Harvest Homes Memory Care

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, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 06/13/25 revealed: 1. Memory care unit’s Fireside kitchenette was observed at 11:00 am and the following was identified: a) Splatters, spills, drips, dust and food/debris noted on: * Interior of reach in refrigerator and freezer; * Interior and exterior of multiple drawers and cabinets; * Backsplash and wall behind the sink; * Exterior and interior of the oven; * Interior of the microwave; * Cabinet under the sink; and * Kitchenette flooring and baseboards. b. A plastic tub containing cloths was stored on the floor. c. The cabinet behind the paper towel rack had chipped finished and exposed surface and was in need of repair. 2. Memory care unit’s Gardenside kitchenette was observed at 11:15 am and the following was identified: a. Splatters, spills, drips, dust and food/debris noted on: * Interior of reach in refrigerator and freezer; * Backsplash and wall behind the sink; * Exterior and interior of the oven; * Interior of the microwave; and * Kitchenette flooring and baseboards. b. There was a missing cabinet door adjacent to the entry of the kitchenette that was in need of repair. c. Dish machine was found not sanitizing at correct sanitation level, and rinse temperature’s maximum rinse temperature observed was 100 degrees F. During an interview on 06/13/25 at 11:40 am, Staff 1(Administrator) confirmed the machine was put out of order until maintenance could attend to the issue. On 06/13/25 at approximately 12:45 pm, the areas in need of cleaning, repair and attention were reviewed with Staff 1. She acknowledged the findings.

OAR 411-057-0140(2) Administration Compliance - Referral Citation Z0142 OAR 411-057-0140 (2) The same corrections outlined in C0240 apply and have been Implemented under the oversight of The Administrator or designee will review all facility inspections to ensure compliance with both OAR 411-054 and 411-057.

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, 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.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule 1 (a) Immediate Action Completed by 6/17/2025 -Both Fireside and Gardenside kitchenettes received deep cleaning by housekeeping staff. 2 (a) Daily, weekly, & monthly cleaning audits will be performed and documented. 3 (a) Kitchen staff will be responsible for completing daily kitchen cleaning and once weekly cleaning audits will be completed. 4. (a) The community administrator, dietary manager, and RCC will be responsible for overseeing these corrections. 1 (b) Immediate Action Completed - the plastic tub containing cloths was removed. 2 (b) Education will be provided to kitchen staff related to infection control measures. During weekly audits staff will ensure the floor is free of any clutter and that clean cloths are stored appropriately. 3 (b) The kitchen will have daily, weekly, and monthly cleaning and kitchen cleanliness and infection control measures will be audited once weekly. 4 (b) The community administrator, dietary manager, and RCC will be responsible for overseeing coorections. 1 (c) Immediate action taken - Damage to cabinet was repaired. 2 (c) During weekly kitchen audits any identified building or appliance repair needs will be communicated to the maintenance director and addressed within 72hrs. 3 ( c) Weekly kitchen audits and walk-throughs will be conducted to ensure cleanliness and that the building and appliances are in good repair. 4 ( c) The facility administrator, dietary manager, RCC and maintenance director will be responsible for overseeing corrections. 1 (2a) Immediate correction - the refrigerator, freezer, backsplash, oven, microwave, flooring and baseboards were deep cleaned to remove all spills, dirt, and debris. 2 (2a) Daily, weekly, and monthly cleaning/deep-cleaning will be conducted with weekly audits completed to ensure cleanliness. 3 (2a) Weekly kitchen audits will be performed to ensure compliance. 4 (2a) The administrator, dietary manager, and RCC will be responsible for overseeing corrections. 1 (2b) Immeidate Action - Missing cabinet door has been replaced. 2 (2b) During weekly kitchen audits, any identified building or appliance repair needs will be communicated to the community maintenance director and will be addressed within 72hrs. 3 (2b) Weekly audits will be performed to ensure cleanliness and building/appliance repair needs are addressed. 4 (2b) The community administrator, dietary manager, RCC, and maintenance director will be responsible for overseeing corrections. 1 (2c) Immeadiate action - The community maintenance director adjusted water temperature to ensure water reaches appropriate temperatures in the dishwasher. 2 (2c) Weekly water temperatures will be obtained and recorded. 3 (2c) The maintenance director will obtain and record weekly water temperatures and will report any findings outside of required temps to the administrator. 4 (2c) The facility administrator and maintenance director will be responsible for overseeing corrections.

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 ensure the kitchen was clean and in good repair and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 12/07/23 at 10:15 am, the kitchen was inspected and the following was identified: 1. The kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dust, dirt, rust, and black matter was observed on, inside, around or underneath the following: * Walls and ceilings throughout the kitchen and dry storage area; * Sprinklers and smoke detectors on the ceilings throughout the kitchen; * Stainless steel shelving throughout the kitchen; * Stainless steel cabinets throughout the kitchen; * Legs of stainless steel shelving throughout the kitchen; * Two fans affixed to the walls; * Warewasher; * Ceiling lights; * Handles and exterior of dry goods bins; * The turquoise cart holding jams; * Shelving, drawers, and heat lamp frame in the grill area; * Pipes, walls, and shelving in, under, and around the warewasher; * Kitchen light switches on the wall near the back office; * Toaster; and * Ceiling vent. b. The following equipment was found in poor repair: * Dishwasher racks; * Metal bread rack with brown trays; * The floor between the dishwashing area and pot storage had a large crack, exposing subflooring; * A piece of laminate baseboard next to the garbage can in the food prep area was peeling away from the wall and had food debris on it; * The freezer pipe on the ceiling had a large stalactite hanging from it; * The ice machine was leaking on both bottom front corners; and * The white spatulas had pieces chipped off. 2. Staff were observed preparing and serving food and the following was identified: * Scoops were stored inside the dry goods bins; * The hobart and stand mixers were uncovered; * The eggs were stored on the top shelf above other food in the refrigerator; * Staff 3 (Cook) observed to wear the same pair of single-use gloves while completing a number of tasks including making sandwiches, throwing expired food away, and retrieving food from the refrigerator; * Staff 7 (CG) and Staff 8 (CG) were observed serving and feeding residents without wearing a protective barrier over potentially contaminated clothing; and * Staff 7 was observed delivering uncovered plates and beverages to resident rooms. During an interview at 10:30 am on 12/07/23, Staff 2 (Kitchen Manager) confirmed eggs were used for soft preparations and could not confirm the eggs used were pasteurized. The need to ensure the kitchen was clean and in good repair and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ALF Administrator) on 12/07/23. She acknowledged the findings.

Resident Services Meals, Food Sanitation Rule: 1.) The following areas have been deep cleaned and dust/food/debris removed: a. Walls & ceilings throughout in kitchen and dry storage area, b. sprinklers and smoke detectors on the ceilings throughout the kitchen, c. stainless steel shelving throughout the kitchen, d. stainless steel cabinets throughout the kitchen, e. legs of stainless steel shelving throughout the kitchen, f. fans affixed to the walls, & warewasher; g. ceiling lights, h. handles and exterior of dry goods bins, i. the turquoise cart holding jams, j. shelving, drawers, and heat lamp frame in the grill area, k. pipes, walls, and shelving in, under, and around the warewasher, l. kitchen light switches on the wall near the back office, m. toaster, & n. ceiling vent. 2.)A daily, weekly, & monthly cleaning log with instructions will be followed by kitchen staff and will include all deficiencies listed above. The kitchen staff will maintain/clean all areas of kitchen based on cleaning schedule implemented. 3.) Community Admin & Dietary manager will review the kitchen, including all deficiencies above, once weekly during walk-throughs of the kitchen. 4.) Community Admin & Dietary Manager will be responsible to ensure all corrections are made and maintained. Resident Services Meals, Food Sanitation Rule: 2a.) The folloiwing equipment will either be repaired or replaced if repair isn't possible, a. dishwasher racks, b. metal bread rack with brown trays, c. the floor between the dishwashing area and pot storage had a large crack, exposing subflooring, d. a piece of laminate baseboard next to the garbage can in the food prep area was peeling away from the wall and had food debris on it, e. the freezer pipe on the ceiling had a large stalactite hanging from it, f. the ice machine was leaking on both bottom front corners, & g. the white spatulas had pieces chipped off. 2b.) As part of the weekly walk-through of the kitchen, the dietary manager and admin will identify equipment that is in need of repair or replacement. The administrator will work with the dietary manager on an on-going plan & timeline of repairs or replacements needed. 2c.) The admin and dietary manager will do once weekly walk-throughs of the kitchen to better identify cleaning & repair needs. 2d.) The dietary manager and admin will responsible for ensuring oversight & compliance in this area. Resident Services Meals, Food Sanitation Rule: 3a.) The scoops were removed from the dry storage bin, hobart and stand mixers have been covered, & eggs are now stored in the appropriate spot in the refrigerator (removed from top shelf to reduce risk of contamination to food underneath eggs). All dietary and universal staff are scheduled to receive infection control & prevention training. This training will include: washing hands and the use of gloves in the kitchen secondary to cross contamination, the imortance of wearing clothing protectors/aprons when assisting with feeding and/or delivering food, and all kitchen staff will be trained on the importance & requirement that all eggs must be pasteurized. Staff have been educated on covering beverages and plates when delivering meal trays to resident rooms. 3b.) As a part of the weekly walk-through of the kitchen, the admin and dietary manager will observe dry storage areas & equipment to ensure appropriate storage of mixers and scoops. During weekly walk-through of the kitchen, the admin and dietary manager will observe dietary and universal staff when delivering food and/or when assisting residents with feeding to ensure appropriate infection control measures are in place at all times. Dietary staff will continue required on-going education on infection control & cross contamination, as required. 3c.) Dietary manager and admin will conduct once weekly walk-throughs of the kitchen to ensure compliance with the above citations as well as complete visual observation of dietary staff to mitigate risk of infection or cross contamination. 3d.) The dietary staff and admin will be responsible for ensuring oversight and compliance into all above cited areas.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair and food was stored in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: On 02/21/24 at 1:33 pm, the kitchen was inspected and the following was identified: 1. Food spills, splatters, debris, dust, dirt, rust, and black matter was observed on, inside, around or underneath the following: * Fire sprinklers on the ceilings throughout the kitchen; * Pipes and walls, underneath the warewasher and sprayer sink; * Walls in the dry food storage area and janitor's closet; * Knife storage racks and knives stored on the wall in the dry food storage area; * Kitchen light switches on the wall near the back office and janitors closet; and * Walk-in freezer floors had an accumulation of food debris. 2. The following equipment was found in need of repair: * The floor throughout the kitchen had large cracks and exposed subflooring in multiple areas; * Laminate baseboard throughout the kitchen was peeling away from the wall; * The ice machine was leaking on both bottom front corners; * The "Heated Holding Cabinet" (next to the stove) was inoperable; * The painted finish on the walk-in refrigerator was peeling off; * Multiple refrigerator/freezer shelving was rusted; * The hinges and door handle on the walk-in freezer door were rusted; * The freezer pipe on the ceiling had a large stalactite hanging from it and exposed electrical wire; and * The wooden janitor's closet door had chipped and exposed wood rendering the surface uncleanable. 3. Observations of food storage identified the following: * Food product in the walk-in freezer was stored on the floor, was improperly shelved and food was left open to air creating a situation for the potential of environmental cross contamination and freezer burn; * There were multiple unlabeled, undated food items in the walk-in refrigerator; and * Multiple food items in the dry food storage area were left open to air. The need to ensure the kitchen was clean and in good repair and food was stored in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ALF Administrator), Staff 6 (MCC Administrator) and Staff 7 (Community Coordinator) on 02/21/24. They acknowledged the findings.

C 240 SS=F OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule 01. Immediate actions taken to correct the rule violation include: The main kitchen has been deep cleaned, addressing cleanable surfaces. A plan is in place to repair items/areas that were unable to be resolved immediately. Plan of correction was created ensuring that all areas noted on the SOD are to be resolved, cleaned and repaired. All items requiring replacement have been ordered/scheduled for replacement. a. Food spills, splatters, debris, dust, dirt, rust, and black matter was observed on, inside, around or underneath the following: i. Fire sprinklers on the ceilings throughout the kitchen- cleaned, removing dust/dirt & replacement of sprinkler heads that were uncleanable. ii. Pipes and walls, underneath the warewasher and sprayer sink-were scrubbed clean removing food debris/dust/dirt. iii. Walls in the dry food storage area and janitor's closet- cleaned and repainted dry storage, install of  FRP to reinforce and provide cleanable surfaces on/in janitor closet and on refrigerator wall in dry storage. iv. Knife storage racks and knives stored on the wall in the dry food storage area- cleaned & moved to meal prep area wall for safety. Disposed of all knives that had porous  handles. v. Kitchen light switches on the wall near the back office and janitors closet- removed and replaced with clean/new plates. vi. Walk-in freezer floors had an accumulation of food debris- shelving units moved and floors have been cleaned. b. The following equipment was found in need of repair: i. The floor throughout the kitchen had large cracks and exposed subflooring in multiple areas- flooring is being replaced throughout the entirety of the kitchen. Supplies ordered, scheduled install date between April 15-26th 2024, due to supplies ordered delivery expectation. ii. Laminate baseboard throughout the kitchen was peeling away from the wall- baseboards throughout the kitchen will be replaced with install of new flooring. iii. The ice machine was leaking on both bottom front corners- machine is being replaced, ordered pending delivery estimated 3/18/24. To be installed upon delivery. iv. The "Heated Holding Cabinet" (next to the stove) was inoperable- cabinet is being removed and replaced, ordered pending delivery estimated 3/18/24. To be installed upon delivery. v. The painted finish on the walk-in refrigerator was peeling off- surface area has been cleaned, removed peeling finish, scheduled to repaint the surface week of 3/12/24. vi. Multiple refrigerator/freezer shelving was rusted- shelves cleaned, removed rust and painted with rustoleum. vii. The hinges and door handle on the walk-in freezer door were rusted- areas to be scrubbed/removed rust and sealed with rustoleum paint. viii. The freezer pipe on the ceiling had a large stalactite hanging from it and exposed electrical wire. - Closure of box with exposed wire replaced, pipe is now covered w/pipe insulation. To be monitored daily, if issue arises again, repair of pipe to be completed by refrigeration specialist. ix. The wooden janitor's closet door had chipped and exposed wood rendering the surface uncleanable- door replaced. c. Observations of food storage identified the following: i. Food product in the walk-in freezer was stored on the floor, was improperly shelved and food was left open to air creating a situation for the potential of environmental cross contamination and freezer burn.--- all food items moved, placed on shelving unit off of floor. Containers closed- proper storage/sealed units purchased for storage of opened food items ii. There were multiple unlabeled, undated food items in the walk-in refrigerator- thorough review and removal of all food products with no open date and or unlabeled. Re-training of kitchen/dietary personnel provided and direction/guidelines posted for staff reminders/review. iii. Multiple food items in the dry food storage area were left open to air - thorough review and removal off all food products with no open date and or unlabeled. Re-training of kitchen/dietary personnel provided and direction/guidelines posted for staff reminders/review. 02. The system will be corrected so this violation will not happen again by : coaching and teaching kitchen staff proper cleaning and utilizing the Kitchen weekly cleaning schedule checklist for staff to use as a guide. The checklist has been updated to incorporate all required components to ensure the kitchen is clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000 03. The cleaning schedule checklist which includes review of proper food storage and labeling, will be reviewed weekly ongoing by the administration team and quarterly with internal company mock survey environmental audits. 04. The Executive Director or designee will be responsible for reviewing/monitoring the weekly cleaning schedule to ensure the corrections remain in compliance.

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.

Z142 - Referral Citation: Please see above plan of correction.

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

OAR 411-057-0140(2) Administration Compliance Refer to C240

Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240 and Z 142.

C455 OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval Refer  C 240 and Z 142. 1. Immediate action to correct the rule violation include: Creation of a tracking sheet for compliance monitoring and utilizing an outside person for compliance oversight. A cleaning checklist was updated to include all areas cited in SOD to provide clear guidelines for staff when cleaning. 2. The system will be corrected so this violation will not happen again by utilizing the SOD and POC to teach and train, creating a tracking sheet for compliance monitoring. 3. The compliance spreadsheet and cleaning schedule checklist will be reviewed weekly with dietary and maintenance team until all areas out of compliance are completed and within compliance of Food Sanitation Rules OAR 333-150-000 4. The Executive Director or designee will be responsible for reviewing/monitoring the weekly cleaning schedule and compliance checklist to ensure the corrections are completed in a timely manner and when completed remain in compliance.??????

The findings of the kitchen inspection, conducted 11/07/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 12/07/23, conducted 02/21/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second re-visit to the kitchen inspection of 12/07/23, conducted 05/13/24, 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, it was determined the facility failed to ensure resident to resident altercations were immediately reported the local SPD office for 1 of 1 sampled resident (#1) whose records were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in October 2021 with diagnoses including dementia. Progress notes, dated 10/13/21 through 01/11/22 were reviewed and revealed the following: * 12/19/21 - the resident "poked the other resident" with his/her cane "several times;" * 12/27/21 - at 2:02 pm, Resident 1 went to another resident and pinched his/her neck; * 12/27/21 - at 7:33 pm, the resident pulled another resident's arm, which caused the other resident to lose his/her balance. The resident pulled a chair while another resident was sitting on it. Staff documented the other resident was not injured but did state s/he was "a bit scared" of Resident 1; and * 01/07/22 - the resident "put [his/her] cane purposely down on [another resident's] foot." There was no documented evidence the facility immediately reported the incidents to the local SPD office. The need to ensure all physical resident to resident altercations were reported to the local SPD office was discussed with Staff 1 (Admin/President/CFO/Owner) on 01/12/22 and 01/13/22. She acknowledged the findings. The surveyor requested and received verification that the above incidents were reported to the local SPD office on 01/12/22.

C231 1. Immediate action was taken and an APS report was created to document actions by Resident #1 against other residents. Follow up with APS is ongoing.   Further APS reports were created later for another incident involving Resident #1. 2. Harvest Homes curent abuse and requirement policy is part of the initial employment onboarding paperwork. We also do an inservice yearly on abuse. Administrator will review incidents reports daily and report incidents of possible abuse within 24 hours. 3.As each incident happens administrator will determine whether or not it is potential abuse and needs to be reported. 4. Administrator

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 3) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task. During the acuity interview on 01/11/22, Resident 3 was identified to be administered insulin injections by non-licensed staff. Resident 3's MARs, reviewed from 12/01/21 through 01/11/22, revealed insulin had been given by non-licensed staff once daily. Delegation documentation for Staff 8 (ALF Administrator), Staff 14 (MT) and Staff 15 (RCC), was reviewed on 01/12/22 and revealed the following: * Delegation was transferred on 11/20/21 from Staff 16 (previous RN) to Staff 2 (RN). * There was no current delegation from Staff 2 authorizing Staff 8, 14 and 15 to give insulin to Resident 3. In an interview on 01/12/22 at 2:15 pm, the documentation was reviewed with Staff 2. Staff 2 stated she started at the facility in November 2021 and was unaware she needed to complete her own delegation of staff to administer insulin. OSBN Division 47 Rules relating to transfer of delegation was discussed with Staff 2 during the interview. The RN Surveyor informed Staff 2 that staff needed to be delegated by her to administer insulin. She acknowledged and stated she would complete the delegations. Failure to ensure delegation was completed in accordance with OSBN Division 47 rules was reviewed with Staff 1 (Admin/President/CFO/Owner) on 01/13/22. She acknowledged the findings.

C282 1 Nurse will have all deligations completed by February 10th 2022. 2. Nurse understands the rules concerning delegations and has marked her calender to make sure this is done timely. 3. Monthly 4. Administrator

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month. Findings include, but are not limited to: Fire drill and fire and life safety records from 06/29/21 to 11/30/21 were reviewed on 01/12/22. There was no documented evidence the facility was conducting fire drills every other month. The requirements regarding fire drills were reviewed with Staff 1 (Admin/President/CFO/Owner) on 01/13/22. She acknowledged the findings.

C420 1.The memory care fire drill schedule has been completed for 2022. A copy has been given to maintenance. 2. Administrator and maintenance will meet the first week of the month the fire drill is due and determine a date for the drill. Administrator will mark her calendar as a reminder. 3.  Fire drills are done every other month. 4. Administrator will be responsible.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and located above the first floor. Findings include, but are not limited to: The interior of the facility was toured on 01/11/22 at 11:00 am, and revealed the following: * A window located outside of Room 13 was observed to be open approximately 12 inches wide. Upon inspection, the window was found to lack any means of limiting how wide the window could be opened to prevent accidental falls. The height of the windowsill was 22 inches above the floor. *Rooms 502, 503 and 509, with sills measuring 22 inches to 34 inches, were also found to lack any means of limiting how wide the window could be opened. The need to ensure windows above the first floor were designed to prevent accidental falls was discussed with Staff 1 (Admin/President/CFO/owner) and Staff 3 (CSO/Owner) on 01/13/22. They acknowledged the findings .

C515 1. Maintenance ordered locks from amazon immediately. They arrived on the 14th and were installed. 2 Maintenance has added to the weekly surveillance checklist to make sure all window locks have not been removed and are installed properly. Staff has been educated as to the importance of window locks and informed to tell the Med Tech or Administrator if locks have been removed and are missing. 3.Weekly by building manager to make sure everything is done. 4 Administrator will review with building manager monthly.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 231, C 420 and C 515.

refer to C231,C420, and C515

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly hired staff (#5) completed all required pre-service training, 1 of 3 newly hired staff (#5) completed competency training within 30 days of hire or prior to independently providing personal care to residents, and 3 of 3 sampled direct care veteran staff (#s 9, 10 and 11) completed 16 hours of annual in-service training. Findings include, but are not limited to: Staff training records were reviewed with Staff 18 (Human Resources Director) on 01/12/22. The following deficiencies were identified: 1. Staff 5 (MT), hired on 10/18/21, lacked documentation she completed pre-service training in all required areas prior to beginning performance of job duties and had documentation of demonstrated competency in all required areas within 30 days of hire. 2. Staff 9 (CG), Staff 10 (CG) and Staff 11 (MT), hired on 12/14/20, 12/10/20 and 02/16/20 respectively, lacked documentation of completing 16 hours of annual training related to provision of care in CBC which included six hours of dementia care. The need to ensure staff completed all required training in a timely manner and prior to working independently was discussed with Staff 18 on 01/12/22 and Staff 1 (Admin/President/CFO/Owner) on 01/13/22. They acknowledged the findings.

Z155 1 Immediate action was taken and employee signed all orientation paperwork. 2. Protocol put in place to require all hires and re-hires to fill out all paperwork completely before starting their duties. A check off sheet was created and all paperwork is now in payroll company records so the onboarding is electronic. An employee can not be scheduled without completing all paperwork on payroll website. This prevents this from happening in the furture. Staff were given inservices and required to keep them up to date. 3.administrators will check monthly to make sure payroll system is working. Staff who are lacking monthly training were given inservices and required to have them turned in by February 26th. Depending on covid situation monthly staff meetings are held to help keep inservices up to date. 4.The Administor is responsible for tracking and will review monthly to make sure inservices have been completed..

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 282.

refer to C282

The findings of the re-licensure survey conducted 01/11/22 through 01/13/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the re-licensure survey of 01/13/2022, conducted 03/10/2022, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.