Monarch Gardens Memory Care

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were monitored with weekly progress noted until the condition resolved for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who were reviewed for changes of condition. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 10/2025 with diagnoses including dementia. The resident’s 02/02/26 through 05/03/26 clinical record was reviewed. The following was identified: In a 04/08/26 observation note, staff documented the resident experienced a witnessed fall and sustained a skin tear above his/her left eyebrow. There was no documented evidence the resident’s skin condition was monitored, with progress noted at least weekly through resolution. In an interview on 05/07/26 at 10:45 am, Staff 4 (RCC) confirmed the lack of documented monitoring through resolution for Resident 4’s skin tear. The need to ensure changes of condition were monitored with weekly progress noted until the condition resolved was discussed with Staff 1 (Administrator) and Staff 4 on 05/07/26 at 2:00 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 09/2026 with diagnoses including congestive heart failure and atrial fibrillation. The resident’s 01/01/26 through 05/04/26 clinical record was reviewed and the following was identified: The resident’s service plan indicated the community nurse would monitor weeping edema in bilateral legs and a wound on the resident’s right shin weekly. There was no documented evidence the resident’s skin condition was monitored, with weekly progress noted through resolution. On 05/07/26 at 12:10 pm, Staff 4 (RCC) confirmed the documentation of skin monitoring did not occur at least weekly through resolution. On 05/07/26 at 2:35 pm, the need to ensure short-term changes of condition were monitored with weekly progress noted until the condition resolved was reviewed with Staff 1 (Administrator) and Staff 4. They acknowledged the findings. 3. Resident 2 moved into the facility in 02/2026 with diagnoses including Alzheimer’s dementia. The resident’s 02/02/26 to 05/04/26 clinical record was reviewed and the following was identified: An observation note dated 03/29/26 documented an unwitnessed fall, which resulted in surgical repair of the resident’s left hip. The resident returned to the facility on 03/31/26. An observation note on 04/03/26 documented, “This morning caregiver reported that the bandage on injured hip is turning dark,” and the resident was sent to the ER to have the incision treated. There was no documented evidence of monitoring of the surgical incision again until 04/15/26, twelve days after the resident’s ER visit. The facility failed to document weekly progress of the surgical incision through resolution. Staff 6 (LPN) documented the incision was healed and discontinued monitoring on 04/25/26. On 05/07/26 at 12:10 pm, Staff 4 (RCC) confirmed monitoring of the incision had not been completed with weekly progress noted through resolution. The need to ensure short-term changes of condition were monitored with weekly progress noted until the condition resolved was reviewed with Staff 1 (Administrator) and Staff 4 on 05/07/26 at 2:35 pm. They acknowledged the findings. 4. Resident 3 moved into the facility in 02/2025 with diagnoses including Alzheimer’s disease. The resident’s 02/02/26 through 05/03/26 clinical record was reviewed. The following was identified: In a 03/15/26 incident report, staff documented the resident “became combative” with the staff during a shower and “sustained a triangle shaped skin tear on [his/her] right arm.” There was no documented evidence the resident’s injury was monitored, with weekly progress noted through resolution. In an interview on 05/07/26 at 10:19 am, Staff 4 (RCC) confirmed the lack of documented monitoring through resolution for Resident 3’s skin tear. The need to ensure changes of condition were monitored with weekly progress documented until resolution was discussed with Staff 1 (Administrator) and Staff 4 on 05/07/26 at 1:35 pm. They acknowledged the findings.

1. Residents identified have had the short term monitoring found resolved. Current review completed of all Temporary Service plans with confirmation that short term monitoring is being documented and nursing staff completing resolution and weekly skin monitoring as indicated. Community will ensure short term changes of condition are monitored with weekly progress notes until the condition is resolved. 2. The community will follow the following processes to assure temporary service plans are completed timely and any short term change of condition is documented at least weekly through resolution. The community utilizes the following processes available in EHR (electronic health record.) a.Temporary Service Plans (TSP) in the EHR. Med Techs are to use only the approved TSP's and are to implement and notify RCC and RN using the Nurse reporting guidline form. RCC or RN to review and DC TSP's. b.EHR Alert Charting following the Alert Charting Guidelines c. White board updated for all skin concerns for licensed nursing to review, assess, and document weekly in the EHR. Clinical Meeting held Monday - Friday- responsibilities: a.Review Observation Notes Monday- Friday b.Review Incident Reports Monday -Friday- Coordinate with Administration for investigations c.Nurse to work with Med Techs and RCC to assure alert charting and TSP’s are utilized appropriately and that the information is accurate.. d.Review Alert Charting in EHR Monday-Friday Med Tech responsibilities: a. Use only approved EHR TSP. b.Prompt notifications following Nurse notification guidelines document. c.Follow charting guidelines to assure prompt and accurate reporting of resident status Administrator Responsibility a.Morning Stand up done daily with clinical meeting b. Administrator reviews all IR's and observation notes Monday through Friday. Staff trained to provide weekend notifications to ED per Call Guideline document. 3. Daily review of TSP's, Weekly clinical meeting with Regional RN.This system requires daily monitoring and weekend Med Techs trained regarding notifications to Nurse and Administrator using the company notification form. 4. RCC, RN and Administrator with oversight of VP of Health Services and COO.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were administered only after documented, non-pharmacological interventions were tried with ineffective results for 1 of 2 sampled residents (# 2) who had an order for PRN psychotropic medications. Findings include, but are not limited to: Resident 2 moved into the facility in 02/2026 with diagnoses including Alzheimer’s dementia. The resident’s 04/01/26 to 05/04/26 MAR and clinical record were reviewed and revealed the following: The resident had an order for Lorazepam 1 mg tablet, administer 0.5 tablet to 1 tablet two times daily as needed for anxiety. The MAR indicated staff administered the 1 mg dose of the medication on six occasions between 04/01/26 and 04/30/26. The resident’s record lacked documented evidence non-pharmacological interventions were attempted and ineffective for four of the six administrations. On 05/07/26 at 12:10 pm, Staff 4 (RCC) confirmed staff had not consistently been documenting attempted non-pharmacological interventions were ineffective prior to administering the psychotropic medication. The need to ensure PRN psychotropic medications were administered only after documented, non-pharmacological interventions were tried with ineffective results was reviewed on 05/08/26 at 2:35 pm with Staff 1 (Administrator) and Staff 4. They acknowledged the findings.

1.The residents identified has had MAR updated for resident specific non-pharmacological interventions prior to administration of medications. A new question was added to the EMAR to prompt for documentation that 4 non-pharmacological interventions were attempted prior to administration of psychtropic medication.All residents on a PRN psychotropic medication were audited to assure that non-pharmacological interventions were in place with question to document prior to use. Community will ensure PRN psychotropic medications are administered only after documented, nonpharmacological interventions are tried with ineffective results. 2.Nursing adds non-pharmacolocal resident specific interventions any time a new medication is ordered. Med Techs trained to notify nursing any time they see a PRN psychotropic. In addition with the 3rd check of all orders the RN will review. In additon, this will be reviewed quarterly with the service conference and referral to nursing if resident has a PRN psychotropic medication. 3. With all new orders and quarterly 4. RCC and RN with oversight of Administrator.

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 the Acuity-Based Staffing Tool (ABST) accurately capture care time and care elements staff were providing to residents for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 02/2025 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the 04/13/26 service plan and Resident 3’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Monitoring physical conditions or symptoms; and * Supervising, cueing or supporting while eating. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Administrator) and Staff 4 (RCC) at 1:35 pm on 05/07/26. They acknowledged the findings. 2. Resident 4 moved into the facility in 10/2025 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the 04/22/26 service plan and Resident 4’s ABST data was completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Safety checks and fall prevention; * Monitoring physical conditions or symptoms; * Assisting with leisure activities; * Providing non-drug interventions for behavior; * Providing non-drug interventions for pain; * Providing supervision, cueing or support while eating; * Providing ambulation assistance, escorting to and from meals and activities; * Providing transfer assistance in or out of bed or chair; and * Helping with bowel and bladder management. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (Administrator) and Staff 4 (RCC) on 05/07/26 at 2:00 pm. They acknowledged the findings. 3. Resident 1 moved into the facility in 09/2026 with diagnoses including congestive heart failure and atrial fibrillation. Observations of the resident, interviews with staff, and review of the 04/22/26 service plan and Resident 4’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Safety checks and fall prevention; * Providing treatments; * Supervising, cuing, or supporting while eating; and * Transferring in or out of bed or chair. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (Administrator) and Staff 4 (RCC) on 05/07/26 at 2:35 pm. They acknowledged the findings. 4. Resident 2 moved into the facility in 02/2026 with diagnoses including Alzheimer’s dementia. Observations of the resident, interviews with staff, and review of the 04/15/26 service plan and Resident 4’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Monitoring behavioral conditions or symptoms; and * Safety checks and fall prevention. The need to ensure the ABST addressed the amount of staff time needed to provide care was discussed with Staff 1 (Administrator) and Staff 4 (RCC) on 05/07/26 at 2:35 pm. They acknowledged the findings.

1.Residents 1, 2, 3, 4were updated on the ABST specifc to the items mentioned in the SOD. The remainder of the residents were reviewed and updated using caregiver reports on multiple shifts and while reviewing service plans in conjunction. Schedule and staffing has been reviewed to meet the needs in relation to ABST. The current RCC now has the duty of maintaining the ABST with oversight of RN and Administrator. RCC received additional training from an RCC at another community with extensive experience and no deficiences on ABST. 2. The ABST is updated promptly as changes occur ensuring reflecting current needs. Any new staff completing the ABST will received company sponsored training with staff with ABST competency. 3. The ABST is reviewed at least weekly and with changes of condition, new admissions, and quarterly with service conferences by the RCC to ensure accuracy. The schedule is updated daily as needed when changes occur to reflect current ABST needs meeting state requirement. New admissions are done prior to move in. 4. RCC and Administrator with oversight of COO and VP of Health Services as company quality assurance activities.Community will ensure the Acuity Based Staffing Tool (ABST) accurately captures care time and care elements staff are providing to residents.

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 interior was free from unpleasant odors. Findings include, but are not limited to: The interior of the memory care was toured on 05/04/26 at 3:25 pm. The following was identified: Pervasive odors were present throughout the Monarch and Garden sides and did not dissipate during the survey. On 05/05/26 at 10:20 am, Staff 18 (Regional Facilities Services Director) stated the facility was replacing flooring from residents’ rooms when they were vacated in an effort to mitigate odors by recurrent incontinent episodes. The odors proliferated into the common areas, however, and he did not know of any plans to replace the flooring in those areas. The need to ensure the facility was free of unpleasant odors was reviewed with Staff 1 (Administrator) and Staff 3 (Facilities Services Director) on 05/06/26 at 10:30 am. They acknowledged the findings.

1. Community will ensure the interior is free from unpleasant odors. Additional air fresheners (15) have been purchased and placed strategically throughout Community to ensure odors are eliminated. Flooring has been removed and replaced with waterproof LVP in identified areas to eliminate odors. Walkthrough of the Community was completed and verified that no additional odors were noted. 2.The following systems are implemented to assure this violation is corrected. a. Daily walkthrough by administrator or designee to assure community is free from unpleasant odors. b. Maintenace department and/or Housekeeping will be promptly notified of any unpleasant odors. c. In-service completed will all staff regarding notification of unpleasant odors promptly to housekeeping or maintenance. If odor continues, prompt notification to administrator. 3. Daily walkthrough by administrator or designee. Report during morning stand-up of any concerns that have arisen with prompt plan of correction. Monthly during company mini-mock survey. 4. Housekeeping and Maintenace with oversight of administrator.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit.

Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers and failed to provide a manually operated emergency call system in each toilet and bathing facility used by residents and visitors. Residents were unable to contact staff to request help when needed, constituting a threat to their health, safety, and welfare. Findings include, but are not limited to: The facility was a memory care unit that was had two “sides,” Monarch and Garden. Staff on either side communicated through walkie talkies. During the tour of the facility’s interior on 05/04/26 at 3:25 pm, direct care staff in Monarch and Garden units were interviewed regarding the facility’s call system. Staff 9 (CG) reported seeing pull cords in resident bathrooms, but had never responded to a call from one, and did not know if they were operable. Care staff were instructed to provide hourly safety checks to all residents to offer ADL assistance. Staff 9 reported some residents had whistles to use to summon care staff. In an interview on 05/04/26 at 4:14 pm, Staff 11 (CG) stated two residents in Garden unit had tab alarms and “one or two” residents in Monarch unit had whistles to summon care staff when they required assistance. He stated care staff provided hourly safety checks to residents to offer assistance with care needs. On 05/04/26 at 4:35 pm, Staff 1 (Administrator) confirmed the facility had no call system connecting resident units to the care staff. Staff 1 and Staff 4 (RCC) confirmed the pull cord call system in each resident’s bathroom had not been operable for “a couple of years.” The facility failed to ensure residents had a working call system, which left residents unable to call for assistance when needed and placed the residents’ health, safety, and welfare at risk. On 05/04/26 at 5:34 pm, a written plan of correction was requested of Staff 1, to be submitted by 9:30 am on 05/05/26. The plan of correction was accepted at 11:05 am on 05/05/26. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to have an operational call system that connected residents to the care staff or staff pagers was discussed with Staff 1 and Staff 4 (RCC) on 05/05/26. They acknowledged the findings.

1. A new call system was installed and verified working on 5/8/2026/ 2. Community Maintenance Team staff will ensure system correction by performing weekly spot checking and monthly full system checking. Staff Inserviced on need for immediate reporting of call system is noticed to not be functioning properly. 3. Weekly and Monthly testing of system. Monthly reporting to corporate team during Mini-Mock Survey report required. 4. Community Maintenance Team with oversight of Administrator.

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

Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit. Findings include, but are not limited to: On 05/04/26 at 5:03 pm, observations of the shared bathroom between roommates in Rooms 221 and 223 on the Monarch side revealed no locking mechanism for the residents to lock the doors from inside the bathroom. On 05/05/26 at 8:30 am, Staff 4 (RCC) demonstrated the locks on shared bathroom doors in Garden side were inoperable because strike plates had not been installed for the door latches to secure into. Staff 4 confirmed residents throughout the facility were not able to lock their shared bathroom doors from inside their bathrooms for privacy. On 05/08/26 at 2:35 pm, the need to ensure each individual had privacy in his or her own unit, including privacy when using shared bathrooms between roommate units, was discussed with Staff 1 (Administrator) and Staff 4. They acknowledged the findings.

Community will ensure each individual has privacy in his or her own unit. Community Maintenance Team staff will ensure system correction by ensuring each resident bathroom has locking doors. Community Maintenance Team staff will ensure sytem correction by performing quarterly audits of resident bathrooms throughout the community. Community Maintenance Team staff who will ensure the systems corrections are completed and monitored consists of the Communities Regional MD, MD and AMD. All failures to ensure systems corrections shall be reported to the Community Administrator immediately.

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 C513 and C555.

Referral tag- refer to C513

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 3 of 3 newly hired direct care staff (#s 11, 13, and 17) completed all required pre-service dementia training topics and demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 05/05/26 at 2:35 pm with Staff 2 (Business Office Manager). The following was identified: a. There was no documented evidence Staff 11 (CG), Staff 13 (CG), and Staff 17 (MT), hired 02/10/26, 03/16/26, and 04/06/26, respectively, had completed one or more of the following pre-service dementia training topics for direct care staff: * Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia; and * Use of supportive devices with restraining qualities in memory care communities. b. There was no documented evidence Staff 11, Staff 13, and Staff 17 demonstrated competency in one or more of the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documenting and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * Other duties, including medication pass and treatments. The need to ensure the required pre-service training was completed and staff demonstrated competency in assigned job duties within 30 days of hire was discussed on 05/05/26 at 2:35 pm with Staff 2 and on 05/07/26 at 2:00 pm with Staff 1 (Administrator) and Staff 4 (RCC). They acknowledged the findings.

1. Complete training audit under review to assure that all staff are trained per policy and OAR. All staff to be completed by the alleged compliance date. 2.Designated staff trainers (experienced Med Tech, Caregiver and/or RCC, Dining supervisor) perform evaluated competency checks on their department staff to observe demonstrated performance skills. The Business Office Manager (BOM) monitors competency checks using tools such as the training tracker spreadsheet to ensure training is properly completed, and then record the documents in appropriate files. All on-line modules (Relias and Oregon Care Partners) are completed prior to beginning work on the floor or within the 30 day compliance date depending on if it is pre-service or 30 days. Company approved Orientation and competencies are done for each employee. Process: Hire, Onboarding with Orientation form and required pre-service trainings including CPR, First Aid,and Food Handerlers, shadowing on the floor, demonstrated competencies, finish 30 day trainings. BOM monitors staffing to assure compliance and trainings are completed. 3.The Business Office Manager or designee maintains the tracking spreadsheet to assure accuracy of training and within all required timeframes per policy and OAR. The BOM notifies managers if there are staff who are not in compliance. 4. BOM with Administrator oversight.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

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 C270, C330, and C362.

Referral Tag- refer to C270

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 OAR 333-150-000. Findings include, but are not limited to: On 03/24/26, between 10:30 am and 12:45 pm, the facility kitchen was observed, and the following was identified: 1. Sanitation: * PH test strips were not available to monitor sanitizer of dish washer; * Fine tip thermometer was not available; and * Food/beverage was not covered throughout delivery to resident rooms. 2. Menus: * A seven-day menu was not made available to all residents. 3. Food Storage: * Multiple food items that were expired and/or not dated were found in the reach-in refrigerator. The surveyor found an undated bag of raw chicken breasts floating in the juices from thawing in the refrigerator. Staff 1 (PIC / Dining Services Manager) reported that they would be cooked and served the next day. The surveyor requested that staff discard them. The surveyor found multiple leftovers that were expired and requested that staff discard them. The areas of concern were observed and/or discussed with Staff 1 (PIC/Dining Services Manager) and Staff 2 (Resident Care Coordinator). Staff acknowledged the findings at approximately 12:45 pm on 03/24/26.

1) Community Dining Services Manager and Executive Director will perform weekly audits to ensure violation is corrected. 2) System correction will be ensured through weekly audits of areas of concerns perfomed the the Communites Dining Services Manager and Executive Director. 3)The areas needing correction will be evaluated weekly through internal audit performed by the Communites Dining servies Manager and Executive Director. 4) The Communities Dining Servies Manager and Eecutive Director will be resposible for monitoring and completing 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 follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

1) - Community has purchased newfine tip Thermometer and will ensure use. - Community has purchased PH test strips and will ensure use. - Community has purshaced Food coverings for meal delivery and will ensure there use. - Community has posted 7 day menu. - Community wil ensure that all food items are labeled and dated after opening. 2) Community will ensure sytems will be corrected by conducting weekly evaluations of concerns along with additional Training for all Kitchen Staff. 3) The areas in need of correction will be evaluated weekly by the Communities Dining Services Manager and Executive Director. 4) The Communites Dining Services Manager and Executive Director.

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 06/17/25 showed the following areas needed cleaning or repair: * Sections of flooring throughout the kitchen and dry storage had dark stains, black accumulation along the edges of baseboards and flooring, pieces of flooring were cracked and/or missing pieces and were pulling apart at seams. Patches to the flooring were pulling apart at edges and creating gaps in the floor; * Dry storage shelving had spills and debris on multiple shelves and debris was noted underneath the shelving units; * Refrigerator units were noted with spills and debris on the shelves and on bottoms of the units; * Spills and splatters were noted on the large three-door refrigerator doors and vents, and a broken handle was noted on the center unit refrigeration side; * Numerous lights in the kitchen had dead bugs, debris and/or dust gathered in the interiors; * Four cutting boards were extremely worn and frayed, two mixing spatulas were missing small pieces and cracked, and two blender pitchers were cracked and stained; * Debris, spills and discolored flooring was noted between and around equipment edges throughout the kitchen; * Splatters were noted on the ceiling near the steam table and stove area. Large amounts of dust and webs were gathered on vents at the front of the kitchen and hanging from a video camera from the ceiling; * Drains throughout the kitchen were darkly stained with black/brown accumulation and/or debris in the drain; * Multiple plastic edge coverings and plastic wall pieces were cracked and missing large pieces near the window and the handwashing sink; * Spills and splatters were noted on walls throughout the kitchen and along the fronts of both ovens; and * An air conditioning wall unit, above the window, had thick dark accumulation and dust on the inner vent slats. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 2 (Facility Services Director) on 06/17/25. They acknowledged the findings.

1. Damaged Flooring – Seams Pulling Apart and Gaps Forming • Corrective Action Taken: New flooring has been ordered. Kitchen flooring will be patched as an interim fix. • Systemic Change: Ongoing monitoring and preventative maintenance will be implemented to detect early signs of flooring damage and address them promptly. • Evaluation Frequency: Monthly inspections by Maintenance or Executive Director (ED). Weekly observations by Dining Services Manager (DSM). • Responsible Party: Maintenance Director, Dining Services Manager, and Executive Director. 2. Dry Storage Shelving – Debris on Shelves and Underneath • Corrective Action Taken: Shelving and surrounding area will be fully cleaned by Dining Department staff by 8/10/2025. • Systemic Change: Routine cleaning schedule reinforced and documented in daily cleaning logs. • Evaluation Frequency: Weekly checks by DSM. Monthly audits by DSM or ED. • Responsible Party: Dining Services Manager, with oversight by Executive Director. 3. Refrigerator Door and Handle – Spills and Spatter Present • Corrective Action Taken: Area has been cleaned. Door and handle will be replaced. • Systemic Change: Added to daily cleaning checklist. Shift lead cooks verify cleaning at close of each shift. • Evaluation Frequency: Daily checks by cooks. Weekly reviews by DSM. Monthly audits by DSM or ED. • Responsible Party: Cook staff, Dining Services Manager, Executive Director. 4. Ceiling Lights – Dust and Debris Present • Corrective Action Taken: Lights cleaned by Maintenance on 7/8/2025. • Systemic Change: Monthly maintenance schedule updated to include light cleaning in kitchen and food service areas. • Evaluation Frequency: o Monthly by Maintenance or ED. • Responsible Party: Maintenance Director and Executive Director. 5. Cutting Boards and Mixing Spatulas – Damaged/Frayed • Corrective Action Taken: Damaged items discarded on 6/17/2025. New equipment received on 6/30/2025. • Systemic Change: Weekly supply checks implemented. Replaced items logged with date. • Evaluation Frequency: Weekly by DSM. Monthly by ED. • Responsible Party: Dining Services Manager, Executive Director. 6. General Cleaning – Spills, Spatter, and Debris in Kitchen • Corrective Action Taken: Daily cleaning protocols are being enforced and documented. • Systemic Change: Cleaning checklists are posted and signed off daily by cook staff and reviewed weekly. • Evaluation Frequency: Daily cleaning by cooks. Weekly reviews by DSM. Monthly spot checks by DSM and ED. • Responsible Party: Cook staff, Dining Services Manager, Executive Director.

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

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

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

Refer to 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.

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 between 05/15/24 and 05/16/24 showed the following areas were in need of cleaning or repair. a. An accumulation of food spills, splatters, debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Pipes, walls, and flooring behind/underneath the dish machine; * Floor drains; * Spice shelf and drawers; * Floors throughout the kitchen and dry storage had black matter build-up, food debris, and grease in corners, along baseboards, under equipment, and around perimeter edges; * Exterior of refrigerator and freezer doors; * Ice machine; and * Trash cans. b. Additional observations showed the following: * The air conditioning/heating unit mounted above the kitchen window had an accumulation of dirt, dust, and debris; * The kitchen window screen was not properly sealed to prevent containments and debris from entering the kitchen; * Water was leaking from the pipes on top of the dish machine during the rinse cycle; * The double countertop soup warmer was broken; * Cutting boards were heavily scored and stained; * The exterior of plastic bins containing flour, oats, and sugar had food spills and splatters and had cups or scoops stored in them; and * The reach-in refrigerators and freezers were overloaded with boxes and food items, making airflow difficult. The  need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED) on 05/16/24. She acknowledged the findings.

Repair or Replacement -kitchen window screen 1. Will be repaired by Maintenance Manager 2. Dining Manager will ensure all items needing repaired are addressed with Maintenance Manager 3. Maintenance Manager will inspect monthly with a monthly inspection list. 4. ED to monitor for completion during weekly 1:1 with both managers. -Water leak from top of dishwasher 1. Maintenance Manager to contact repair company to repair this leaking pipe. 2. Dining Manager to ensure items needing repaired are addressed with Maintenance Manager 3.Maintenance Manager will inspect monthly with a monthly inspection list. 4. ED to monitor for completion during weekly 1:1 with both managers. -Double Countertop Soup Warmer 1. Replacements have been ordered and soup warmers disposed of. 2. Dining Manager will ensure all items needing repaired or replaced are addressed with Maintenance Manager 3. Maintenance Manager will notify ED if replacement of item is needed. 4. ED to monitor for completion of this purchase and will have weekly 1:1 meetings with both managers. -Cutting Boards 1. Cutting Boards have been replaced with new professional grade boards. 2. Dining Manager to ensure items needing repaired/replaced are being addressed with Maintenance Manager. 3. Maintenance Manager to notify ED if replacement of items is necessary. 4. ED to monitor for completion of this purchase and will have weekly meetings with both managers -Plastic Bins(containing dry goods) 1. New plastic bins have been ordered to replace the aged ones 2. Item was added to the Dining Managers checklist to ensure bins are not damaged or stained. 3. Dining Manager will inspect these monthly and as needed. 4. ED to ensure that Dining Manager is completing his weekly/monthly checklists with 1:1 weekly meetings. CLEANING AND SANITATION 1. Staff will clean all spills, splatters debris, dust, black matter and grease from the air conditioning unit/heating unit, as well as the pipes and flooring behind the dish machine, floor drains, spice shelf and drawers, floors throughout the kitchen and dry storage, exterior of refridgerator and freezer doors, ice machine, and trash cans. 2. Daily/Weekly/Monthly cleaning lists have been updated to prevent violation from reoccuring. 3. Cleaning list will be checked/evaluated daily/weekly/monthly as well as daily rounding by alternating managers. 4. Dining Service Manager will be responsible to see that tasklist/cleaning lists are completed daily/weekly/monthly while the ED will monitor Dining Service Manager weekly during 1:1 to assure proper cleaning and sanitationis complete as well as task/cleaning lists.

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. This is a repeat citation. Findings include, but are not limited to: Observations of the kitchen on 09/09/24 showed the following areas were in need of cleaning or repair: * Floors throughout the kitchen and dry storage had black matter build-up, black stains and/or food debris, along baseboards, under equipment, and around perimeter edges; * Flooring in the dry storage area had a large gap between two floor types which created a lip and a gap which debris and dirt were accumulated in. Two chunks of flooring were missing and a large section under the shelving was lifted off the floor; * The flooring in multiple areas of the main kitchen, including the office area, had cracks, gouges, scratches and/or seams that were pulling apart which allowed dirt and debris to accumulate. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 4 (Dietary Services Manager) on 09/09/24. The staff acknowledged the findings.

Repair or Replacement -kitchen floor 1. Will be repaired by Maintenance Manager with the assistance of the Regional Maintenance Manager and COO of Lenity.  2. ED, Kristine Smith, will ensure all items needing repaired/replaced are addressed with Maintenance Manager 3. Maintenance Manager will inspect monthly with the Dining Service Manager to ensure kitchen floor repairs are done in a timely manner. 4. ED to monitor for completion during weekly 1:1 with the MM.

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

Refer to C 240

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 C 240.

see C 240

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.

see C 240

The findings of the kitchen inspection conducted 05/15/24 through 05/16/24 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 revisit to the kitchen inspection of 05/16/24, conducted 09/09/24, 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 revisit to the kitchen inspection of 05/15/24, conducted 01/13/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.

Based on interview and record review, it was determined the facility failed to investigate incidents to rule out abuse, document all required areas of an investigation, and/or report to the local Seniors and People with Disabilities (SPD) office if abuse could not be ruled out for 2 of 4 sampled residents (#s 1 and 3) reviewed for injuries of unknown cause, resident-to-resident altercations, and unwitnessed falls. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia. A review of the resident's clinical record, including progress/observation notes, incident reports, and service plans dated between 09/09/23 to 11/27/23, and staff interviews identified the following: * 09/17/23 - Bruise to the right upper extremity; * 10/11/23 - Bruise on left upper extremity; and * 10/29/23 - Unwitnessed fall. There was no documented evidence the bruises or the unwitnessed fall had been investigated to rule out abuse or suspected abuse, nor evidence the local SPD was immediately notified of the incidents. During an interview on 11/29/23 at 12:32 pm, Staff 1 (ED) confirmed the incidents were not promptly investigated to rule out abuse or neglect and were not reported to the SPD office. The facility was requested to notify the SPD office of the incidents. Confirmation of the reporting was received on 11/30/23 prior to survey's exit. The need to immediately investigate injuries of unknown cause and unwitnessed falls to rule out abuse or suspected abuse and to notify the local SPD if abuse could not be ruled out was discussed with Staff 1 and Staff 3 (RCC) on 11/30/23. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2023 with diagnoses including dementia. A review of the resident's clinical record, including progress/observation notes, incident reports, and service plans dated between 09/02/23 to 11/27/23, and staff interviews identified the following: * 09/17/23 - Resident to resident altercation; * 09/18/23 - Staff to resident altercation; * 10/18/23 - Resident to resident altercation; * 10/28/23 - Resident to resident altercation; and * 11/19/23 - Resident to resident altercation. There was no documented evidence these incidents had been reviewed by the administrator. The need to ensure documented evidence of administrator review of incidents of abuse or suspected abuse was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

1. Incidents have been investigated and reported to APS for each incident. 2. Incidents will be reviewed daily by the clinical team (ED, RCC, RN, LPN) Investigations will be completed within 24 hours of incident. Once investigations are completed they will be emailed to ED to review and sign. 3. IR will be added to to daily, weekly and/or monthly checklists. will be discusssed during morning meeting or weekly 1:1's 4. Clinical Team (ED, RCC, RN, LPN)

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#4) whose new move-in evaluation was reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 10/2023 with diagnoses including vascular dementia. Review of the record revealed the new move-in evaluation failed to address the following elements: * Customary routines, including sleeping, eating, and bathing; * Cultural preferences and traditions; * Personality, including how the person copes with change or challenging situations; * Pain, including pharmaceutical and non-pharmaceutical interventions and how a person expresses pain or discomfort; * Nutrition habits, fluid preferences and weight if indicated; and * History of dehydration. The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

1. Additional training on the completion of initial evals to be done with the LPN. LPN has been instructed to ensure all boxes are checked and a narrative for each portion of the evaluation/service plan to ensure step by step instructions for staff to care for resident. 2.RN and ED will review eval prior to moves in to ensure all areas have been completed. 3. Evals will be reviewed prior to each move in. Then every 30, 60, and 90 days. 4. Clinical Team (ED, RCC, RN, LPN)

2. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia. The resident's service plan, last modified on 10/26/23, was reviewed, interviews with staff were conducted, and observations were made. The service plan was not reflective of the resident's needs and preferences and/or was not implemented in the following areas: * Pain, including the resident's non-verbal expressions of pain; * Evacuation status; * Preferences around room lighting and room temperature; * Divided plate and straws used with meals; and * Allergy / preferences regarding eggs. The need to ensure service plans were reflective of the identified needs and preferences of the resident, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident preferences and needs and were implemented for 2 of 4 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2023 with diagnoses including dementia. The resident's current service plan, last modified 11/15/23, was reviewed, interviews with staff were conducted, and observations were made. The service plan was not reflective of the resident's needs/preferences and/or was not implemented in the following areas: * Use of cane for mobility; * Use of dentures; * Evacuation instructions; * Hearing status and staff instructions; and * Behavior strategies from Behavior Support Services. The need to ensure service plans were reflective and implemented was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

1. Additional training on the completion of person centered service plans to be done with the LPN and RCC. LPN and RCC  has been instructed to ensure all boxes are checked and a narrative for each portion of the evaluation/service plan to include resident prefrences and needs. 2.RCC, LPN, and ED to ensure adequate details are added to each service plan as well as step by step instructions for staff to follow.   3. Evals will be reviewed prior to each move in. Then every 30, 60, and 90 days. 4. Clinical Team (ED, RCC, RN, LPN) Additional training on the completion of person centered service plans have been done with the LPN and RCC.   Resident 1- Care plan has been updated to include or update mobility, dentures, evacuations, and hearing status as well as to include staff instructions for each item. Resident 2 - Care Plan has been updated to include pain/expression of pain, evacuation status and room prefrences. Also staff instruction for each item.

2. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia. The resident's current service plan, last modified on 10/26/23, Interim Service Plans (ISPs) dated 09/01/23 through 11/27/23, progress notes dated 09/01/23 through 11/27/23, and corresponding incident reports were reviewed. Observations of the resident and interviews with caregivers were completed between 11/28/23 and 11/30/23. a. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted, at least, weekly through resolution: * 09/23/23 - Runny nose and watery eyes; * 10/10/23 - Scooted out of wheelchair; * 10/11/23 - Bruise on left upper extremity; * 11/02/23 - Purple/red area on back from sitting on a birdhouse; and * 11/20/23 - Diarrhea episodes. b. The following changes of condition lacked documented evidence they were monitored, at least weekly, through resolution: * 10/29/23 - Redness and bruising following a fall. The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. She acknowledged the findings. 3. Resident 4 was admitted to the facility in 10/2023 with diagnoses including vascular dementia and generalized weakness. The resident's clinical record, including progress notes, was reviewed, and interviews were conducted. The following was revealed: a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and the communication of the determined actions or interventions to staff on all shifts: * 10/18/23 - Resident found on floor; * 10/25/23 - Nosebleed; and * 11/27/23 - Nosebleed. b. The following short-term changes of condition lacked progress noted, at least weekly, through resolution: * 10/16/23 - Wound to left buttocks; and * 11/03/23 - Resident moved units, monitor for any concerns related to change. The need to ensure actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure actions or interventions determined for changes of condition were documented and communicated to staff on each shift and monitored weekly until the condition was resolved for 3 of 4 sampled residents (#s 1, 2, and 4) with short-term changes of condition. Findings include but are not limited to: 1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including dementia. Resident 2's clinical record was reviewed for changes of condition and revealed the following: On 10/18/23, Resident 2 was placed on alert charting for redness to his/her groin area. During an interview on 11/29/23 Staff 11 (CG) reported Resident 2 no longer had any redness to his/her groin area. There was no documented evidence the facility had monitored the change of condition through resolution. On 11/30/23, the need to ensure residents who experienced a change of condition were monitored until resolution was discussed with Staff 1 (ED). She acknowledged the findings.

- 1. Adequate documentation and resolution to be added to the short term changes. 2. All potential short term or significant change in conditions will be reviewed by reading the observation notes daily. Any changes or concerns will be sent to the RN and LPN to review. 3. Daily by the administrator reading all of the observation notes. This will also will be added to daily/weekly checklist to ensure ISP and Alert Charting are completed as well as weekly monitoring and resultions by the nursing team. 4. Clinical Team (ED, RCC, LPN, RN) For short tem and and significant change of conditions appropriate documentation has been added for residents 1, 2 and 4 as well as added to weekly observation/checks. LPN or Rn to provide resolution note and take off weekly checks once resolved.

2. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia. Resident 1's MAR dated 11/01/23 through 11/27/23, corresponding progress/observations notes, and current physician's orders were reviewed. The resident's physician prescribed the following medications: * Senna/docusate 8.6-50 mg - Take one tablet by mouth two times daily for constipation. Hold for loose stools; and * Loperamide 2 mg - Take two tablets by mouth initially, then one tablet with each loose stool as needed for diarrhea. Resident 1's observation notes revealed the following: * 11/05/23 - "Very watery BM [bowel movement] twice during AM shift"; * 11/20/23 - "This morning during rounds resident also had diarrhea"; and * 11/20/23 - "During rounds after lunch, resident had diarrhea." The facility did not hold the senna/docusate per the physician's order on 11/05/23 and on 11/20/23. Additionally, the facility did not administer the loperamide per the physician's order on 11/05/23 and on 11/20/23. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 5) whose medication orders were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 04/2023 with diagnoses including dementia. The resident's 11/01/23 to 11/27/23 MARs and physician orders, dated 10/27/23, were reviewed. The resident had an order for Novolog (for lowering blood sugar) that instructed staff to notify the prescriber if the resident's CBG reading was over 351. Staff documented CBG readings over 351 on eight occasions from 11/01/23 to 11/27/23. There was no documented evidence the prescriber was notified on any occasion. During an interview at 9:25 am on 11/29/23, Staff 14 confirmed there was no documentation the prescriber was notified of the resident's CBG readings over 351. The need to ensure orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

1. In depth MT training to ensure all MT's are completing medication and treatment orders. Complete MAR audit to be completed. 2. Staff are instructed and trained to notify the clinical team of any medication / treatment orders. Staff continue to follow 3 Step medication approval. 3. Monthly MAR audits to be completed as well as any medication/treatment orders to be addressed when sending the 90 day orders. 4. MT's, and Clinical Team (ED, RCC, LPN, RN) In depth  training to be provided. Residents 1 and 5 PCP has been faxed, Staff has faxed PCP regarding previous missed notifications. PCP is also being faxed to update for resident 1. Med changes have since been made.

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified if a resident refused consent to an order for 2 of 3 sampled residents (#s 1 and 2) who had documented medication and treatment refusals. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia. The resident's MAR dated 11/01/23 through 11/27/23, and current physician orders were reviewed. Facility staff documented Resident 1 refused the following orders on 11/24/23:   * Acetaminophen (a pain reliever); * Melatonin (a sleep aid); * Mirtazapine (for appetite); * Multivitamin (a supplement); and * Senna (for constipation). On 11/28/23 at 3:30 pm, Staff 3 (RCC) confirmed there was no documented evidence the facility notified Resident 1's physician of the refusals. The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (ED) and Staff 3 on 11/30/23. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2021 with diagnoses including dementia. Resident 2's signed physician orders and 11/01/23 through 11/27/23 MAR were reviewed. The facility failed to provide documented evidence Resident 2's physician was notified related to the following medication and treatment refusals: * On 11/14/23: Amlodipine (for blood pressure), Divalproex (for seizures), multivitamin with minerals (a supplement), quetiapine (a mood stabilizer), and sertraline (a mood stabilizer), and levetiracetam (for seizures); * On 11/17/23: Amlodipine, Divalproex, multivitamin with minerals, quetiapine, sertraline, levetiracetam, and nystatin ointment (for yeast infection); * On 11/22/23: Nystatin ointment; and * On 11/27/23: Nystatin ointment. On 11/30/23, the need to notify the physician when a resident refused consent to an order was discussed with Staff 1 (ED). She acknowledged the findings.

1. PCP will be faxed regarding all missed medications 2. New forms to be faxed to pcp for notification of missed medications to determine when the pcp would like to be faxed. Once fax is returned, RN will add when to notify to the MAR. Form to be utilized for all residents. Missed medication form to be pulled weekly to assure compliance with any missed medications for the week and to assure notifications were completed. 3. PCP notification form to be reviewed or sent upon move in, frequent missed medications, or during 90 day eval. 4. MT,  and Clinical Team (ED, RCC, LPN, RN)

2. Resident 1 was admitted to the facility in 08/2019 with diagnoses including anxiety. Review of Resident 1's MAR dated 11/01/23 through 11/27/23, corresponding progress/observation notes, and physician orders revealed the following: Resident 1 was prescribed and received PRN lorazepam (for anxiety or agitation) on two occasions between 11/05/23 and 11/17/23. The facility lacked documented evidence non-pharmacological interventions were attempted and determined to be ineffective prior to administration of the lorazepam. On 11/30/23, Staff 14 (MT) reported the facility's electronic MAR system does not prompt staff to document the non-pharmacological interventions attempted prior to administering psychotropic medications, and staff were expected to document in the observation notes. Staff 14 confirmed no additional information was documented in the facility's observation notes when Resident 1 received the two doses of lorazepam.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         The need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions were attempted with ineffective results prior to the administration of a PRN psychotropic medication for 2 of 2 sampled residents (#s 1 and 6) who were prescribed a PRN psychotropic medication. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 06/2020 with diagnoses including dementia. Resident 6 was prescribed PRN alprazolam for anxiety. Review of Resident 6's 11/01/23 through 11/27/23 MAR showed the PRN alprazolam was given on 10 separate occasions without documented evidence the facility had attempted non-drug interventions with ineffective results prior to administration of the medication. On 11/30/23, the need to ensure staff documented non-pharmacological interventions as ineffective prior to administering a PRN psychotropic medication was discussed with Staff 1 (ED). She acknowledged the findings.

1. Additional training and updates made to care plan to list non-pharmacological interventions 2. MT's are to ensure that care staff or themselves have attempted and completed non-pharmacological interventions, interventions have been documented prior to adminsitration of PRN. Monthly review by clinical team of all PRN Administrations to assure compliance. 3. At least weekly, and monthly during MAR Audit.   4. MT,  and RCC

Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted every other month and included documentation of all required components, and fire and life safety instruction was provided to staff on alternate months of fire drills. Findings include, but are not limited to: Facility fire drill records dated 06/2023 through 11/2023 were reviewed with Staff 1 (ED) on 11/30/23. The facility lacked documented evidence unannounced fire drills were conducted every other month and included the following components: * Date and time of fire drill; * Location of simulated fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the fire drills; * Evacuation time needed; and * Number of occupants evacuated. In addition, the facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills. The need to ensure unannounced fire drills were conducted and documented every other month and included all required components, and fire and life safety instruction was provided to staff on alternate months of fire drills was discussed with Staff 1 (ED) on 11/30/23. She acknowledged the findings, and no additional documentation was provided.

1. Fire and Elopement drills to be held every 90 days.  The last one was completed in October 2023, the next will be completed in Dec 2023. 2. The system will be corrected by implementing a new schedule at the beginning of the year to follow what month the drill should be completed, and which shift. Added to daily/weekly checklist. As well as discussed during weekly meetings. 3. daily/weekly and yearly plan 4. Facilities director is responisble to ensure fire and elopment drills are completed on alternative months. ED to ensure they are completed by Facilities director. 1. Fire and Elopment drills will be completed every 60 days. The last one was completed in October 2023, the next will be completed in Dec 2023.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to: The facility's fire and life safety records were reviewed on 11/30/23. There was no documented evidence residents were provided fire and life safety procedure training within 24 hours of admission to the facility or were being re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. The need for residents to be instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (ED) on 11/30/23. She acknowledged the findings, and no additional documentation was provided.

1. Annual fire and life training to be completed with all current residents by 12/31 to be in compliance for the 2023 year and then scheduled for the following year. 2. The system will be corrected by adding the training to our yearly plan. New form implemented to track this requirement and assure compliance. 3. Added to daily/weekly and yearly plan to ensure completion.   4. Facilities to ensure fire and life training is completed within 24 hours of initial move in and annually. ED to ensure they are completed by Facilities director.

Based on observation and interview, it was determined the facility failed to ensure the facility was free of unpleasant odors. Findings include, but are not limited to: Observations of the Monarch memory care unit from 11/28/23 through 11/30/23 revealed a strong, pervasive urine odor detected inside and in the hall near Room 227. On 11/30/23, the need to ensure the facility was free from unpleasant odors was discussed with and observed by Staff 1 (ED). She acknowledged the findings.

1. Additonal cleaning supplies and updates made to resident care plan to ensure room is free of odors. Fax for bedside commode to assist with resident urinary issues. 2. Additional training to be done for daily manager rounding. Checking for upleasent odors or smells every morning. 3. Added to daily maanger rounding 4. ED, RCC, DSM, LEM, FD , all staff

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: Observations from 11/28/23 through 11/29/23 revealed exit doors to the interior courtyards of the Garden and Monarch memory care units failed to have an alarm or other acceptable system to alert staff when residents entered and exited the courtyard. On 11/29/23, the need to ensure exit doors were equipped with an audible alarm or other acceptable system was discussed with Staff 1 (ED) and Staff 8 (Facilities Services Aide). They acknowledged the findings.

1. Alarms were added to the exit doors to ensure there is proper notification. This was completed on 11.30.2023. 2. Facilities director will ensure alarm is in working condition. 3. Monotring of door alramrs to occure daily/week. Added to checklist. 4. FD, ED to ensure completed.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C420, C422, C513, and C555.

Refer to C231, C420, C422, C513, C555

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff completed all required pre-service orientation and dementia training topics prior to beginning job duties. Findings include, but are not limited to: Staff training records were reviewed on 11/29/23 at 1:00 pm. a. There was no documented evidence Staff 9 (Housekeeping), Staff 10 (CG), Staff 13 (MT), or Staff 18 (Cook), hired 10/04/23, 10/20/23, 10/06/23 and 09/13/23, respectively, completed Infectious Disease Prevention training prior to beginning their job duties. b. There was no documented evidence Staff 10 or Staff 13 completed the following dementia care training topics prior to providing resident care and services independently: * Environmental factors which are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; and * Use of supportive devices with restraining qualities in the memory care communities. The need to ensure all staff training was completed in the required time frames was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

1. Currently working on receiving an updated training plan and add to Relias. 2. We will have an updated training list to folow that is reflective of state requirements. 3. Training plans and updates checked weekly, added to BOM weekly checklist. 4. To be completed by BOM and ED to ensure completed. 1. Infectious diseas prevention training have been assigned to all staff and due to be completed by 01.28.2023. We are also currently working on an updated training plan to add to our Relias.

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 C252, C260, C270, C303, C305, and C330.

Refer to C252, C260, C270, C303, C305, C555

2. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia. The resident's current service plan, last updated 10/26/23, was reviewed, interviews with staff were conducted, and observations were made. The resident's service plan lacked a nutrition and hydration plan based on the resident's preferences and needs in the following areas: * Food and drink preferences; * Adaptive equipment used during meals; and * Instructions to staff when the resident did not wake for meals. The need to develop and document in the service plan an individualized nutritional plan addressing the resident's preferences and needs was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 10/2023 with diagnoses including vascular dementia. The resident's current service plan was reviewed, interviews with staff were conducted, and observations were made. The resident's service plan lacked a nutrition and hydration plan based on the resident's preferences and needs in the following areas: * History of dehydration; and * Favorite foods and liquids. The need to develop and document in the service plan an individualized nutritional plan addressing resident's preferences and needs was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 01/2021 with diagnoses including dementia. The resident's current service plan was reviewed, interviews with staff were conducted, and observations were made. The resident's service plan lacked a nutrition and hydration plan based on the resident's preferences and needs in the following areas: * History of dehydration; and * Favorite foods and liquids. On 11/30/23, the need for individualized nutrition and hydration plans was discussed with Staff 1 (ED). She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to document a daily meal program for nutrition and hydration based on the resident's preferences and needs in the service or care plan for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2023 with diagnoses including dementia. The resident's current service plan was reviewed, interviews with staff were conducted, and observations were made. The resident's service plan lacked a nutrition and hydration plan based on the resident's preferences and needs in the following areas: * History of dehydration; * Favorite foods and liquids; and * Feeding abilities, including how the resident's visual deficits impact his/her ability to self-feed. The need to ensure documentation in the service plan of a daily meal program based on the resident's preferences and needs was discussed with Staff 1 (ED) and Staff 3 (RCC) on 11/30/23. They acknowledged the findings.

1. Service Plan and Care Plan to be updated to in clude an individualized nutrition plan for each resident. 2. Service/Care Plan to address history, likes & dislikes, etc. Clinical team will update current care plans to be reflective of nutritional needs, likes, and dislikes. 3. Initally, then 30, 60, and 90 days and every 90 dyas thereafter. 4. Clinical Team (ED, RCC, RN, LPN)

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3, and 4's records were reviewed during the survey. a. There was no documented evidence an activity evaluation had been completed to reflect one or more of the following required components: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. b. There was no individualized activity plan developed for the sampled residents. On 11/30/2023, the need to evaluate each resident for activities, with all requirements addressed, and develop individualized activity plans was discussed with Staff 1 (ED). She acknowledged the findings.

1. Service Plan and Care Plan to be updated to in clude an individualized acitivity plan for each resident. 2. Service/Care Plan to address history, likes & dislikes, etc. Life enrichment manager or Clinical team will update current care plans to be reflective of activity needs, likes, and dislikes. 3. Initally, then 30, 60, and 90 days and every 90 dyas thereafter. 4. Clinical Team (ED, RCC, RN, LPN)

Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area. Findings include, but are not limited to: Observations of the Garden and Monarch memory care units, from 11/28/23 through 11/29/23, revealed interior courtyard doors were locked, preventing residents from entering and exiting without staff assistance. There were no observations of inclement weather during that time. On 11/29/23 the need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (ED) and Staff 8 (Facilities Services Aide). They acknowledged the findings.

1. Exit doors are to remain unlocked unless during inclement wheather 2. Doors will be checked daily during morning manager rounding. 3. Added to FD daily/weekly checlist to ensure process is being evaluated. 4. ED, RCC, DSM, BOM, LEM, FD. All staff

The findings of the change of ownership survey, conducted 11/28/23 through 11/30/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the revisit to the re-licensure survey of 11/30/24, conducted 05/15/24 through 05/16/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to maintain the kitchen clean and in good repair in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: The kitchen was toured on 04/05/23. An accumulation of food spills, splatters, loose food debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Pipes and walls under the dishwasher; * Shelves and shelving units; * Mop sink; * Window sill; * Utility/Dish carts; * Laminated wall signs; * The tracks of the chest freezer; * Doors, door frames, thresholds; * Buildup of grease on the grill; * Buildup of dust on the fans in the refrigerators; and * Dense black matter and smudges on the flooring throughout the kitchen, with increased density by bases and edges of walls, appliances, shelving units, and food preparation tables. The following areas were in need of repair or replacement: * The caulking around the dish machine area had a buildup of black matter; * A square metal floor trap between the dishwasher and triple sink had brown/black matter on it and rust was developing; * The coating on multiple wire refrigerator shelves had peeled off and rust was developing; * Overhead light fixtures by the back door and between the stove and the pass-through windows were missing their covers; * Multiple cutting boards were heavily scored and discolored; * There were cracks, chips, and areas where the linoleum flooring had separated observed in the dry storage closet, by the entrance doors, and by the stand refrigerators;   * There were multiple gouges and chipped paint on the walls throughout the kitchen; * A hand held metal sifter and potato masher had areas where rust had developed; * The test strips for the sanitation buckets had expired in 2020 and did not work properly; * The wall covering above the pass-through window had separated from the wall; and * The painted shelves in the dry storage had areas where the paint had peeled or worn off and raw wood was exposed. The need to maintain the kitchen clean and in good repair in accordance with the Food Sanitation Rules, OAR 333-150-000 was discussed with Staff 1 (Administrator) and Staff 2 (Dietary Director) on 04/05/23. They acknowledged the findings.

Cleaning & Sanitation:   1. Staff will clean all spills, splatters, debris, dust, etc.            - wooden shelving removed to be replaced w/ wire shelving   2. Daily, Weekly, and Monthly cleaning lists have been updated to prevent violation from reoccuring.          - pipes, walls, window sill, utility/dish carts, wall signs, fridges and freezer tracks, doors, and grill all updated on cleaning lists   3. Cleaning list will be checked/evaluated daily, weekly, and monthly as well as daily rounding by alternate  managers.   4. Dining Service Manager will be responsible to see that tasklist/cleaning lists are completed daily, weekly, and monthly while the executive director will monitor Dining Service Manager weekly during 1:1 to assure proper cleaning and satiation is complete as well as taks/cleaning lists. Repair or Replacement -Caulking   1. Will be repaired by Maintenance Manager.   2. Dining Manager will ensure all items needing replaced or repaired are addressed with Mainintenace Manager.     3. Maintenance Manager will inspect monthly with monthly Inspection Checklist.   4. ED to monitor for completion during weekly 1:1 with both Dining and Maintenance Managers. -Square Metal Floor Trap   1. Metal trap will need to be replaced by Maintenace Manager.   2. Item was added to monthly checklist to ensure grease traps or water drains are not damaged or rusted.   3. To be completed during monthly inspection.   4. Dining Manager will be responsible to see that inspection is completed monthly, ED to monitor weekly during 1:1. - Coating on wire refridgerator racks   1. Dining manager will order new racks for the refridgerator.   2. Item was added to monthly checklist to be inspected for rust, peeling paint, and damages.     3. To be completed during monthly inpspection.   4. Dining Manager will be responsible to see that inspection is completed - Overhead light fixtures   1. Maintenance Manger will order new covers.   2. Item is on monthly inspection checklist to ensure lights/fixtures are not in need of repair/cleaning.   3. To be completed during monthly inspection.      4. Maintenace manager to ensure corrections are completed, ED to moonitor for completion during weekly 1:1's - Fooring   1. Maintenance manager will replace flooring where damaged.   2. Item is on monthly inspection checklist to ensure lights/fixtures are not in need of repair/cleaning.   3. To be completed during monthly inspection.      4. Maintenance manager to ensure corrections are completed, ED to moonitor for completion during weekly 1:1's - Cutting Boards/ Kitchen utenisils, small equipment   1. All old, stained, damaged cutting boards thrown away.   2. Dining Manager will ensure inpsection of all utensils or small kitchen equipment is done weekly or monthly. Any items needing replaced will be added to the weekly department order form.     3. To be completed during monthly inspections.   4. Dining Manager will be responsible to see that inspection is completed, ED to monitor for completion during 1:1's. - Sanitation Test Strips.   1. New strips have been ordered and delivered.   2. Dining manager will check test strips weekly and and to order if needed.   3. Added to monthly inspection to ensure strips have not expired.     4. Dining Manager will be responsible to see that inspection is completed, ED to monitor for completion during 1:1's. - Wall coverings   1. Maintenance will replace   2. Item is on monthly inspection checklist to ensure walls are not in need of repair/cleaning. Dining will report any damages promptly to Maintenane Manager.   3. To be completed during monthly inspections.   4. Maintenace manager to ensure corrections are completed, ED to moonitor for completion during weekly 1:1's - Painted/Wood Dry Storgae Shelves.   1. New wire/metal shelves have been ordered and delivered on 04/12/2023. Wooded Shelveds will be removed and replaced.   2. Item was added to monthly checklist to be inspected for rust, peeling paint, and damages.     3. To be completed during monthly inpspection.   4. Dining Manager will be responsible to see that inspection is completed

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

Refer to C 240

The findings of  the kitchen inspection, conducted on 04/05/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit to the kitchen inspection of 04/05/23, conducted 08/30/23, 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.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 04/04/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 04/04/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 04/04/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 04/04/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 04/4/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 04/04/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the unannounced complaint investigation conducted 04/04/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.