Sea Aire Assisted Living Community

Based on interview and record review, conducted during a site visit on 09/17/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:   A review of the facility's ABST report, with the last update dates, indicated there had been 27 of 40 residents who had not been quarterly evaluated. A review of the facility's ABST indicated the "minimum time needed based on acuity" on the day shift was 14.45 direct care staff, and less than one staff member for the swing and the night shifts. A review of the facility's posted staffing plan indicated the following: · 6:15 am to 10:00 am: o 3 CG, 1 MT, and a bath aide Mon-Fri; · 10:00 am to 2:30 pm: o 2 CG, 1 MT, and a bath aide Tues-Thurs; · 2:15 pm to 10:30 pm: o 2 CG and 1 MT; · 10:15 pm to 6:30 am: o 1 CG and 1 MT. A review of the facility's staff schedule from 09/11/25 through 09/17/25 indicated the facility had been short-staffed for the day shifts per the staffing requirements indicated in the ABST. An interview with Staff 3 (Resident Care Coordinator) was conducted, which indicated the facility had not known that residents needed to be reviewed quarterly in the ABST. S/He indicated the facility staffed the following: · Day: 1 MT and 2 CGs; · Swing: 1 MT and 2 CGs; and · Night: 1 MT and 1 CG.   The facility failed to update and review the ABST evaluation for each resident no less than quarterly; the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs; and the facility failed to use the results of the ABST to develop and routinely update the facility's posted staffing plan.   The findings of the investigation were reviewed and acknowledged by Staff 1.

Based on interview and record review, conducted during a site visit on 09/17/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:   A review of the facility's ABST report, with the last update dates, indicated there had been 27 of 40 residents who had not been quarterly evaluated. A review of the facility's ABST indicated the "minimum time needed based on acuity" on the day shift was 14.45 direct care staff, and less than one staff member for the swing and the night shifts. A review of the facility's posted staffing plan indicated the following: · 6:15 am to 10:00 am: o 3 CG, 1 MT, and a bath aide Mon-Fri; · 10:00 am to 2:30 pm: o 2 CG, 1 MT, and a bath aide Tues-Thurs; · 2:15 pm to 10:30 pm: o 2 CG and 1 MT; · 10:15 pm to 6:30 am: o 1 CG and 1 MT. A review of the facility's staff schedule from 09/11/25 through 09/17/25 indicated the facility had been short-staffed for the day shifts per the staffing requirements indicated in the ABST. An interview with Staff 3 (Resident Care Coordinator) was conducted, which indicated the facility had not known that residents needed to be reviewed quarterly in the ABST. S/He indicated the facility staffed the following: · Day: 1 MT and 2 CGs; · Swing: 1 MT and 2 CGs; and · Night: 1 MT and 1 CG.   The facility failed to update and review the ABST evaluation for each resident no less than quarterly; the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs; and the facility failed to use the results of the ABST to develop and routinely update the facility's posted staffing plan.   The findings of the investigation were reviewed and acknowledged by Staff 1.

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 the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen was reviewed on 03/18/25 from 11:30 am through 2:00 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Reach in freezer bottoms; *Walk in cooler metal racks; * Metal shelving storing spices; * Industrial can opener and housing; * Industrial mixer; * Walk in cooler fan cages and ceiling near fans; * Kitchen drains; * Blender base; * Right oven; * Floor under and behind ovens/range/grill; * Hood vents; * Juice machine; * Interior of drawers in the beverage area in dining room and * Light switches; b. The following areas were in need of repair: * Ceiling vent above reach in coolers/freezers with dust/dirt accumulation and large gaps; * Section of wall behind 3 compartment sink with damage * Several small sections of flooring seams missing/gaps in sealent creating non smooth/continuous flooring. * Chemical sanitizing dish machine wash cycle not reaching minimum temperature of 120 degrees as required. * Electrical outlet/switch for dish machine hood fan with missing bottom half posing a hazard. * Multiple cabinets/drawers in dining room beverage area with un smooth surfaces. Section of cabinet in kitchen area with piece of protective laminate missing exposing pourous wood. * Reach in freezer with large accumulation of ice/frost buildup and pealing/missing protective covering for racks yielding sections of rusted metal; c. Ice machine drain hose observed stored directly inside a dirty drain. The hose was touching the bottom of the drain and had a thick layer or biofilm. Staff were unaware that the drain hose could not be touching the bottom of the drain and that a air gap was needed as a back flow prevention. d. Utility cart noted to be damaged with burn rings from hot containers making cart unsmooth surface. e. Single use plates and bowls were found stored with food contact surfaces exposed to potential contamination. f. Utensils in the dining room were pre set without the food contact surfaces covered/protected from potential contamination. Staff pre set the next meals utensils directly after the meal. The dining room is open to residents, visitors, vendors and staff in between meals. h. Clean and sanitized utensils were found stored in the kitchen areas with the food contact surfaces pointing up and exposed to potential contamination. i. A white bucket was being used as a trash can and did not have a lid as required for when not in use. j. Red sanitizer bucket used for sanitizing surfaces appeared dirty and was not at the required parts per million (PPM) of sanitizer. Staff 2 (Cook/dedicated Person In Charge) was not able to identify the correct required sanitizer concentration (PPM). k. Copy of Oregon food sanitation rules kept on premises was from 2002. l. Facility did not have a food worker sick and exclusion policy as required. At approximately 2:00 pm, surveyor reviewed above areas with staff 1 (Administrator) and staff 3 (Assistant Administrator), who acknowledged the identified areas.

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

Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen was reviewed on 07/25/25 from 11:30 am through 1:30 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Reach in freezer bottom far left; * Blender base/buttons; * Juice machine; * Window screens * Windowsill * Ceiling vent above reach in coolers b. The following areas were in need of repair: * Section of wall behind 3 compartment sink with excessive water damage/hole * small sections of flooring seams missing/gaps in sealent creating non smooth/continuous flooring. c. Multiple pans of ready to eat foods (RTE) were observed stored in walk in uncovered and exposed to potential contamination. One pan of deserts for lunch meal was observed stored uncovered and exposed to potential contamination. The pan was next to open an window which was dirty. d. Kitchen employees were observed to handle RTE foods with potentially contaminated gloves. Staff were observed to leave service line multiple times and open Walk-in cooler door touching handle with gloved hands, handle containers of sauce, handles of skillet pans and wipe clothing all with same gloves that they handled ready to eat foods. Staff was observed to handle highly allergenic food product (Fried shrimp) with gloved hands and then handle other food products (sandwiches). Food code requires different utensils are used to serve different food products to protect from potential cross contamination. Food code requires single use gloves to be changed and hands cleaned when switching tasks. e. Single use plates and bowls were found stored with food contact surfaces exposed to potential contamination. f. Clean and sanitized utensils were found stored in the kitchen areas with the food contact surfaces pointing up and exposed to potential contamination. At approximately 1:00 pm, surveyor reviewed above areas with staff 1 (Administrator), Staff 2 (Maintenance) and staff 3 (Assistant Administrator), who acknowledged the identified areas.

Concerning spills, splatters and dust. Inside freezers,blender, juice mashine,window screens, window sills, and ceiling vent will added to kitchen cleaning chores, if not on list already. All chores will be delegated to each kitchen staff. These chores will be done one time weekly. Administrator will oversee these corrections. B. Sheetrock above dish sink and the floor seams will be repaired by maintenance team. Any repairs in the future will be repaired in a timely manner. Maintenance team will complete a 2x monthly walk through, looking for anything out of compliance. Administrator will oversee monitoring. C and D. A kitchen team training will be scheduled. The training will be including proper food storage, proper covering of foods and proper storage placement. Proper glove use will be included in training. Observation will be done weekly, at meal serving time. Corrections will be made immediately, if necessary. Administrator will oversee monitoring. E. Dishes exposed to potential contamination will be covered. Covers will be used at appropriate times by kitchen staff, including after last serve of the day. The closing cook will be sure covers are applied. correction will be evaluated daily. The Administrator will oversee monitoring. F. All utensils stored in countertop containers will be stored with all handles pointing up. This instruction will be included in the kitchen training.All kitchen staff will be aware of proper storage. Administrator will check often and monitor.

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

Based on record review and interview, it was determined the facility failed to have developed policy and procedures to prevent and respond to potential communicable and food borne diseases. This includes protocols to prevent the development and transmission of communicable diseases including possible food borne outbreaks and gastrointestinal outbreaks including but not limited to Noro Virus. This also includes having a food worker sick policy for exclusion as outlined in Oregon Food Sanitation Rules. Findings include but are not limited to; On 03/18/25 during a kitchen survey, facility was asked to provide policy and procedures surrounding food worker illness and exclusion and Gastrointestinal illness outbreaks. Staff 3 (Assistant Administrator) was interviewed at 1:40 pm and stated they were unable to locate policy’s that address GI/Noro outbreaks/communicable disease response or food worker illness and exclusion. Staff 3 was provided information from food code that outlines the requirement. At approximately 2:00 pm Staff 1(Administrator) was notified via telephone of the need for these policies and procedures. No further information was provided to the surveyor.

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

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

Sea Aire will be sure implemented corrections stay in place and stay in compliance. please see POC for C240.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

Based on interview and record review, it was determined the facility failed to promptly investigate all incidents to rule out potential abuse and/or neglect and document the Administrator's review for 1 of 1 sampled resident (#3) who had incidents of falls and an injury of unknown cause. Findings include, but are not limited to: Resident 3 was admitted to the facility in 01/2023 with diagnoses including dementia and ocular degenerative disease. Progress notes, dated 07/02/23 through 10/02/23, were reviewed and revealed the following: * 07/02/23 - fall with head wound, the resident could not report what happened; * 07/24/23 - found on floor, Resident 3 could not report what happened; * 07/31/23 - found sitting on the floor, dressed without shoes or socks on and the alarm did not alert staff; * 08/13/23 - fall from the resident's wheelchair; * 08/21/23 - fall and Resident 3 did not know how s/he fell; and * 09/13/23 - quarter sized bruise found on the resident's left upper arm, "resident unaware of how bruise happened." There was no documented evidence of the facility promptly investigating the incidents to rule out abuse or neglect which included documentation of the Administrator's review. On 10/04/23, Staff 2 (Administrator) reported there was no documented evidence she had investigated the above incidents to rule out abuse and/or neglect. The need to ensure incidents were promptly investigated to rule out abuse and/or neglect and included documentation of the Administrator's review was discussed with Staff 1 (Owner) and Staff 2 on 10/05/23 at 10:47 am. They acknowledged the findings.

Sea Aire will conduct an investigation to rule out abuse and neglect immediately following incident. Interventions will also be placed as needed. This will be the plan of correction for investigations where abuse and neglect needs to be ruled out. System will be evaluated at each incident, where abuse and neglect is needing to be ruled out. Responsible staff will be administrator and owner.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#5) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 5 was admitted to the facility in 09/2023. The Initial Evaluation and Assessment, dated 09/07/23, was reviewed. The following elements were not addressed: * Customary routines including bathing; * Interests, hobbies, social, leisure activities; * Spiritual, cultural preferences, and traditions; * Physical health status including vital signs if indicated by diagnosis, health problems, or medications; * Mental Health issues including presence of depression, thought disorders, or behavioral or mood problems; * Cognition, including confusion and decision making abilities; * Personality including how the person copes with change or challenging situations; * Ability to understand and be understood; * Assistance needed with toileting, bowel and bladder management; * Assistance needed with dressing, grooming, bathing, and personal hygiene; * Assistance needed with mobility, ambulation, and transfers; * Pain including pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Nutrition habits and fluid preferences; * Indicators of nursing needs including potential for delegated nursing tasks; and * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature. On 10/04/23 at 2:47 pm, Staff 2 (Administrator) confirmed Resident 5's move-in evaluation was only the second one she had completed since she had taken over as the Administrator. The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Owner) and Staff 2 on 10/05/23 at 10:47 am. They acknowledged the findings.

All pre move-in evals will be completed at time of initial visit. All blanks and required info will be completed. This corrected system will take place at each pre move-in evaluation. At each pre move-in visit and also at time of move in. Administrator and owner will be responsible

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to an order for 1 of 2 sampled residents (#3), who had documented medication refusals. Findings include, but are not limited to: Resident 3 was admitted to the facility in 01/2023 with diagnoses including dementia and ocular degenerative disease. The resident's MARs dated 09/01/23 through 10/02/23, progress notes, dated 07/02/23 through 10/02/23, and physician's orders were reviewed and revealed the following: * 07/07/23 - staff documented the resident refused some of his/her medications; * 08/03/23 - staff documented, "resident didn't want to finish taking [his/her] medications"; * 09/06/23 - the MAR reflected refusals of atorvastatin (to lower cholesterol), B complex (supplement), cranberry capsule (for reducing bladder infections), lisinopril (for high blood pressure), and memantine (for dementia); and * 09/25/23 - the MAR reflected the resident refused vitamin B-12 (supplement). There was no documented evidence the physician was notified of the refusals. On 10/04/23, Staff 2 (Administrator) reported she thought the physician would only be notified when a resident refused to consent to orders three consecutive times. The need to notify the physician when a resident refused consent to orders was discussed with Staff 1 (Owner) and Staff 2 on 10/06/23 at 10:47 am. They acknowledged the findings.

Forms for med rejections will be made and put in med room. Med techs will place form in folder after each med rejection on their shift. Folder will be checked daily at stand up meeting. Mar will be checked weekly for efficiency backup. The actions above will correct the system. Correction will be evaluated 1X daily with new forms, at stand up meeting. Mar will be checked 1X weekly checking for med rejections. RCM will be responsible for keeping track of med rejections and faxing physicians as needed.

Based on interview and record review, it was determined the facility failed to ensure all residents were entered into the Acuity-Based Staffing Tool (ABST). Findings include, but are not limited to: On 10/04/23 at 1:15 pm, the facility's ABST was reviewed with Staff 1 (Owner). She stated there was a resident who was no longer in the facility. When she attempted to delete the resident from the tool, it deleted an entire wing of residents. She had to reenter all the residents back into the ABST. The tool was reviewed by the survey team at approximately 2:00 pm on 10/04/23. It was discovered there were three residents that were not entered into the tool and multiple other residents were in the tool twice causing the census to be inaccurate. The findings were shared with Staff 1 and Staff 2 (Administrator) on 10/04/23. They acknowledged the findings and stated they would reach out to the State for guidance with deleting the duplicates and adding the missing residents.

New move-in's will be entered in ABST prior to move-in. It will be entered alongside with electronic careplan. This will ensure it will be complete and entered before move-in. This will be the change to the system to achieve compliance. RCM will evaluate system and efforts. Administrator and owner will be responsible to ensure all corrections are monitored.

Based on interview and record review, it was determined the facility failed to document pre-service training had been completed for 2 of 3 newly-hired staff (#s 9 and 14) whose pre-service training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 010/04/23 and the following was identified: a. Training records for Staff 9 (MT), hired on 02/28/23, lacked documented evidence of pre-service training prior to beginning job responsibilities in the following areas: * Resident rights and values of CBC care; * Abuse reporting requirements; * Infectious Disease Prevention; * Fire safety and emergency procedures; * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communication and responses to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach. b. Training records for Staff 14 (MT), hired on 02/28/23, lacked documented evidence of pre-service training prior to beginning job responsibilities in the following areas: * Infectious Disease Prevention; * Fire safety and emergency procedures; * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communication and responses to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach. The requirement to document completed pre-service training prior to providing care to residents was discussed with Staff 1 (Owner) and Staff 2 (Administrator) on 10/05/23. They acknowledged the findings.

All CEU requirements will now be completed before any activity or training with residents. All required CEU's for new staff for new staff will be scheduled, in house, for three, eight hour days to complete required units. This will ensure system stays in compliance. System will be updated monthly to ensure updates are in compliance. Administrator and owner will be responsible for corrections being completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly-hired staff (#11) completed pre-service orientation prior to beginning their job responsibilities and pre-service dementia training prior to providing care to residents. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 01/30/24. a. There was no documented evidence Staff 11 (CG), hired 01/05/24, had completed the following pre-service orientation topics: * Resident rights and values of CBC care; * Abuse reporting requirements; * Infectious Disease Prevention; * Fire safety and emergency procedures; * Written job description; b. There was no documented evidence Staff 11 had completed the following pre-service dementia training: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need for newly hired staff to complete all pre-service training in a timely manner, and to retain documentation of the training was discussed with Staff 1 (Owner) and Staff 5 (Admin Asst) on 01/30/24. They acknowledged the findings.

New system will be discussed with management team. Pre training will be more closely monitored and overseen. Area will be monitored with every new hire. Administrator will be responsible. For citation 370, Staff #11. I addressed Staff #11, addressing the training education issue. I went over training courses with #11 and gave deadline for completion.

Based on interview and record review, it was determined the facility failed to ensure there was documentation 2 of 3 newly-hired direct care staff (#s 9 and 14) had demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 10/04/23 and identified the following: a. Training records for Staff 9 (MT), hired on 02/28/23, lacked documentation of demonstrated competency in the following areas: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First Aid and abdominal thrust. b. Training records for Staff 14 (MT), hired on 02/28/23, lacked documentation of demonstrated competency in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First Aid and abdominal thrust. The need to ensure documentation of staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Owner) and Staff 2 (Administrator) on 10/05/23. They acknowledged the findings.

All CEU requirements will now be completed before any activity or training with residents. All required CEU's for new staff will be scheduled, in house, for three, eight hour days to complete required units. This will ensure system stays in compliance. System will be updated monthly to ensure updates are in compliance. Administrator and owner will be responsible for corrections being completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 18, 19, and 21) demonstrated satisfactory performance in any duty they were assigned. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 01/30/24. There was no documented evidence Staff 18 (CG), Staff 19 (MA), or Staff 21 (MA), hired 11/06/23, 12/01/23, and 12/17/23, respectively, had demonstrated competency in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; * Other duties as applicable (Med pass, treatments); and * First Aid/Abdominal Thrust. Staff 1 (Owner) reported there was no documentation MAs had demonstrated competency related to medication pass. Survey requested the facility observe and document medication pass competency for the MA on shift, prior to the next med pass, as well as for the MA on the next shift. Confirmations of these observations were received. The need to ensure new staff demonstrate satisfactory performance in all assigned duties within 30 days of hire was discussed with Staff 1 (Owner) and Staff 5 (Admin Asst) on 01/30/24. They acknowledged the findings.

new system will be put in place by management team.there will be a closer view of new employee training before floor training. The system will be evaluated with each new hire. Administrator will be responsible. Citation 372, Staff #18, 19, 21. Discussed  the within 30 day training courses with staff and explained the requirements. Staff received review of training and a deadline for completion

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to: The facility was toured on 10/04/23. The following issues were identified as needing repair: * Exterior sidewalks around the facility had multiple drop-offs up to 4 inches, measured from the concrete to the ground. These drop-offs created potential hazards for residents. * The courtyard had a brick walkway which was uneven in places, creating a potential tripping hazard. On 10/05/23, the areas were discussed with Staff 1 (Owner) and Staff 2 (Administrator). They acknowledged the findings.

Drop off's will be built up with sand, fill dirt, and garden stepping bricks. The sand and brick will keep brick from moving. Brick will be layed to be flush with sidewalk and surrounding lawn. Bricks on walkway will be removed, repacked, and releveled and put back in place. Monthly quality checks will include outside environment, courtyard, and sidewalks surrounding the building. Maintenance manager-Avan Final check for compliance-Robin Allen

Based on observation and interview, it was determined the facility failed to ensure pathways and courtyard surfaces were level and did not create a tripping hazard for residents. Findings include, but are not limited to: The facility was previously cited on 10/05/23 related to uneven surfaces in the resident courtyard. The facility requested and was granted an extension for completion of this repair. The resident courtyard was not looked at during the revisit to the relicensure survey conducted on 01/30/24 as the facility's correction period had not ended for the courtyard repair.

Original plan of correction...Drop off's will be built up with sand, fill dirt, and garden stepping bricks. The sand and brick will keep brick from moving. Brick will be layed to be flush with sidewalk and surrounding lawn. Bricks on walkway will be removed, repacked, and releveled and put back in place. Monthly quality checks will include outside environment, courtyard, and sidewalks surrounding the building. Maintenance manager Final check for compliance-Administrator Extension approved until 3/2/24 related to soggy ground and standing water making repairs impossible. Per Administrator on 3/8/24 the ground continues to be extremely soggy but plan is to attempt the leveling in current condition. Plan using sand and foot stones. The ground will be leveled next to sidewalk edges. The sand, then stones will be placed and be flush with edges of sidewalk. Administrator plans to have this completed by current compliance date of 3/15/24 Emailed Administrator Robin Allen and asked for additional information for staff training tags. Information was emailed back to me and added to the citations within the POC with Robins permission. Discussion with Robin via phone on 3/7/24 and email on 3/8/24 were had, previous POC and update sent via email placed in the POC related to the environment. Spoke with supervisor Jeanne Bristol regarding use of the newest AOC date for the environment and the current revisit items which she approved.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 370 and C 372.

Referral, see report

The findings of the Change of Owner survey, conducted 10/02/23 through 10/05/23, 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 and OARs 411 Division 004 Home and Community Based Services Regulations. 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 10/05/23, conducted  01/29/24 through 01/30/2024, 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 and Home and Community Based Services Regulations OARs 411 Division 004. 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 2nd revisit to the re-licensure survey of 10/05/23, conducted on 04/03/24 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 .

Based on observation and interview, it was determined the facility failed to maintain the kitchen clean and in good repair and prepare food in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: The following was observed when the kitchen was toured with Staff 2 (Cook) on 04/13/23: a. An accumulation of food spills, splatters, loose food debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Doors, door frames, and walls throughout the kitchen; * Under and behind the stove; * Pipes under food preparation and triple sinks, under and on top of dishwasher, and behind the stove; * Light switches; * Emergency fire pull; * Refrigerator and walk-in cooler door handles; * Interior of microwave; * Industrial can opener and housing unit; * Cabinets and drawers in coffee/juice station in the dining room; * Fan in the dairy refrigerator; * Tape and tape residue on walls, shelves in the kitchen, and in the walk-in cooler; * Perimeter of floor drains under the sinks and dishwasher; * Paper and laminated signs; * The walls and shelving units in the walk-in cooler; and * Floors throughout the kitchen had black matter along perimeter edges and the items stored there. b. The following areas were in need of cleaning or repair: *The caulk behind hand-washing sink was blackened; * Wooden shelves in the kitchen and in the dry-storage room had areas where the laminate had come off or paint had chipped and raw wood was exposed. * The trim above the food preparation sink was made of raw wood; * The cutting board attached to the steam table was made of wood; * The spray hose for the triple sink was ;mounted to a piece of raw wood on the wall; * One of the rolling food/utility carts was heavily stained; * Dishwasher build up of minerals, dirt, dust, grease on and on pipes beneath; * Multiple cutting boards were deeply scored; * The coating on the shelves in the stand-up refrigerators and freezer had peeled away and there was rust developing on the metal below; * There were areas with chipped paint and/ or gouges in the walls, doors, and door frames throughout the kitchen; * The vent above the dairy refrigerator was broken; * There was a build-up of white mineral matter on the pipes below the refrigeration unit in the walk-in cooler: * There was chipped paint along the seams of the ceiling in the walk-in cooler; * Multiple metal shelving units and food preparation tables had rust developing at the bases and edges of shelves; and * There was a build up of white, green, and orange mineral/corrosive matter on the pipes on top of and under the dishwasher and in the walk-in cooler below the refrigeration unit. c. Multiple servers were not wearing aprons. d. Staff 2 (Cook) was observed to touch ready-to-eat foods with bare hands. The kitchen and food service findings were reviewed with Staff 1 (Administrator) on 04/13/23. The need to maintain the kitchen clean and in good repair and to prepare food in accordance with the Food Sanitation Rules was discussed at that time. She acknowledged the findings.

All areas of food spillage, splatters,loose food debris, dirt, dust, black matter and grease will be cleaned. The community will do an extensive clean of all kitchen areas Caulk will be replaced on the back of handwashing sink. Cabinets and shelves and doors sanded, will be repainted or replaced. All raw wood, trim and spray hose for triple sink will be sanded and painted. Floor issues will be repaired or replaced. New cutting boards will be purchased. The dishwasher area will be deep cleaned. The walls in walk-in will be deep cleaned or pressure washed. Stained rolling carts will be replaced or stains removed.Laminated signs will be replaced. Rusty shelves in standing refrigerator and freezer will be replaced. Broken vent above dairy fridge will be repaired. Chipped paint and gouges will be sanded and repainted. White mineral material will be removed from all pipes, dishwasher, and walk-in cooler. The interior microwave and all doors will be cleaned. Can opener, door handles, emergency pulls and coffee and juice stationed will be scrubed and clean. Also light switches. Tape and tape residue will be removed from walls. Shelves with coating and rust present will be replaced or recoated. All servers will be educated on the need to wear aprons. Aprons will be provided. All cooks and staff will be provided with education on food service and sanitation , as well as wearing gloves for ready to eat foods. To prevent this issue, moving forward a weekly cleaning list and log, as well as a monthly deep clean list and log will be carried out. The ED and kitchen lead will walk kitchen weekly to ensure build up and unsanitary issues are prevented from reacurring and addressed timely, moving forward. There will be no exposed raw wood in the kitchen and no wood cutting boards to be used moving forward. These systems will be autited for compliance monthly during continuing quality improvement meetings, as well as any immediate concerns addressed daily in stand up by the ED and kitchen manager.

The findings of  the kitchen inspection, conducted on 04/13/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 04/13/23, conducted 07/13/23, 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.