planning, to ensure correction. 4.  The Executive Director will ensure the corrections are completed and monitored.

2. Resident 5 was admitted to the facility in 2019 with diagnoses including normal pressure hydrocephalus and dementia. Progress notes, dated 07/27/21 through 10/27/21 noted the resident experienced changes of condition as follows: Resident 5 experienced 19 falls between 07/28/21 and 10/26/21. Most of the falls were unwitnessed and the resident did not sustain any injuries as a result of the falls. Interim service plans and incident reports for the falls were reviewed along with the service plan completed on 10/25/21. Incident reports identified interventions to be tried, however, these interventions were not consistently added to the service plan or communicated to staff. The records lacked evidence that interventions were monitored for effectiveness to try an reduce the re-occurrence of falls. The need to monitor changes of condition, identify and communicate interventions and monitor the interventions for effectiveness was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist). They acknowledged the findings. Staff 1 modified the service plan form in the electronic system to include current interventions.

Based on observation, interview and record review, it was determined the facility failed to evaluate changes of condition, monitor according to evaluated needs, and identify and implement interventions for 2 of 4 sampled residents (#s 5 and 7) reviewed for changes of condition including weight loss, falls and pain. Resident 7 experienced ongoing pain and severe weight loss. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in May 2021 with diagnoses including Alzheimer's disease and chronic lower back pain. During the entrance conference, on 10/27/21, staff indicated Resident 7 needed cueing to eat. a. Observations, interviews with staff, and a review of the service plans and interim service plans were conducted during the survey. A review of Resident 7's weight records revealed the following: * Resident's initial weight after move-in, 05/27/21, was 141 lbs; * On 06/29/21 resident weighed 128.2 pounds, which constituted a severe weight loss of 12.8 lbs. or 9.08 % of his/her total body weight. The following additional weights were recorded as follows: * 07/15/21: 126.01 lbs.; * 07/21/21: 124.8 lbs.; * 07/28/21: 123.8 lbs.; * 08/3/21: 122.8 lbs.; * 08/11/21: 123.6 lbs.; * 08/18/21: 120.7 lbs.; * 08/25/21: 121.4 lbs.; * 09/1/21: 119 lbs.; * 09/8/21: 117 lbs.; * 09/15/21: 119 lbs.; * 09/22/21: 118.2 lbs.; * 09/28/21: 114.6 lbs.; * 10/5/21: 120 lbs. (progress note, 10/6/21, documented this was an inaccurate weight); * 10/13/21: 115.6 lbs.; and * 10/20/21: 113.8 lbs. Resident 7's initial service plan, dated 05/21/21, noted the resident had a history of weight loss which included a 14-pound loss within two months prior to admission. The initial service plan lacked weight loss interventions. Resident 7's current service plan dated 8/30/21 and interim service plans included the following instructions and/or information for staff: * 07/15/21 offer to reheat food, remake the meal or offer an alternative; * 07/19/21 document weight and meal monitoring on MAR; * 07/19/21 encourage resident to come out of room, utilize weight day during the week to do this, offer nutritional supplements, offer alternatives or have family bring in food; * 07/21/21 offer pudding, peanut butter and jelly sandwich, Jello, chicken or veggie soup; * 07/28/21 continue to offer meals and snacks, monitor intake; * 08/4/21 encourage resident to eat meals or snacks; * 09/8/21 offer food of interest and encourage her to come out for two meals; and * 10/12/21 Puree diet and thin liquids. On 07/15/21 Staff 8 (Wellness Nurse) documented the following: * "ability to eat: independent"; * "hydration concerns: yes"; and * "Poor appetite and weight loss, offer alternatives and snacks, PCP prescribed Mirtazapine 7.5 mg in hopes of stimulating appetite. This does not appear to be effective, family brings in nutritional supplements, PCP appointment to discuss poor meal intake and weight loss, resident is on weekly weights, meal monitoring." Staff 8 noted previous interventions related to the residents weight loss, however, failed to evaluate the effectiveness of the interventions or develop new interventions when the resident experienced continued weight loss. On 10/25/21 staff documented in a progress note the resident "doesn't want to eat the puree food, [s/he] said that it is a baby food and [s/he] is not going to eat that". Review of the MAR dated 10/1/21 through 10/26/21 identified meal monitoring percentages were not documented on 32 occasions and nutritional supplements were not documented as given on four occasions. In interviews conducted on 10/28/21, Staff 21 (MT) and Staff 13 (MT) stated the following: * "I don't force [him/her] to eat anything, I approach three times, if [s/he] doesn't want to eat then [s/he] doesn't." "No, we have not tried to cue or sit with [him/her], I think [s/he] wouldn't like that and besides, I feel like I would be overstepping. [S/he] is independent and can physically eat, [s/he] just doesn't want to." * "I just ask [him/her] why [s/he] isn't eating and I ask if [s/he] wants something else. I don't know, what else is there to do?" Resident 7 experienced a severe weight loss from 05/27/21 to 06/29/21, when s/he lost 9.07% of total body weight within 30 days. The resident continued to lose weight from 06/29/21 to 8/25/21 for a total of 13.90 %, or 12.8 lbs. within three months. On 10/29/21 at 9:45 am, Surveyor observed Staff 9 (Wellness Nurse) weigh the resident and recorded the weight at 113.0 lbs. This constituted an additional severe weight loss of 19.86% of  his/her total body weight within six months. There was no documented evidence the residents continued weight loss had been evaluated, weight loss interventions were monitored or reviewed for effectiveness, new interventions attempted and documented and resident-specific instructions communicated to staff when the resident continued to lose weight. This put the resident at risk for continued weight loss. b. Observations, interviews with the resident and staff, review of the service plan and interim service plans (ISP's) and review of the progress notes were conducted during the survey. A review of the initial service plan dated 05/21/21 noted "pain is rare for [resident]. Team will follow most current orders on the MAR and notify wellness team of any changes." A review of the current service plan dated, 08/30/21, failed to address pain issues. Resident 7's clinical records indicated the Resident had been prescribed PRN Oxycodone on 06/4/21. Between 08/6/21-10/7/21 the resident was administered PRN Oxycodone on 34 occasions. The resident ran out of the pain medication on 10/7/21. At the time of the survey the facility had not refilled the order; and * Resident 7 was prescribed a Capsaicin Patch for pain, three times per day. The MAR dated 10/1/21- 10/26/21 identified 30 incidents where the pain patch had not been initialed as administered. The facility was unable to verify the resident received the medication. During interviews with Resident 7 on 10/28/21 and 10/29/21, s/he stated: "I'm not feeling well, my back hurts real bad, and "It hurts, hurts, hurts, that's why I'm laying down, it's the only thing that helps." In an interview Staff 13 (MT) stated "I don't think [s/he] has a PRN for Oxycodone." Surveyor and Staff 13 reviewed the med cart and the eMAR record on 10/28/21 and discovered the Resident was still prescribed Oxycodone however, there medication had not been received by the facility and was not available. There was no documented evidence the facility evaluated the residents pain, consistently monitored the resident's pain level, failed to implement non-pharmacological interventions for pain and document resident-specific instructions to staff, or updated the service plan with interventions related to chronic pain. The failure of the facility to evaluate or monitor Resident 7's pain resulted in unreasonable discomfort to the resident. The need to ensure pain and weight loss interventions were monitored or reviewed for effectiveness, new interventions attempted and documented and resident-specific instructions communicated to staff, or the service plan updated with interventions when the resident continued to have severe weight loss was discussed with Staff 1 (Administrator), Staff 2 (Operation Specialist), Staff 4 (Assistant Administrator) and Staff 8 (Wellness Nurse) on 10/28/21. They acknowledged the findings.

1.  Resident #5 and #7:  A change of condition evaluation was completed, monitoring implemented or updated, and the service plan updated with identified needs including clear instruction to staff.  Remaining resident records will be reviewed to ensure change of condition has been identified, evaluated, appropriate interventions and monitoring , including effictiveness of interventions, until resolved and until resolution is documented. 2.  The Executive Director, Assistant Executive Director, and the Wellness team received additional training on the Change of Condition policy and procedure that address this rule. 3.  The Executive Director and Wellness Team will review this area daily per their individual Quality Assurance Review Schedules; 24 hour book Change of Condition, to ensure correction. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#7) who experienced significant changes of condition related to weight loss and chronic pain. Resident 7 continued to experience significant weight loss and pain. Findings include, but are not limited to: Resident 7 was admitted to the facility in May 2021 with diagnoses including Alzheimer's disease and chronic lower back pain. a. Observations, interviews with staff, and a review of the service plan and interim service plans were conducted during the survey, and revealed the following: Resident 7 experienced a severe weight loss of 12.8 lbs. or 9.08 % of his/her total body weight from 5/27/21 to 6/29/21. This constituted a significant change of condition related to severe weight loss. An RN assessment was completed two weeks later, on 7/15/21 for the severe weight loss identified on 6/29/21. The RN completed an interim service plan for the change of condition on 7/19/21. Resident 7 experienced an additional weight loss of 6.8 pounds between 5/27/21- 8/25/21, which constituted a severe weight loss of 13.90 % in a three-month period. There was no documented evidence the facility RN completed an assessment for the severe weight loss identified on 8/25/21, documented findings, resident status, and interventions made as a result of the assessment and communicated clear instructions for staff or updated the service plan when the resident continued to lose weight. On 10/29/21 at 9:45 am, Surveyor observed Staff  9 (Wellness Nurse) weigh the resident and recorded the weight at 113.0 lbs. This constituted an additional significant weight loss of 5.95% for a total of 19.86% total weight loss within six months. b. Resident 7 had chronic lower back pain that was identified in June when s/he was prescribed PRN Oxycodone. On 7/23/21, Resident 7 was prescribed Capsacian pain patch for chronic lower back pain. * Between 8/6/21-10/7/21 the resident was administered PRN Oxycodone on 34 occasions. The resident ran out of the pain medication on 10/7/21. The facility had a current prescription for the medication, however failed to follow up to ensure the medication was received and available for administration;  and * Resident 7 was prescribed a Capsaicin Patch for pain, three times per day. The MAR dated 10/1/21- 10/26/21 identified 42 incidents where the pain patch had not been initialed as administered. The facility was unable to verify the resident received the medication. On 8/23/21, Staff 8 (Wellness Nurse) documented in a progress note the resident wasn't feeling well due to back pain and felt better if s/he were laying down. There was no documented evidence Staff 8 assessed the residents pain to include documented findings, resident status, and interventions made as a result of the assessment or update the service plan. During interviews with Resident 7 on 10/28/21 and 10/29/21, s/he stated: "I'm not feeling well, my back hurts real bad, and "It hurts, hurts, hurts, that's why I'm laying down, it's the only thing that helps." The facilities failure to assess the residents pain resulted in ongoing untreated pain and discomfort. The need to ensure the facility RN completed an assessment for significant weight loss and pain, documented findings, resident status, and interventions made as a result of the assessment and communicated clear instructions for staff or updated the service plan was discussed with Staff 1 (Administrator), Staff 2 (Operation Specialist), Staff 4 (Assistant Administrator) and Staff 8 (Wellness Nurse) on 10/28/21. They acknowledged the findings. Refer to C 270, example 1 a and 1b.

1.  Resident #7:  The community RN completed a change of condition nursing assessment.  Remaining resident records will be reviewed to ensure identified change of condition has been assessed by the community RN.   2.  The Executive Director, Assistant Executive Director, and the Wellness team received additional training on the Change of Condition policy and procedure that address this rule. 3.  The Executive Director and Wellness Team will review this area daily per their individual Quality Assurance Review Schedule; 24 hour book Change of Condition, to ensure correction. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 5 sampled residents (#7) whose orders were reviewed. Findings include, but are not limited to: Resident 7's current physician orders dated 7/29/21 and 10/1/21 through 10/26/21 MAR identified the following deficiencies: * Resident 7 had a  physician order for a Capsaicin patch for pain to be administered three times daily. The October MAR identified 42 occasions the pain patch was not documented as administered to the resident as ordered; and * Nutritional Supplement was not documented as administered on four occasions. Facility staff were unable to verify the medication and nutritional supplement were given as ordered. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (Operation Specialist) on 11/1/21. They acknowledged the findings.

1.  All Medication Administration Records (MAR) will be reviewed to ensure medication or treatment orders are carried out as prescribed. 2.  The Executive Director, Assistant Executive Director, Wellness Team and all Med Tech's received additional training on the Medication Administration policy and procedure, including documenting when a medication or treatment is delivered, that address this rule. 3.  The Executive Director and Wellness Team will review this area daily per the Quality Assurance Master Review Schedule; Daily Stand Up Clinical Review, to ensure correction.  The Med Tech's will review this area each shift per the 24 HR Resident Report MAR review, to ensure correction. 4.  The Executive Director will ensure the corrections are completed and monitored.

2. Resident 7's 10/1/21 through 10/26/21 MAR was reviewed, and the following inaccuracies were identified: * PRN Tylenol exceeded the daily dose parameter; * On 10/9/21, Isosobride (blood pressure medication) hold parameter was not followed; * There were multiple blanks on the MAR for the following medications or treatments: - Tylenol; - Capsaicin Patch (for pain); - Eliquis; - Fluticasone nasal spray; - Isosobride (blood pressure medication); - Levothyroxine (thyroid medication); - Memantine (dementia medication); - Vitamin D3; - Nutritional Supplement; - Weekly weights; - Covid-19 monitoring; - Meal monitoring and meal percentages; - Monthly weights and vitals; - Blood pressure vital; - Oxygen saturation levels; and - Temperature. The need to ensure MAR's included clear parameters for unlicensed staff, parameters were being followed and included documentation that all medications and treatments were initialed as administered during the medication pass was reviewed with Staff 1 (Administrator) and Staff 2 (Operation Specialist) on 11/1/21. They acknowledged the inaccuracies.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication-specific instructions and had specific parameters for PRN medications for 3 of 5 sampled residents (#s 2, 5 and 7). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in October 2021 with diagnoses including diabetes. The resident's 10/13/21 through 10/27/21 MARs and TARs and 10/13/21 physician orders were reviewed. The MARs/TARs contained blank spots in the documentation for the following treatments and medications: * Humalog kwikpen (for diabetes); * Latanaprost (eye drops); * Lotrisone (antifungal cream); and * Cranberry capsules (supplement). The need for accurate records was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 10/29/21 and 11/1/21. The staff acknowledged the findings. 3. Resident 5 was admitted to the facility in October 2019 with diagnoses including dementia.  Review of the MAR, dated 10/1/21 to 10/27/21, indicated the following deficiencies: * The MAR lacked parameters for PRN pain medications acetaminophen and hydrocodone and morphine, regarding which to administer first; * The MAR lacked parameters for PRN bowel medications Senna, Bisacodyl and Milk of Magnesia regarding the sequential order of use; and * Multiple blank spaces on the MAR for medications including acetic acid, Quetiapine and daily blood pressure readings. On 10/29/21 the need to maintain an accurate MAR for all medications/treatments ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (Administrator). She acknowledged the findings.

1.  The Medication Administration Record for resident #2, #5 and #7 were updated and remaining resident MAR's reviewed, to ensure accurate medication records including medication specific instructions and specific parameters for PRN medications. 2.  The Executive Director, Assistant Executive Director, and Wellness team received additional training on the Medication Administration policy and procedure; processing orders and all Med Techs received additional training on the Medication Administration policy and procedure; following orders and documenting when a medication or treatment is delivered, that address this rule. 3.  The Executive Director and Wellness Team will review this area daily per the Quality Assurance Master Review Schedule; Daily Stand Up Clinical Review, to ensure correction.  The Med Tech's will review this area each shift per the 24 HR Resident Report MAR review, to ensure correction. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 4 and 5) who were prescribed PRN medications to treat the residents' behaviors. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in November 2020 with diagnoses including bipolar disorder and anxiety. Resident 4 was prescribed PRN lorazepam to treat symptoms of bipolar disorder. The 10/2021 MAR indicated the resident was administered the medication on 4 occasions. The facility failed to document what non-pharmacological interventions were attempted and ineffective prior to administering the psychotropic medication on 4 of the 4 occasions. The need to ensure staff attempted and documented non-pharmacological interventions were ineffective prior to administering PRN psychotropic medications to treat a resident's behavior was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 11/1/21. They acknowledged the findings. 2. Resident 5 was admitted to the facility in October 2019 with diagnoses including dementia. Resident 5 was prescribed PRN lorazepam for anxiety. The 10/2021 MAR indicated the resident was administered the medication on 10/26/21. The facility failed to document what non-pharmacological interventions were attempted and ineffective prior to administering the psychotropic medication. In an interview on 10/29/21, Staff 1 (Administrator) stated the non-pharmacological interventions were added to the electronic MAR, and staff training was needed to ensure Med Tech's documented the attempts prior to administering the PRN medication. The need to ensure staff attempted and documented non-pharmacological interventions were ineffective prior to administering PRN psychotropic medications to treat a resident's behavior was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 10/29/21. They acknowledged the findings and stated the staff training on the electronic system would occur.

1.  The community electronic system has been modified to improve the process of documenting non-pharmacological interventions attempted and ineffective prior to administering pshychotropic medication. 2.  The Executive Director, Assistant Executive Director and Wellness team received additional training on the Medication Administration policy and procedure; monitoring documentation and all Med Techs received additional training on the Medication Administration policy and procedure; documentation, that address this rule. 3.  The Executive Director and Wellness Team will review this area daily per the Quality Assurance Master Review Schedule; Daily Stand Up Clinical Review, to ensure correction.  The Med Tech's will review this area each shift per the 24 HR Resident Report MAR review, to ensure correction. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not contain drop-offs to prevent a tripping hazard for residents. Findings include, but are not limited to: The facility consisted of five houses. The outdoor courtyard/patio areas were toured on 10/28/21 and 10/29/21. Drop-offs were observed along the sidewalks in each of the courtyard and patio areas of all houses. The need to ensure all exterior pathways were maintained free of drop-offs was discussed with Staff 1 (Administrator) and Staff  2 (Operations Specialist) on 10/29/21. They acknowledged the findings.

1.  The sidewalk to yard edges have been filled in, where needed, in all outdoor courtyard and patio areas. 2.  The Executive Director, Assistant Executive Director and Maintenance Director received additional training on the Safe Walk Survey that address this rule. 3.  The Executive Director and Maintenance Director will review this area quarterly per the Maintenance Quality Assurance Review Schedule; Safety, to ensure correction. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 152, C 231 and C 510.

Refer to C 152, C 231 and C 510

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 260, C 270, C 280, C 303, C 310 and C 330.

Refer to C 260, C 270, C 280, C 303, C 310 and C 330

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition plan was developed and included in the service plan for 2 of 2 sampled residents (#s 5 and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5's current service plan was reviewed during the survey. The service plan stated the resident required food be cut up into small pieces, was independent with eating and was able to make dining needs and preferences known. Observations of meals on 10/28/21 and 10/29/21 showed Resident 5 ate meals in bed, was able to feed him/herself once set up by staff and required reminders and assistance from staff to receive any snacks or fluids. Weight records reviewed from 4/1/21 through 10/1/21 showed slow, gradual weight loss over 6 months. The service plan lacked information and instructions for staff to follow related to the slow weight loss, when and how to provide snacks and ensure individualized nutrition needs and preferences were being met. The need to provide a daily meal program for nutrition and hydration based upon the resident's preferences and needs, available throughout each resident's waking hours and documented in the resident's service plan was discussed with Staff 1 (Administrator) and Staff 2 (Operations Specialist) on 10/29/21. They acknowledged the findings. 2. Resident 7 was admitted to memory care in May 2021 with diagnoses including Alzheimer's disease with late onset. Observations, interviews with staff, review of the service plan and interim service plans were conducted during the survey. A review of Resident 7's clinical records revealed the following: * Resident 7's service plan, dated 5/21/21, noted the resident was independent with eating, was a light eater, needed strong encouragement to eat, and had experienced a 14-pound weight loss prior to move in. Although the recent history of weight loss was identified, the initial service plan lacked a resident specific nutrition and hydration plan to address the weight loss; and * Resident 7 continued to experience severe weight loss after move in. The service plan dated 8/30/21 noted resident was independent with eating, was a light eater, needed strong encouragement to eat and was at risk of dehydration. The service plan continued to lack information and staff instruction related to individualized nutrition and hydration needs to address the weight loss and dehydration risk. On 11/1/21, the need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) and Staff 2 (Operation Specialist). They acknowledged the findings.

1.  The Service Plan for resident #5 and #7 have been updated with an individualized nutrition plan.  Remaining resident Service Plans will be reviewed to ensure an individualized nutrition plan. 2.  The Executive Director, Assistant Executive Director  and the Wellness team, received additional training on the Service Plan policy and procedure and the Service Plan guide that address this rule. 3.  The Executive Director and Wellness Team will review this area weekly per their individual Quality Assurance Review Schedules; Service Planning, to ensure correction. 4.  The Executive Director will ensure the corrections are completed and monitored.

The findings of the re-licensure survey, conducted 10/27/2021 through 11/1/2021, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 11/01/21, conducted 02/09/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 004 Home and Community Based Services Regulations and Division 57 for Memory Care Communities.