Raleigh Hills Assisted Living

Based on interview and record review, it was determined the facility failed to immediately report incidents of abuse to the local Seniors and People with Disabilities (SPD) office and promptly investigate and document reports of abuse including the date of the incident and administrator’s review for 1 of 1 sampled resident (# 1) who was involved in a resident-to-resident altercation. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 03/2024 with diagnoses including cognitive disorder.

Review of the resident's 04/22/25 through 07/21/25 progress notes, 06/03/25 service plan, and interim service plans revealed the following:

* 04/22/25 - "One resident got up and wanted to go down to lunch when [Resident 1] physically stopped [him/her] by grabbing [his/her] wrist and telling the other resident to sit back down.”

Review of the investigation into the incident revealed the incident was not reported to the local SPD office and the investigation lacked documentation of the date of the incident and the administrator's review.

During an interview on 07/23/25 at 9:10 am, Staff 1 (Director of People and Operations) confirmed the incident was not reported to the local SPD office and the investigation lacked the required information.

The facility was directed to report the incident to SPD. On 07/24/25 at 8:35 am, documentation was provided to the survey team that SPD had been notified.

The need to immediately report abuse to the local SPD office and ensure investigations into abuse included the date of the incident and the administrator’s review was discussed with Staff 1 and Staff 2 (ALF RN) on 07/23/25 at 3:12 pm. They acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

(Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 4 moved into the facility in 06/2025 with diagnoses including mild cognitive impairment.

The resident’s “Pre-Admit Assessment” was reviewed, and the following required elements were not addressed:

* Date of the assessment;
* Customary routines;
* Interests, hobbies, social, leisure activities;
* Mental health issues including presence of depression, thought disorders or behavioral or mood problems, history of treatment, and effective non-drug interventions;
* Pain, including non-pharmaceutical interventions, and how a person expresses pain or discomfort;
* Nutrition habits;
* Complex medication regimen;
* Unsuccessful prior placements;
* Environmental factors that impact the resident’s behavior including but not limited to noise, lighting, and room temperature; and
* Gender identity and preferred name.

The need to address all required elements on the resident’s move-in evaluation was discussed with Staff 1 (Director of People and Operations) and Staff 4 (ALF RN) on 07/24/25 at 8:40 am. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN.
(a) The facility must determine whether a potential resident meets the facility's admission requirements.
(b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability.
(c) Each resident record must, before move-in and when updated, include the following information:
(A) Legal name for billing purposes.
(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding:
(i) Name.
(ii) Pronouns.
(iii) Gender identity.
(C) Prior living arrangements;
(D) Emergency contacts;
(E) Service plan involvement - resident, family, and social supports;
(F) Financial and other legal relationships, if applicable, including, but not limited to:
(i) Advance directives;
(ii) Guardianship; (iii) Conservatorship; and
(iv) Power of attorney.
(G) Primary language;
(H) Community connections; and
(I) Health and social service providers.

(2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.
(a) Resident evaluations must be:
(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and
(B) Performed at least quarterly, to correspond with the quarterly service plan updates.
(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.
(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.
(E) Documented, dated, and indicate who was involved in the evaluation process.
(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.

(3) EVALUATION REQUIREMENTS AT MOVE-IN.
(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.
(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.
(c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs.
(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.
(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.

(4) QUARTERLY EVALUATION REQUIREMENTS.
(a) Resident evaluations must be performed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.
(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.

(5) The resident evaluation must address the following elements:
(a) For service planning purposes, if indicated by the resident,
(A) Name.
(B) Pronouns.
(C) Gender identity.
(b) Resident routines and preferences including:
(A) Customary routines, such as those related to sleeping, eating, and bathing;
(B) Interests, hobbies, and social and leisure activities;
(C) Spiritual and cultural preferences and traditions; and
(D) Additional elements as listed in 411-054-0027(2).
(c) Physical health status including:
(A) List of current diagnoses;
(B) List of medications and PRN use;
(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and
(D) Vital signs if indicated by diagnoses, health problems, or medications.
(d) Mental health issues including:
(A) Presence of depression, thought disorders, or behavioral or mood problems;
(B) History of treatment; and (C) Effective non-drug interventions.
(e) Cognition, including:
(A) Memory;
(B) Orientation;
(C) Confusion; and
(D) Decision-making abilities.
(f) Personality, including how the person copes with change or challenging situations.
(g) Communication and sensory abilities including:
(A) Hearing;
(B) Vision;
(C) Speech;
(D) Use of assistive devices; and
(E) Ability to understand and be understood.
(h) Activities of daily living including:
(A) Toileting, bowel, and bladder management;
(B) Dressing, grooming, bathing, and personal hygiene;
(C) Mobility - ambulation, transfers, and assistive devices; and
(D) Eating, dental status, and assistive devices.
(i) Independent activities of daily living including:
(A) Ability to manage medications; (B) Ability to use call system;
(C) Housework and laundry; and
(D) Transportation.
(j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.
(k) Skin condition.
(l) Nutrition habits, fluid preferences, and weight if indicated.
(m) List of treatments - type, frequency, and level of assistance needed.
(n) Indicators of nursing needs, including potential for delegated nursing tasks.
(o) Review of risk indicators including:
(A) Fall risk or history;
(B) Emergency evacuation ability;
(C) Complex medication regimen;
(D) History of dehydration or unexplained weight loss or gain;
(E) Recent losses;
(F) Unsuccessful prior placements;
(G) Elopement risk or history;
(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and
(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.
(p) Environmental factors that impact the resident's behavior including, but not limited to:
(A) Noise.
(B) Lighting.
(C) Room temperature.
(6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.

Stat. Auth.: ORS 410.070, 441.122, 443.450
Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, including reasons for use for all medications for 2 of 4 sampled residents (#s 1 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 06/2025 with diagnoses including mild cognitive impairment.

Review of Resident 4's 07/01/25 through 07/21/25 MAR revealed the following routine medications lacked documentation of a reason for use:

* Donepezil;
* Memantine;
* Lisinopril; and
* Cephalexin.

The need to ensure medication administration records included reasons for use was reviewed with Staff 1 (Director of People and Operations) on 07/24/25 at 8:40 am. She acknowledged the findings.

2. Resident 1 was admitted to the facility in 03/2024 with diagnoses including cognitive disorder.

The resident's 05/13/25 signed physician orders, and 07/01/25 through 07/21/25 MAR were reviewed.

The MAR showed there was no reason for use documented for the following medications:

* Amlodipine;
* Losartan;
* Quetiapine; and
* Mirtazapine.

On 07/23/25 at 3:12 pm, the need to ensure medication administration records included reasons for use was discussed with Staff 1 (Director of People and Operations) and Staff 2 (ALF RN). They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

(2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, including reasons for use for all medications for 2 of 4 sampled residents (#s 9 and 12) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 moved into the facility on 10/14/25 with diagnoses including high blood pressure.

Resident 9's MAR, reviewed from 10/14/25 through 10/20/25, revealed the resident had orders for two routine medications: Clonidine and AMLOD/VALS/HCTZ (Amlodipine-valsartan-hydrochlorothiazide). The MAR lacked a reason for use for both medications.

The need to ensure medication administration records included reasons for use was reviewed with Staff 12 (Executive Director) and Staff 5 (Staffing Coordinator/MT) on 10/20/25 at 4:10 pm. They acknowledged the findings.

2. Resident 12 was admitted to the facility in 08/2025 with diagnoses including hypothyroidism, depression and pain.

The resident's 10/01/25 through 10/20/25 MAR was reviewed. The MAR showed there was no reason for use documented for the following medications:
* Bupropion;
* Vitamin D3;
* Gabapentin;
* Levothyroxine;
* Memantine;
* Midodrine;
* Mirtazipine;
* Olanzapine;
* Omeprazole;
* Senna:
* Sodium Chloride;
* Topiramate;
* Vitamin B-1;
* Oxycodone; and
* Nicotine patch.

In an interview with Staff 12 (Executive Director) and Staff 5 (Staffing Coordinator/MT) on 10/20/25 at 4:10 pm, they acknowledged that Resident 12’s medication administration records lacked reasons for use.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:

The facility's ABST was reviewed and discussed with Staff 1 (Director of People and Operations) on 07/22/25 at 11:55 am. The following was identified:

* Two former residents were in the ABST; and
* Four unsampled residents and one sampled resident (#4) were not entered into the ABST.

The need to implement an ABST which met the regulation was discussed with Staff 1 and Staff 4 (ALF RN) on 07/24/26 at 9:05 am. They acknowledged the findings.

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements

(1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall:
(a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule.

(2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule.
(a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements:
(A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule.
(B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element.
(C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident.
(D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day.
(E) Identify the date the resident’s ABST evaluation was last completed.
(F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule.

(b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following:
(A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule.
(B) Completed ABST PDRR Form.
(C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes.
(D) The facility’s ABST policy required under OAR 411-054-0025(7)(i).
(c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form.
(d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time.
(e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference.
(f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31.
(g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST.

(3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements:
(a) Personal hygiene.
(b) Grooming.
(c) Dressing and undressing.
(d) Toileting, bowel, and bladder management.
(e) Bathing.
(f) Transfers.
(g) Repositioning.
(h) Ambulation.
(i) Supervising, cueing, or supporting while eating.
(j) Medication administration.
(k) Providing non-drug interventions for pain management.
(l) Providing treatments.
(m) Cueing or redirecting due to cognitive impairment or dementia.
(n) Ensuring non-drug interventions for behaviors.
(o) Assisting with leisure activities, assist with social and recreational activities.
(p) Monitoring physical conditions or symptoms.
(q) Monitoring behavioral conditions or symptoms.
(r) Assisting with communication, assistive devices for hearing, vision, and speech.
(s) Responding to call lights.
(t) Safety checks, fall prevention
(u) Completing resident specific housekeeping or laundry services performed by care staff.
(v) Providing additional care services. If additional services are not provided, this element can be omitted.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated before a resident moved in for 1 of 1 sampled resident (#4) whose move in evaluation was reviewed and one unsampled resident who had recently moved in. Findings include; but are not limited to:

During the acuity interview on 07/21/25 at 9:05 am, Staff 1 (Director of People and Operations), Staff 4 (ALF RN), and Staff 5 (Staffing Coordinator/MT) confirmed Resident #4 and an unsampled resident had moved to the facility within the last 90 days.

The facility’s ABST data was reviewed on 07/21/25 at 1:00 pm and revealed Resident #4 and one unsampled resident had no ABST data.

The need to ensure residents’ ABST was updated before a resident moved in was discussed with Staff 1 and Staff 4 on 07/24/25 at 9:05 am. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated before a resident moved in for 2 of 2 sampled residents (#s 9 and 12) and two unsampled residents who had recently moved in. This is a repeat citation. Findings include; but are not limited to:

During the acuity interview on 10/20/25, Staff 5 (Staffing Coordinator/MT) and Staff 13 (Assistant Executive Director) stated the facility was using the ODHS ABST. They confirmed Residents 9 and 12 and two unsampled residents had moved into the facility within the last 60 days.

The facility’s ODHS ABST data was reviewed on 10/20/25 and revealed Residents 9 and 12, and two unsampled residents had no ABST data.

The need to ensure residents’ ABST was updated before a resident moved in was discussed with Staff 12 (Executive Director) and Staff 5 (Staffing Coordinator/MT) on 10/20/25 at 4:10 pm They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire drill records from 02/2025 through 07/2025 were reviewed on 07/22/25. The facility failed to document the following required components:

* Location of simulated fire origin;
* Escape route used;
* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time-period needed;
* Number of occupants evacuated; and
* Evidence alternate routes were used during fire drills.

On 07/23/25, the need to ensure all required components of fire drills were documented and evidence of alternate routes were used during fire drills was discussed with Staff 1 (Director of People and Operations). She acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

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

This Rule is not met as evidenced by:

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

Refer to C310, C363 and C613.

Based on observation and interview, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse, and chemicals and toxic materials were secured in locked storage. Findings include but are not limited to:

The facility grounds and interior of the Assisted Living Facility (ALF) was toured on 07/21/25 and 07/22/25, and observations were made throughout the survey. The following was identified:

a. Building Interior:

* Cleaning chemicals were stored in an unlocked laundry and storeroom on the first floor next to the enhanced care unit; and
* Cleaning chemicals were stored in an unlocked room on the 2nd floor;

b. Building Exterior:

* East front entrance area: Three stacked grey round plastic containers, a green compost container, and a discarded small table were stored near the barbecue.

The findings were reviewed in a tour of the facility on 07/23/25 at 2:00 pm with Staff 1 (Director of People and Operations).

The need to ensure all chemicals, and other toxic materials were stored in locked storage, and to ensure the grounds were free of litter and refuse was discussed with Staff 1 on 07/24/25 at 8:40 am. She acknowledged the findings.

OAR 411-054-0300 (3)(a-h) General Building Exterior

(3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the interior and exterior of the facility environment was clean and maintained in good repair. Findings include, but are not limited to:

1. Interior of the building:
* The carpet in the common areas, dining room and at Room 114 had stains;
* The elevator door frame on all three floors had black marks and was chipped/scuffed;
* The wood baseboard in the common areas and around the dining area was chipped/scuffed;
* The inside door of the bathroom near the dining area had black marks, the door frame was chipped/scuffed, the door inside/outside had worn varnish, and the door lock was difficult to lock;
* An exit door on the first floor facing the driveway had black marks and was chipped/scuffed;
* The windowsill next to the eastside sitting area on the first floor had chipped paint and pieces were on the floor;
* The eastside sitting area on the second floor had an end table that was peeling, worn and rough to the touch;
* The laundry room on the second floor had a hole in the ceiling and heavy dust on top of the cabinets;
* The third floor sitting area had a worn and stained recliner;
* Near the boiler room on the third floor there was white repair spackle on the wall and the ceiling light was missing a cover;
* Room 303 plastic door guard and the door frame had black marks and was chipped/scuffed;
* Room 304 had a carpet stain outside the door; and
* Room 316 had white repair spackle on the wall outside the door and there were missing ceiling lights outside Room 316.

2. Exterior of the building:

a. East front entrance area:
* A wood bench was worn and rough to the touch.

b. The back courtyard area:
* The gazebo roof had clumps of moss, branches and sticks;
* The gazebo structure was dirty;
* A wood plank nailed between two of the gazebo posts was chipped and rough to the touch;
* Two large wood planter boxes were worn and rough to the touch; and
* Three green plastic chairs were dirty and peeling.

The findings were reviewed in a tour of the facility on 07/23/25 at 2:00 pm with Staff 1 (Director of People and Operations).

The need to ensure the interior and exterior of the building was clean and maintained in good repair was discussed with Staff 1 on 07/24/25 at 8:40 am. She acknowledged the findings.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable

(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 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. An ALF 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 must be kept clean and in good repair.

This Rule is not met as evidenced by:
Based on observation and interview, it was determined the facility failed to ensure the interior of the facility environment was clean and maintained in good repair. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility on 10/20/25 at 1:00 pm revealed the following:

* Carpet stains were observed in the lobby, first floor hallways, dining room, and stairwell (located by Room 121);
* The elevator door frame on all three floors had black marks and was chipped/scuffed;
* The door of the bathroom near the dining area had worn varnish on the interior and exterior;
* Exit doors on the first floor (located near Room 118 and 121) had scraped paint on the door and/or jamb; and
* Room 303’s plastic door guard and door frame had black marks and was chipped/scuffed.

The surveyor toured the environment with Staff 1 (Executive Director) on 10/20/25 at 1:20 pm. She acknowledged the findings.

Based on interview and record review, the facility failed to ensure the move-in evaluation addressed all required elements, including pronouns and gender identity, for 1 of 1 resident (# 4) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Refer to: C 252.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN.

(c) Each resident record must, before move-in and when updated, include the following information:

(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity.

(5) The resident evaluation must address the following elements:

(a) For service planning purposes, if indicated by the resident,

(A) Name

(B) Pronouns.

(C) Gender identity.

This Rule is not met as evidenced by:

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:

The facility’s kitchen was toured on 06/17/25 at 10:10 am. The following was identified:

a. An accumulation of food spills, splatters, loose food debris, grease, dirt, dust, garbage, or black matter was observed on, in or underneath the following:

* Floor and baseboard junctions throughout the kitchen;
* Walls behind appliances and sinks throughout the kitchen;
* Gas pipes to the stove and griddle;
* Water pipes to the warewasher and ice maker;
* Floor drains;
* Floors underneath storage racks in the walk-in refrigerator;
* Ceiling vent above the juice machine;
* Hood above the warewasher;
* Interior casing of the can opener;
* Plastic shavings were piled below cutting board racks where boards had scraped against metal dividers as they were removed;
* Inside the ice maker along the cartridge that dispenses ice; and
* Rust and corrosion were noted on floating ceiling tile supports, lighting fixtures and vents around the warewasher and three-compartment sink, as well as the ceiling seams in the walk-in refrigerator.

b. The following kitchen items required repair or replacement:

* Hole in the wall underneath warewasher;
* Cut-out in the drywall in the janitor’s closet exposed water shut-off valves, pipes and insulation;
* Broken drain for the cold prep sink;
* Rusted drain under the three-compartment sink;
* Rusted metal access panel under the three-compartment sink with splitting tile mortar around the panel interface;
* Gap along the bottom edge of the exterior door could allow entry of insects and pests;
* Drywall and corners in the dry food storage room were gouged and scratched;
* Cabinet doors on the service line and coffee/juice stations did not close;
* Floors in dining room cabinet that supported the soda dispenser were either missing or sagging and were stained and/or coated with black matter;
* Cabinetry under the coffee/juice station had worn corners and laminate panels, exposing bare wood;
* Ladder in dry storage room was heavily coated with dried paint and stains; and
* Handwashing sink in cold prep room did not have a splash guard between it and the adjacent prep table.

c. Poor infection control practices observed, but not limited to:

* Stand mixer and mixing bowl were left uncovered when not in use;
* Kitchen staff did not have access to chemical testing strips;
* Kitchen staff failed to perform hand hygiene consistently between clean and dirty tasks; and
* Silverware on preset dining tables was not covered.

A kitchen walkthrough was completed with Staff 1 (ED) and Staff 2 (Administrator) on 06/17/25 at 12:37 pm. The areas that did not meet the rules were discussed with Staff 1 and Staff 2. They acknowledged the findings.

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).

This Rule is not met as evidenced by:

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).

This Rule is not met as evidenced by:
Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner and ensure food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This is a repeat citation. Findings include, but are not limited to:

On 08/26/25, from 12:04 pm to 1:37 pm, interviews with staff and observations of the facility kitchen, food storage areas, food preparation, and food service were conducted. The following was identified:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following:

* Four floor drains located throughout the kitchen;
* Rust and corrosion were noted on floating ceiling tile supports around the ware washer and three-compartment sink; and
* The interior of the dining room cabinet that supported the soda dispenser.

b. The following areas were noted in need of repair:

* Hole in the wall underneath ware washer;
* Cut-out in the drywall in the janitor’s closet exposed water shut-off valves, pipes and insulation;
* Rust colored drain under the three-compartment sink;
* Rust colored metal access panel under the three-compartment sink with splitting tile mortar around the panel interface;
* The interior and exterior of the dining room cabinet that supported the soda dispenser had missing and broken material and had unsealed wood that supported the base of the cabinet; and
* Cabinetry under the coffee/juice station had worn corners and laminate panels, exposing bare wood.

c. Stand mixer and mixing bowl were left uncovered when not in use.

On 08/26/25 at 1:24 pm, Staff 1 (Executive Director), and Staff 2 (Memory Care Administrator), Staff 3 (Executive Chef), and Staff 4 (Maintenance Supervisor), completed a walk-through of the kitchen with this surveyor and reviewed the above noted areas.

The need to ensure the kitchen was maintained in a sanitary manner and food was prepared and served in accordance with Food Sanitation Rules was reviewed with Staff 1, Staff 2, Staff 3, and Staff 4 on 08/26/25 at 1:28 pm. They acknowledged the findings.

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).

This Rule is not met as evidenced by:

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).

This Rule is not met as evidenced by:
Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner and ensure food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This is a repeat citation. Findings include, but are not limited to:

On 08/26/25, from 12:04 pm to 1:37 pm, interviews with staff and observations of the facility kitchen, food storage areas, food preparation, and food service were conducted. The following was identified:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following:

* Four floor drains located throughout the kitchen;
* Rust and corrosion were noted on floating ceiling tile supports around the ware washer and three-compartment sink; and
* The interior of the dining room cabinet that supported the soda dispenser.

b. The following areas were noted in need of repair:

* Hole in the wall underneath ware washer;
* Cut-out in the drywall in the janitor’s closet exposed water shut-off valves, pipes and insulation;
* Rust colored drain under the three-compartment sink;
* Rust colored metal access panel under the three-compartment sink with splitting tile mortar around the panel interface;
* The interior and exterior of the dining room cabinet that supported the soda dispenser had missing and broken material and had unsealed wood that supported the base of the cabinet; and
* Cabinetry under the coffee/juice station had worn corners and laminate panels, exposing bare wood.

c. Stand mixer and mixing bowl were left uncovered when not in use.

On 08/26/25 at 1:24 pm, Staff 1 (Executive Director), and Staff 2 (Memory Care Administrator), Staff 3 (Executive Chef), and Staff 4 (Maintenance Supervisor), completed a walk-through of the kitchen with this surveyor and reviewed the above noted areas.

The need to ensure the kitchen was maintained in a sanitary manner and food was prepared and served in accordance with Food Sanitation Rules was reviewed with Staff 1, Staff 2, Staff 3, and Staff 4 on 08/26/25 at 1:28 pm. They acknowledged the findings.

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).

This Rule is not met as evidenced by:

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

Refer to 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.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 04/18/24, 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 first revisit to the kitchen inspection of 04/18/24, conducted 06/27/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 04/18/24 at 10:45 am, the kitchen was observed to have the following areas of concern:* Two rolling carts, one next to the convection oven containing individual cake servings and pastries and one in walk in refrigerator had six trays of food items, including individual cake servings, sauce containers and fresh vegetables which were uncovered, exposed to the air and possible cross contamination;* A tray of uncovered individual servings of ice cream in the freezer were uncovered; * In the dry storage area: - A food bin was open which contained open bags of sugar and flour; - A scoop was in a bin of oats; - A cup was in a container of brown sugar which was not tightly sealed; and* The hood vents above the stove/grill had build up of dust and grease. The areas of concern were observed and discussed with Staff 1 (Cook) and discussed with Staff 2 (Executive Director) and Staff 3 (Memory Care Community Administrator) on 04/18/24. The findings were acknowledged.

Based on interview and record review, conducted during a site visit on 03/06/24, it was confirmed the facility failed to provide prompt access to records for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: During an interview on 03/06/24, Staff 1 (Executive Director) stated Resident 1 had requested an investigation for an incident s/he had been involved in. Staff 1 had not given Resident 1 a copy of the investigation and further stated "incident reports" were not a part of the resident record.Resident 1 was unable to be interviewed as s/he was not present in the facility during the site visit.A review of an incident report for Resident 1, dated 12/07/23, indicated the investigation had been completed.It was determined the facility failed to implement the resident's right to have access to his/her records.The findings of the investigation were reviewed with and acknowledged by Staff 1 on 03/06/24.Verbal plan of correction: The facility will provide the incident report to the resident.

Based on interview and record review, conducted during a site visit on 03/06/24, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool (ABST) for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:During an interview on 03/06/24, Staff 1 (Executive Director) stated the facility was "trying to use the state tool" and the facility's ABST was not updated regularly. Staff 1 stated a new "staffing coordinator" had been hired and s/he would be responsible for entering data into the tool going forward.A review of the facility's ABST, indicated the following:- The facility used the Oregon Department of Human Services ABST;- The facility census was 73, only 67 residents were entered into the ABST;- Resident 1's last ABST update was 04/13/22;- Resident 2 was admitted to the facility on 10/03/24, s/he was not entered into the ABST; and- Resident 3's last ABST update was 07/07/22.Findings of the investigation were reviewed with and acknowledged by Staff 1 on 03/06/24. It was determined the facility failed to fully implement and update an ABST.

The findings of the kitchen inspection, conducted 05/10/23, 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 05/10/23, 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.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, food was stored appropriately, and glove use was in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to: On 05/10/23 at 10:55 am the following areas of concern were observed: * In the walk in refrigerator: - Multiple containers of leftovers without labels and/or dates; - Carton of eggnog past "best by" date; and - Roll in cart with food items uncovered including: cake with whipped topping, tarter sauce and guacamole.* In walk in freezer: - Three stacks of boxes on floor; - Open frozen food items without dates; and - Package of breaded fish open to the air.* Dry storage: - Cardboard boxes on the floor included: ice cream cones, cake mixes, cups, bowls, bag of couscous, popcorn, juice; - Bag of whole grain red quinoa open to air; - Open bag of pudding; and - Scoop in bin of oats. * Bag of onions on floor under handwashing sink. * Roll in cart next to reach in refrigerator with uncovered pies and burritos.* In food prep area: uncovered slices of pie on trays. * Handle of scoop in ice bin (not hanging on hook). * Areas in need of cleaning: - Vents above grill/stove with dust/grease; - Grease drippings on stove hood; - Wall behind stove and steamer (grease and splatters) - Wall and ceiling above juice machine and coffee station (dusty); - Vent above cereal containers/clock/coffee station (heavy dust build up); - Light covering above food prep area next to stove (dusty/splatters); - Roll in cart near reach in refrigerator with food debris/crumbs on shelving holder slates; - Two blender bases with food drippings/splatters; - Hood above dishwasher rusty; and - Bottom shelf holding steamer and cutting boards - finish worn off (uncleanable).* Garbage cans uncovered when not in use: - One near stove with open container of shredded cheese and tortilla wraps; - One near the two compartment sinks; - Open can holding food scraps by hand washing sink; and - One near uncovered slices of pie. * Multiple observations of serving staff changing gloves without washing hands before donning clean gloves. Staff were observed conducting multiple food preparation activities without changing gloves or washing hands between activities. The areas of concern were observed and discussed with Staff 1 (Dietary Manager) and Staff 2 (Executive Director) on 05/10/23. The findings were acknowledged.

The findings of the re-licensure survey, conducted 05/02/22 through 05/04/22, are documented in this report. The survey was conducted to determine compliance with 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first revisit to the re-licensure survey of 05/04/22, conducted 07/19/22 through 07/20/22, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against conditions that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:Observations were made during the survey to determine adherence to universal precautions for infection control.On 05/03/22 at 2:01 pm, the surveyor observed Staff 12 (CG) and Staff 13 (CG) provide incontinent care to Resident 1. During the observation, Staff 12 failed to change gloves after removing a soiled incontinent product and wiping fecal matter from Resident 1's bottom and perineum. Staff 12 touched the resident's clean blanket, clean incontinent brief and applied barrier cream to the resident's bottom while wearing the same soiled gloves.The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Administrator) on 05/03/22 at 2:18 pm. Staff acknowledged the findings.

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 residents (#2) whose move-in evaluation was reviewed. Findings include, but are not limited to:Resident 2 moved into the facility in March 2022. The following required elements were not addressed:* Customary eating routine;* Cultural preferences and traditions;* Mental health issues, including effective non-drug interventions for documented mood/behavior issue; and* Memory and decision-making abilities. The need to ensure the initial evaluation included and addressed all required elements was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Resident Care Coordinator), and Staff 7 (RN Consultant) on 05/04/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 2018 with diagnoses including hypertension and right knee pain.Observations of the resident, interviews with staff, the current service plan and clinical records were reviewed during the survey, from 05/02/22 thru 05/04/22, revealed Resident 1's service plan was not reflective of the resident's status and did not provide clear direction to staff regarding the delivery of service in the following areas:* Transfer status; * Hospice service including when to contact and who to contact;* Grooming;* Dining preference;* Activity status;* Use of air mattress status; and* Use of oxygen including who is to change the filter and tubing.On 05/03/22 and 05/04/22, service plans were discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the service plans were not reflective of the resident's status and lacked clear instructions.3. Resident 4 was admitted to the facility in 2019 with diagnoses including congestive heart failure and anticoagulation therapy.Observations of the resident, interviews with staff and the current service plan reviewed during the survey, from 05/02/22 thru 05/04/22, revealed Resident 4's service plan was not reflective of the resident's status in the following:* Bathing status; and* Dressing.On 05/03/22 and 05/04/22, service plans were discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the service plans were not reflective of the residents status.
Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of the resident's current needs, provided clear direction to staff regarding the delivery of services, were reviewed quarterly and were followed, for 3 of 7 sampled residents (#s 1, 4 and 7) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 2014 with diagnoses including history of behavior problems and acute encephalopathy due to phenytoin toxicity and possible opioid use.During the survey, observations were made of the resident, interviews were conducted with another resident and multiple staff, and Resident 7's service plan and the last 60 days of progress notes were reviewed.Resident 7's service plan included dated entries/updates describing various behaviors the resident had exhibited toward other residents and staff since moving into the facility.* The service plan did not always provide instructions for staff as to how to respond to each of the behaviors.* The service plan directed staff to notify the MTs "of any issues" so that the incident could be charted in the facility system. However, the service plan lacked clear instructions as to where or how to document (communication binder, progress note, incident report, alert charting, etc) and when to notify the administration team of an incident.* The service plan directed staff to "remind [resident] to be kind to [his/her] neighbors and treat them as [s/he] would like to be treated" when staff witnessed Resident 7 making fun of other residents, calling them stupid, or making snide comments about them. In an incident dated 5/3/22, staff documented Resident 7 continued to make comments regarding a previous resident altercation in the presence of the other resident, and staff responded only by asking the resident to "drop it" rather than responding as instructed in the service plan.The need to ensure the resident's service plan provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 7 (RN Consultant) on 05/04/22. They acknowledged the need to add additional instructions for staff regarding documentation and reporting.

Based on interview and record review, it was determined the facility failed to consistently determine and document what action or intervention was needed for a resident and ensure the documentation of staff instructions was made part of the resident record in response to a short term change of condition, for 2 of 7 sampled residents (#s 2 and 3) who had a medication change and a skin injury. Findings include, but are not limited to:Resident 2 and 3's current service plans and last 90 days of charting notes were reviewed during the survey. The following deficiencies were identified:1. Resident 2 was admitted to the facility in 2022 with diagnoses including Alzheimer's Disease.A charting note dated 03/31/22 stated was on "Alert Charting" for a new medication - Melatonin.There was no documented evidence actions or interventions were determined and documented for staff and made part of the resident record.2. Resident 3 was admitted to the facility in 2021 with diagnoses including osteoarthrosis, osteoporosis and chronic pain in the hip and lower extremity joints.A charting note dated 03/12/22 stated the resident was being placed on "Alert Charting" after sustaining a minor skin tear on the wrist.There was no documented evidence actions or interventions were determined and documented for staff and made part of the resident record.The need to ensure the facility documented what action or intervention was needed for a resident following a short term change of condition was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 7 (RN Consultant) on 05/04/22. They reported MTs were instructed to document instructions in the Alert Charting note, and that this had not been done.

Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 3 sampled residents (# 1) who received hospice services. Findings include, but are not limited to: Resident 1 was admitted to the facility in 2018 with diagnoses including hypertension. During the acuity interview, the resident was identified to receive hospice services.Resident 1 was observed on 05/03/22, with the following:* Oxygen therapy, setting of 4L/min;* Use of air mattress on bed; * A surgical wound dressing on the right hip area; and * A foam dressing on coccyx area.The resident's clinical record was reviewed and identified the following: * A physician order dated 04/26/22 indicated a flow rate of 2L/min of oxygen; * There was no information regarding the resident was using an air mattress; and * There was no documented evidence the facility was monitoring a surgical wound nor was there documentation the resident had a wound to the coccyx area. The above findings were discussed with the following staff and revealed: * 05/03/22 at 2:01 pm, Staff 12 (CG) stated the air mattress was delivered when the resident was enrolled to hospice service on 04/26/22. She was not aware of an open wound on the coccyx area;* 05/03/22 at 3:20 pm, Staff 2 (RN) stated the hospice team managed the resident's surgical wound on the right hip area, and it was not managed by the facility staff; and* On 05/04/22 at 2:30 pm, Staff 2 and Staff 3 (RCC) stated the hospice team increased the oxygen to 4L/min on 04/29/22 when they visited the resident. However, it was not communicated to the facility staff. She further stated there was no open wound to the resident's coccyx area and was unsure why a dressing had been placed.The need to ensure on-going coordination of care with an outside service provider was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 on 05/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and fire drill records included documentation of all required elements. Findings include, but are not limited to:Fire drill records were reviewed from 11/2021 through 04/2022. Documentation indicated that no residents were relocated during the fire drills, preventing the facility from documenting the following required elements:* Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and* Number of occupants evacuated.The need to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and included documentation of all required elements was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director) on 05/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety training requirements for residents were being met. Findings include, but are not limited to:Fire and life safety records were reviewed from 11/2021 through 04/2022. The following deficiencies were identified:* The facility failed to provide residents with accurate instructions for how to respond during a fire or fire drill, and failed to have a process for documenting that fire and life safety training was reviewed with residents at least annually.The need to ensure residents were instructed in accurate fire and life safety procedures upon admission and at least annually, was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:The facility was toured on 05/02/22. Resident unit windows on the second and third floors, and some of the first floor which was elevated due to the slope of the property, slid open horizontally and windowsills were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls.The lack of a mechanism to prevent accidental falls from windows that were above the first floor was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director) on 05/03/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit (F) or a chemical disinfectant was used when washing residents' soiled linens and clothing, and that the facility stored and handled soiled laundry separately from regular linens and clothing. Findings include, but are not limited to:During a tour of the facility, washers were noted to lack a hot water rinse setting. The laundry detergent observed in the laundry room did not contain a disinfecting agent. There were several large black garbage bags full of clothing and linens on the floor of the laundry room - not all bags were sealed.In an interview on 05/03/22, Staff 4 (Maintenance Director) confirmed the washing machines did not have a rinse temperature of 140 degrees F. He stated the facility either used a resident's personal laundry detergent or the detergent that was observed during the tour.In separate interviews on 5/4/22, Staff 9 (CG) and 12 (CG) both reported housekeeping staff normally took care of resident laundry but caregivers had been helping recently. Staff 9 reported sometimes staff failed to separate soiled laundry items from regular resident laundry when they bagged the items, and acknowledged sometimes garbage bags were not tied shut. Staff 9 confirmed soiled laundry was washed using the laundry detergent observed in the laundry room.The facility's failure to properly handle and launder soiled resident linens and clothing was reviewed with Staff 1 (Administrator) and Staff 7 (RN Consultant) on 05/04/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when they are installed in locations that are subject to incidental contact by individuals or with combustible material. Findings include, but are not limited to:During a tour of the building on 05/02/22, wall-mounted baseboard heaters were observed in multiple resident one- and two-bedroom units. The heaters were located where residents could fall against them. When a heater was turned on it felt hot to the touch, even at the lowest thermostat setting. The top surface temperature of the baseboard heaters in multiple rooms was measured with the surveyor's digital thermometer and found to range from 124 - 135 degrees F.A cadet-style wall heater was observed in the Spa Room on the third floor of the building. When the heater was turned on, the temperature of the lower part of the metal grate was found to quickly climb to 200 degrees F.The heaters were discussed with Staff 4 (Maintenance Director) on 05/03/22 at 11:00 am. He acknowledged one- and two-bedroom resident units had baseboard heaters and confirmed he had replaced the heater in the Spa Room because it had not been working. He stated he was not aware surface temperatures could not exceed 120 degrees F.The heaters were discussed with Staff 1 (Administrator) on 05/03/22 at 11:50 am. She acknowledged the heaters were not in compliance with the rule. Since the resident units also had an alternative heating source and residents were not using the baseboard heaters at this time of year, an immediate plan of correction was not requested by the survey team. On 05/04/22, Staff 1 asked Staff 7 (RN Consultant) to review the heater in the Spa Room with the surveyor. The surveyor and Staff 7 again verified the surface temperature to be in excess of 200 degrees F. Staff 7 said she would have the heater immediately disconnected.