Cedarbrook Place Memory Care

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

Based on observation, interview and record review, it was determined the facility failed to ensure care time and care elements that staff provided were captured accurately for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to: Resident 1 and 2’s service plans and facility ABST entries were reviewed on 03/09/26 and 03/10/26. Multiple care areas had no recorded minutes, incorrect minutes and/or did not reflect two-person assistance was provided in one or more of the following areas: * How much time was spent providing treatments; * How much time was spent providing non-drug interventions for pain management; * How much time was spent repositioning in bed or chair; * How much time was spent transferring in or out of bed or a chair; * How much time was spent responding to call lights; * How much time was spent assisting with communication, assistive devices for hearing, vision, speech; and * How much time was spent monitoring physical conditions or symptoms. In a group interview on 03/10/26, Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Director/LPN), and Staff 14 (Corporate RN), Resident 1 and 2’s ABST minutes and service plans were reviewed. The staff acknowledged there were several care areas that were not reflective of the care time the residents received. Staff 1 indicated he just recently learned how to enter information into the ABST and started doing so the previous week. The staff acknowledged the findings.

Resident 1 and 2 ABST enteries were updated to reflect care minutes received and reflect two person assistance when applicable. Regional Director of Health Services(RDHS) will educate Executive Director (ED), Resident Care Coordinator (RCC) on how to accurately document and reflect the minutes of care provided including any two person care utilzing the ODHS ABST tool by (date)

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

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

Based on observation, interview and record review, it was determined the facility failed to ensure all residents were entered into the ABST and that residents’ care area minutes were reviewed and updated as needed, at least quarterly, for multiple sampled and unsampled residents whose ABST evaluations were reviewed. Findings include, but are not limited to: Review of the facility’s ABST on 03/09/26 showed the following: * Three of the 14 total residents were not entered into the tool; and * Eight of the eleven total residents entered had not been updated since 10/2025. In an interview on 03/10/26, Staff 1 (ED), indicated he just recently learned how to enter information into the ABST and started doing so the previous week. He had no additional information to provide. Staff 1 acknowledged the findings.

The RDHS will complete and audit of the ABST and will update the ABST to reflect current resident admitted to community, the minutes of care received and any two person assistance needed by (date) The RDHS will provide training to the ED/RCC on the requirements of updating the ABST prior to admission, with each change of conditon and at least quarterly by (date) The ED/RCC is responsible to update the ABST prior to admission, with any change in conditon and at least quarterly. The ODHS ABST tool will be audited by the ED/RCC with each service plan update and the staffing pattern will be adjusted accordingly.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

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

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records from 10/2025 through 02/2026 were reviewed and lacked documentation that drills and fire life safety training were conducted every other month on alternating shifts for the memory care. The need to ensure fire life safety training and drills were conducted on alternating months was discussed with Staff 1 (ED) and Staff 4 (Maintenance) on 03/09/26 and 03/10/26. Staff 4 was new to the building and had no further documentation to provide. The staff acknowledged the findings.

1.The Maintenance Director and ED will be educated on regulations by the Regional Director of Operations/Regional Environmental person on policy and regulations regarding fire drills being performed according to the Oregon Fire Code by (date) 2. MD/designee will conduct fire drills and staff education per policy and regulation. 3. Documentation will be maintained in TELS system by the MD/designee 4. The results of this will be discussed at the monthly continuous quality improvement meeting. 5. ED will ensure corrections are completed and monitored

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

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

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 03/09/26 and 03/10/26 showed the following areas in need of cleaning or repair: * Multiple scuffs, gouges and scratches were noted to the laminate flooring in the living room and the dining room. Scratches were several inches in length at the minimum. There were numerous areas that were deep into the surface of the floor creating crevices and divots; * Multiple lights had dead insects or debris gathered in the lights; * Chips and dings to walls in the common areas were noted. A large and deep gouge was dug into the wall near the medication room; and * Spills, splatters and debris were noted on multiple dining room chairs along the backs and seats. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) and Staff 4 (Maintenance) on 03/09/26 and 03/10/26. The staff acknowledged the findings.

The Maintenance Director and ED will be educated on regulation by the Regional Director of Operations/Regional Environmental person on the CBC walk through by (date) 2. MD/designee will clean all areas identified, including lights, walls, dining tables and chairs by (date) 3. MD/designee will repair and/or replace flooring in dining and living room by (date) 4. MD or ED will perform CBC environmental walk through once a week X 2 months, twice monthly X2 months and then monthly ongoing.

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

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

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C362, C363, C420 and C513.

Refer to C362, C363, C420 and C513

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

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

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 sampled newly hired staff completed all required pre-service dementia training topics prior to beginning job duties. Findings include, but are not limited to: Staff training records were reviewed on 03/09/26 and 03/10/26. There was no documented evidence Staff 8 (Dietary) and Staff 15 (CG), both hired on 01/06/26, had completed all required pre-service dementia care training prior to beginning their job duties: The need to ensure all required staff training was completed in the required time frames was discussed with Staff 1 (ED) and Staff 6 (BOM) on 03/10/26. They acknowledged the findings.

The Business Office Manager (BOM) received training from National Director of Training on March 12, 2026 on Relias Video Training plans and Onboarding Employee in Oregon Communities. The BOM will audit all employee files for required pre-service trainings by (date) The BOM will assign and ensure completion of all missing pre-service trainings by (date) The BOM is responsible for assigning and ensuring completion of required trainings for all employees. The BOM, ED/designee will audit 10% employee files weekly ongoing to ensure compliance.

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

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

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 03/09/26 showed the following areas were in need of cleaning or repair: * Drips, splatters and/or debris were observed under shelves, on the ceiling, on shelves in dry storage and the walk-in refrigerator, on equipment handles and front surfaces and on the walls throughout the kitchen, dish room, janitors’ closet and dry storage; * Multiple light fixtures throughout the kitchen and dry storage had dust, hanging cobwebs, debris and/or dead insects on or inside the light covers. Two light covers were cracked with missing pieces of plastic on one of the cracked covers; * Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges; * Missing piece of laminate was noted to the edge of the cupboards located in the dining room; * Three cutting boards were significantly worn with numerous deep grooves and discoloration; * Flooring throughout the kitchen, dish room, janitors’ closet, and dry storage had black streaks, stains, deep gouges, torn edges, cracked and lifting pieces of laminate and/or missing pieces of laminate. Baseboards and corner sections were cracked and/or pulling away at seams and edges in multiple areas; * A large piece of baseboard was missing across from the drink station. The wall had damaged drywall as well; * Two frying pans and two pots had significant oxidation on the exterior, as well as cooking surfaces; * Food debris and garbage was noted under the side-by-side refrigerator and stove; * Peeling and cracked paint was noted on the ceilings in the dish room and between the stove and steam table; * The caulking around the sink in the staff bathroom located in the kitchen was cracked and missing pieces; * Multiple walls in the kitchen and janitors’ closet had dings, gouges and/or deep scratches; and * A large, irregularly shaped chunk of laminate flooring was missing from the office in the kitchen. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Culinary Services Director) on 03/09/26. The staff acknowledged the findings.

All identified areas were cleaned by the Culinary Services Director (CSD) by: 5/8/26 CSD was educated by the CSDS and National Director of Culinary Services on :5/8/26 about daily, weekly and monthly cleaning scheduleds. The CSD and CSDS will educate Culinary staff on cleaning expectations and schedules by 5/8/26 Daily, weekly and monthly cleaning schedules are posted in the kitchen for the staff to follow. CSD will audit the cleaning schedules/cleanliness at least 3 days/week. Executive Director (ED) will audit kitchen cleaning schedules weekly X4 weeks, bi-weekly x4 weeks and then randomly ongoing. All compromised culinary equipment, including worn cutting boards, pitted or scratched frying pans, and dented pots, were discarded and replaced with new, NSF-approved commercial-grade cookware on 5/8/26. Repairs were completed for identified walls and baseboards. 5/8/26 Identified flooring concerns were repaired and/or replaced on 5/8/26

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.

see C240

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

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 08/19/25 at 10:35 am, the facility kitchen was observed to need cleaning in the following areas: * Shelves below coffee station – spills/drips; * Interior of ice maker – pink matter build up; * Floor drains under three compartment sink and in dishwashing area – build up of black matter; * Commercial stand mixer – splash guard with food splatters; * Operating fan near food service line – dusty; * Dishwashing area – black matter build up on wall behind spray hose sink, dried debris on top of dishwashing machine, wall behind dishwasher yellow matter, shelf holding dish racks splatters/spills; * Dry storage – floor beneath racks, debris/cobwebs; * Commercial can opener – blade finish worn/black matter build up; * Flooring throughout the kitchen including underneath cooking equipment, corners and areas close to cove base – build up of black matter/debris/stains; and * Two door reach in refrigerator, bottom shelf – dried food debris. Other areas of concern included: * Colored cutting boards – finish worn and scored; * Two door reach in refrigerator – salads and orange slices uncovered; * Walk in refrigerator and freezer – containers/packages of shredded cheese, cooked sausage, cheese slices, diced chicken and mango slices not labeled and/or dated; and * Lack of facial hair restraint. The areas of concern were observed and discussed with Staff 1 (Dining Room Coordinator) and discussed with Staff 2 (Executive Director) on 08/19/25. The findings were acknowledged.

C0240 Food Sanitation Rule -Shelves below coffee station had drips and spills, interior of ice maker- pink matter build up, floor drains under three compartment sink had build up, commerical stand mixer had food splattered, open fan near food line was dusty, DW area had black build up on wall behind spray hose, debris on top of the DW, shelving holding dish racks with splatter/spills, dry storage had debris under racks, flooring throughout had build up, two door reach in refridgerator had dried food on the bottom. -Commerical can opener worn and black build up. -Colored cutting boards wore and scored. Lack of facial hair restraint being used. A deep clean of the kitchen is scheduled for 9.18.25 All items identified during survey will be cleaned or replaced on or before 10/1/25 A cleaning schedule will be developed and implemented by the Dining Service Coordinator and the Executive Director. All associates will be trained on proper storing and labeling of items by 10.1.25 New cutting boards have been ordered as of 9.2.25 New can opener has been ordered as of 8.30.25 Facial hair restrains was immediately corrected with beard nets in place.

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 C240

Based on observation, interview, and record review, it was determined the facility failed to prepare and serve food in accordance with Oregon Food Sanitation Rules. Findings include, but are not limited to: The kitchen was toured at 9:50 am on 07/25/24. The following was identified: a. Food spills, splatters, debris, dust, grease, pink grime, and/or black matter were observed in the following main kitchen areas: * The white lip inside the ice maker; * The ceilings throughout the kitchen; * The legs of stainless steel shelving throughout the kitchen; * The top of the warewasher; * The metal venting housing and the vents above the hot pass; * The drawer with ice cream scoops and tongs; * The sides and interiors of the gas ovens; * The interior and exterior of the small oven to the right of the gas ovens; * The pipe to the right of the small oven; * The knobs of the warming area to the right of the beverage refrigerator, on the gas oven, and on the hot pass station; * The exterior of the Robot Coupe mixer; * Electrical outlets throughout the kitchen; * The shelf-mounted can opener by the toaster; * The garbage can exteriors; * The vent in the freezer; * Both kitchen doors and their frames; and * Both rack holders in the dining room. b. Food spills, splatters, debris, and dust were observed in the following memory care kitchenette areas: * The top, interior, and sides of the refrigerator and freezer; * The cabinet door frames and interiors; and * The walls and posts in the kitchenette area; c. Items in the memory care kitchenette were not dated and labeled. d. The refrigerator in the memory care kitchenette lacked a thermometer. e. The following areas in the main kitchen were in need of repair: * The caulking behind the handwashing sink; * The wall behind the metal shelving to the right of the hot pass had paint missing; * Wall edges throughout the kitchen had exposed metal and missing paint; * The gas oven was not operable; and * The large stand mixer was rusted and chipped above the bowl, with potential for contaminating food in the bowl. f. Plastic utensils were stored in open containers on the bottom shelf below the hot pass with potential for contamination. g. Staff 3 (Cook) did not have a current food handler's permit. h. There were oranges with visible mold in the walk-in refrigerator of the main kitchen. The need to ensure Oregon Food Sanitation Rules were followed was discussed with Staff 1 (ED) and Staff 2 (Dining Services Director) on 07/25/24. They acknowledged the findings.

1. Orange with mold was removed from the refrigerator and thrown away. An audit of all items was completed to ensure no other spoiled food was present and any items that appeared spoiled were taken out of production and thrown away. All areas identified during survey will be cleaned on or before 8.20.24. Mixer was taken out of service and a new one was ordered on 7.26.24. New trash cans have been purchased, are in use and are added to the cleaning schedule. Food Handlers for cook identified during survey complete course and obtained certificate on 7.25.24 and was emailed to surveyor same day. 2. A deep clean of the kitchen is scheduled for 8.20.24. A cleaning schedule will be developed and implemented by Dining Service Coordinator and Executive Director. All dining associates will be trained on proper food storage and identifying areas of spoilage by 8.5.24. Dining Service Coordinator received ServeSafe training not just completing the course, but also train the trainer to be able to certify other associates. 3. Dining Service Coordinator will review cleaning schedule documentation and completion 3x weekly for the next 30 days, and then twice weekly ongoing as part of standard operations. Executive Director or designee will review cleaning schedule as well as complete kitchen walkthrough twice weekly for the next 30 days and then weekly ongoing as part of standard operations. 4. Touch up paint and caulking will be completed along with corner guards added throughout kitchen. 9/23/2024 Accepted Yes No 2. How will the system be corrected so this violation will not happen again? Accepted Yes No 3. How often will the area needing correction be evaluated? Accepted Yes No 4. Who will be responsible to see that the corrections are completed/monitored? Accepted Yes No P a g e 2 | 2 5. The Executive Director, Dining Service Coordinator and Maintenance Manger are responsible for this plan of correction.

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

Refer to C240.

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

The findings of the first revisit to the kitchen inspection of 07/25/24, conducted 09/26/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, protocols and practices were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 06/21/23 at 11:15 am, the facility kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, debris and/or black/brown matter was observed on or underneath the following: * Lower shelves throughout the kitchen including below the toaster, steam table, steamer and shelf storing pots and pans; * Equipment included:    - Doors on reach in refrigerator; - Small refrigerator doors near steam table; - Oven doors; - End of the steam table; - Rolling cart shelves;    - Wall behind the stove/grill; - Convection oven doors; - Lid on bin holding oatmeal; - Ceiling above steam table; - The lid to the oatmeal bin, behind the mixer; - Light fixture near back door; and - Flooring throughout kitchen and underneath equipment. Two garbage cans were uncovered when not in use near the ice machine and the dishwashing area. Improper food storage: * Uncovered/undated items in walk in refrigerator including: - Two baked pies; - Tray of individual portions of pudding; * Undated items included: - Ham, chopped salad and croissant sandwich; * Bag of onions sitting on the floor in dry storage area; * A sheet pan of cookies on rolling cart (next to steam table) were uncovered; * Scoops/cups were stored in granulated sugar storage bin and three containers of cereal; and * A stack of three boxes and a single box of food were sitting directly on the floor in freezer. b. One staff not wearing beard restraint. c. Uncovered individual servings of pudding on top of cart with trays delivered to the Memory Care Community unit dining room. The areas of concern were discussed with Staff 1 (Dining Services Director) and Staff 2 (Executive Director) on 06/21/23. The findings were acknowledged.

-Food spills, splatters, debris and/or black/brown matter was observed on or underneath the following: * Lower shelves throughout the kitchen including below the toaster, steam table, steamer and shelf storing pots and pans * Equipment included:  - Doors on reach in refrigerator  - Small refrigerator doors near steam table  - Oven doors  - End of the steam table  - Rolling cart shelves  - Wall behind the stove/grill - Convection oven doors  - Lid on bin holding oatmeal  - Ceiling above steam table  - The lid to the oatmeal bin, behind the mixer  - Light fixture near back door  - Flooring throughout kitchen and underneath equipment. A deep clean of the kitchen will be performed and will include but not be limited to the lower shelves throughout the kitchen, including below the toaster, steam table, steamer and shelf storing pots and pans, doors on reach in refrigerators, small refrigerator doors near steam table, oven doors, end of the steam table, rolling cart shelves, thaw wall behind the stove/grill, convection oven doors, lid on bin holding oatmeal, ceiling above steam table, the lid to the oatmeal bin, behind the mixer, light fixture near back door, and the flooring throughout kitchen/underneath equipment. A cleaning task sheet will be posted and followed to ensure continuous cleaning of the kitchen. The ED/designee will be responsible for ensuring compliance. -Two garbage cans were uncovered when not in use near the ice machine and the dishwashing area. All trash cans now have lids, staff will be educated on using lids on trash cans at July All Staff Meeting. The ED/designee will be responsible for ensuring compliance. -Improper food storage was found by uncovered/undated items in walk in refrigerator, a bag of onions sitting on the floor in dry storage area, a sheet pan of cookies on rolling cart (next to steam table) were uncovered, scoops/cups were stored in granulated sugar storage bin and three containers of cereal, and a stack of three boxes and a single box of food were sitting directly on the floor in freezer. All food that was improperly stored has been discarded, kitchen staff retrained on proper food storage to ensure food safety protocols are met. ED/Designee will be responsible for ensuring compliance. -One staff not wearing beard restraint Staff members were retrained on protocols for retraining hair and facial hair, beard restraints are available to staff. ED/designee responsible for ensuring compliance. Uncovered individual servings of pudding on top of cart with trays delivered to the Memory Care Community unit dining room Staff members retrained on expectation and importance of covering all food prior to being brought out of the kitchen/dining room. ED/designee reposinsible to ensure compliance.

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

see C240

The findings of the kitchen inspection, conducted on 06/21/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit to the kitchen re-licensure survey of 06/21/23, conducted 08/24/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

3. Resident 2 was admitted to the facility in August 2022 with diagnoses including dementia. The resident's service plan, dated 09/02/22, and interviews with care staff between 09/19/22 and 09/20/22 indicated the resident required full assistance of two staff for transfers with use of a gait belt. The resident required extensive assistance for ADLs. The resident could make needs known but was forgetful. Review of incident investigations and progress notes from 06/19/22 through 09/19/22 showed the following: An incident report was completed regarding a skin tear to the resident's upper right arm on 09/05/22. A thorough investigation was not completed regarding the skin tear. The incident report/investigation did not include information on how staff ruled out abuse and neglect, staff response at the time of the incident, description of what occurred, and follow up action taken. The facility was asked to report the skin tear to the local SPD office, and confirmation was provided prior to the survey exit. The need to ensure resident incidents were thoroughly investigated to rule out abuse and neglect was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 09/20/22. The staff acknowledged the findings 4. Resident 3 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease. The resident's service plan, dated 07/14/22, and interviews with care staff between 09/19/22 and 09/20/22 indicated the resident required full assistance from staff for care after a recent decline over the last few months. The resident previously was independent with transfers. The resident would not initiate care and staff anticipated the resident's needs. Review of incident investigations and progress notes from 06/19/22 through 09/19/22 showed the following: Incident reports were completed for unwitnessed, non-injury falls on 07/21/22, 07/30/22, and 09/15/22. The incident reports/investigations did not include information on how staff ruled out abuse and neglect. The investigations did not consistently include information regarding staff response at the time of the incident, description of what occurred, follow-up action taken, and administrator review. The need to ensure resident incidents were thoroughly  investigated to rule out abuse and neglect was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 09/20/22. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and unwitnessed falls were promptly investigated to rule out suspected abuse and/or neglect and were reported to the SPD as needed for 4 of 4 sampled residents. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2016 with diagnoses including dementia and stroke. The resident's clinical record from 06/30/22 through 09/19/22, including progress notes, temporary service plans, and incident reports, was reviewed, and interviews with staff were conducted. On 09/14/22 staff completed an incident report for a skin tear on the resident's right forearm. The incident was not investigated to rule out abuse and/or neglect, nor was it reported to the local SPD office. The surveyor requested the RN report the incident on 09/20/22. Confirmation was provided of the reports prior to survey exit. The need to investigate injuries of unknown cause to rule out abuse and/or neglect, and to report the incident to the local SPD office if abuse and/or neglect could not be ruled out, was discussed with Staff 1 (ED) and Staff 2 (RN) on 09/20/22. They acknowledged the findings. The surveyor received confirmation the facility reported the incident on 09/20/22 prior to survey exit. 2. Resident 4 was admitted to the facility in 08/2022 with diagnoses including dementia. The resident's facility record was reviewed, including progress notes, temporary service plans, and incident reports dated from 08/15/22 through 09/18/22, and interviews with staff were conducted. A 09/04/22 progress note indicated staff discovered a skin tear on the resident's lower right arm on 09/03/22. Staff documented on 09/06/22 the resident "did not remember how it happened." There was no documented evidence the facility investigated the injury of unknown cause to rule out abuse and/or neglect, nor did they report the injury to the local SPD office. The surveyor requested the RN report the incident on 09/20/22. Confirmation was provided of the report prior to survey exit. The need to thoroughly investigate injuries of unknown cause was discussed with Staff 1 (ED) and Staff 2 (RN) on 09/20/22. They acknowledged the findings.

1.a An investigaion was conducted and an APS report filed for resident's 1, 2 and 4 on 9/21/22. A post fall investigation was completed for resident 3. 2.a. Education was immediately provided to Med Tech's and caregivers at stand up and at shift change.  In addition it will be provided to staff at our mandatory ALL STAFF meeting on 10/19/22 and at Med Tech meeting 10/20/22 regarding incidents of unknown origin and importance of reporting and documentation completion.  Review of BAIRS form and process.  See attendance log.  Hand outs provided to staff unable to attend.   2.b. Executive Director, Health and Wellness Director, Clinical Coordinator and Resident Care Coordinator to review  "conducting abuse investigation" module to be completed by 10/19/22 2 c. A review of all incidents has been conducted to determine whether others meet reporting criteria. 3. Incidents to be reviewed at clinical meeting 3-5x/week to ensure thorough investigations are completed. 3.The Health and Wellness Director, Clinical Coordinator and Executive Director are responsible for this plan of correction,

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and unwitnessed falls were promptly investigated to rule out suspected abuse and/or neglect and were reported to SPD as needed for 1 of 2 sampled residents (#6) reviewed with incidents.  Findings include, but are not limited to: Resident 6 was admitted to the facility in 12/2021 with diagnoses including dementia. Progress notes reviewed from 11/20/22 through 01/11/23 noted the following: *11/21/22 Resident was placed on alert charting for a non-injury fall; *11/25/22 Discoloration was noted on the top of the resident's left buttock; *12/09/22 Resident was placed on alert charting for a non-injury fall; and *12/14/22 Discoloration was noted on the resident's buttocks. Incident reports were completed for 11/21/22 and 12/09/22 noting unwitnessed non-injury falls. There was no documented evidence of investigations for the discoloration, injuries of unknown cause, that were noted on the resident on 11/25/22 and 12/14/22. The incident reports/investigations were either not completed or did not include information on how staff ruled out abuse and neglect.  The investigations did not consistently include information regarding staff response at the time of the incident, description of what occurred, follow-up action taken, and Administrator review. Thoroughly investigating injuries of unknown cause and non-injury unwitnessed falls to rule out abuse and neglect and reporting as necessary to SPD was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 16 (Health and Wellness Director) on 01/11/23 at 1:20 pm.  Staff acknowledged the findings. The surveyor requested Staff 16 report the incident on 11/21/22 and 12/09/22 to the local SPD.  Confirmation of the reports was provided prior to the end of the day.

1. Incidents on 11/21/2022 and 12/09/2022 were provided to local SPD on 1/11/2023.  Education was immediately provided to Med Tech's and caregivers at stand up and at shift change 1/13/2023.     2. Staff received education on incidents of unknown origin, documentation and reporting requirements on 1/25/2023.  Executive Director, Health and Wellness Director, Clinical Coordinator and Resident Care Coordinator will review OR Abuse Reporting & Investigation guide to be completed by 2/10/2023.  Incidents from the past 30 days have been reviewed to assure reporting as required by rule. 3. Resident incidents will be discussed at daily stand-up meeting and reviewed in detail during routine clinical meeting 3-5 times per week to assure follow-up investigation, and/or APS reporting occurred as needed.  Executive Director will regularly review incident documentation to evaluate for effective follow up and assure reporting has occurred. 4.The Executive Director is responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 1 of 4 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease. Observations of the resident, interviews with staff, and review of the service plan dated 07/14/22 showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Behaviors including uncontrolled weeping/sadness; * Transfers and ambulation; * Walker and wheelchair use; * Full feeding assistance, straw use and supplements; and * Falls and safety interventions. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 09/20/22. The staff acknowledged the findings.

1.Service plan for resident 3 has been updated to reflect current care needs by 10/10/22. All other residents will be reviewed and updated to ensure accuracy of service plans . 2 a.Current resident service plans will be reviewed by our service planning team as necessary to assure they are reflective of needs. The Executive Director and Health and Wellness Director have reviewed rule and community policy as it relates to the service planning process. 2. b  All Med Techs will be educated in the use of TSP's for noting immediate change in care needs at our med tech meeting on 10/20/22. 3.The Executive Director, Health and Wellness Director and or Designee will conduct random audits of service plans twice monthly for 60 days.   4.The Executive Director, and Health and Wellness Director are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat residents' behaviors had written, resident-specific parameters and/or non-pharmacological interventions for staff to attempt prior to administering a PRN psychotropic medication for 3 of 4 sampled residents (#s 1, 3 and 4) who were prescribed a PRN psychotropic medication. Findings include, but are not limited to: Review of 09/01/22 through 09/19/22 MARs and physician orders revealed that Residents 1, 3 and 4 were prescribed a PRN psychotropic medication for anxiety and/or agitation. The following was identified: 1. There were no resident-specific parameters on the MARs indicating how each resident exhibited signs and symptoms of anxiety and/or agitation. 2. Resident 3's MAR did not include any non-pharmacological interventions for staff to attempt prior to administering the PRN psychotropic. The need to include a description of how each resident exhibited signs and symptoms of anxiety and/or agitation, as well as non-drug interventions for staff to attempt before administering a PRN psychotropic medication, was discussed with Staff 1 (ED) and Staff 2 (RN) on 09/20/22. They acknowledged the findings.

1.The mars were updated and staff education was done immediately following discovery of no resident specific parameters on the mars indicating how each resident exhibited signs/symptoms of anxiety and or agitation for residents 1,3 and 4 and for non pharmacological interventions being documented for resident 3.   Signs were posted in the med room and the staff on shift were trained on proper protocols. 1.b A review of all residents on prn psychotropics has been completed by 10/10/22 to ensure compliance. 2.a A med tech meeting will be held on 10/20/22 for review of education and process for documenting resident specific parameters, including non pharmacological interventions prior to administering prn psychotropic medications. 3.a During clinical meeting documentation will be reviewed for psychotropic medications to ensure that the correct documentation is being done. 3.b Executive Director, Health and Wellness Director and/or Designee will conduct random emar audits wekly for 60 days to monitor for compliance. 4.The Executive director and Health and Wellness Director are responsible for this plan of correction

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.

See C231

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 .

See POC 231

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 and C 330.

See C260 and C330

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, and 3's service plans offered some information about the resident's interests, but the facility had not fully evaluated the resident's: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities. Observations on 09/19/22 and 09/20/22 showed multiple small group activities being led by facility staff. Residents 1 and 3 were not consistently invited to activities or provided adaptations to participate in the activity. The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (Program Director/Activities) on 09/20/22. The staff acknowledged the findings.

1.  Residents 1,2 and 3 assessments were completed for assessment of past and current interest, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations for resident participation and activities that could be used as behavioral interventions. 2. A service planning team has been assembled to review all residents service plans and to update their activities to ensure preferences, abilities and adaptations are met. 3. The Health and Wellness Director and or Designee will conduct random audits of resident service plans twice monthly for 60 days. 4. The Health and Wellness Diector and Executive Director are responsible for this plan of correction

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C 231.

See POC 231

The findings of the re-licensure survey, conducted 09/19/22 through 09/20/22, 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, 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 revisit to the re-licensure survey of 09/20/22, conducted 01/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second revisit to the re-licensure survey of 09/20/22, conducted 04/19/23, are documented in this report. It was determined the facility was in compliance with 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.