The Amber Senior Living

Assisted Living Facility
365 SW BEL AIR DRIVE PO BOX 308, CLATSKANIE, OR 97016

Facility Information

Facility ID 70A287
Status Active
County Columbia
Licensed Beds 40
Phone 5037282744
Email [email protected]
Administrator Mallory Miller
Active Date Mar 21, 2003
Owner Sapphire At The Amber, LLC
365 SW BEL AIR DR
CLASKANIE OR 97016
Funding Medicaid
Services:

No special services listed

5
Total Surveys
21
Total Deficiencies
0
Abuse Violations
20
Licensing Violations
3
Notices

Violations

Licensing: 00175244-AP-139150
Licensing: 00174958-AP-138931
Licensing: 00121165-AP-094018
Licensing: 00096074-AP-072697
Licensing: ST180858
Licensing: 00011682AP-008392
Licensing: ST188626
Licensing: ST188573B
Licensing: ST179957
Licensing: CO16148
Licensing: OR0003361300
Licensing: OR0003361302
Licensing: OR0002761200
Licensing: OR0002715801
Licensing: OR0002715800
Licensing: OR0002662702
Licensing: OR0002662704
Licensing: 00104670-AP-079854
Licensing: SR19136
Licensing: OR0001526700

Notices

OR0003883601: Failed to use an ABST
OR0003883602: Failed to provide or maintain resident care equipment
CO16148: Failed to provide safe environment

Survey History

Survey RL007564

6 Deficiencies
Date: 10/29/2025
Type: Re-Licensure

Citations: 6

Citation #1: C0260 - Service Plan: General

Visit History:
t Visit: 10/29/2025 | Not Corrected
Regulation:
OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.
Inspection Findings:
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences and provided clear direction regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the community in 05/2025 with diagnoses including dementia and unspecified sleep disorder.

The resident’s clinical record was reviewed, including the 10/20/25 service plan, observations were made, and interviews were conducted. The following was identified:

The 09/04/25 service plan was not reflective of the resident’s current care needs and did not give clear direction to the staff in the following areas:

* Number of staff and amount of assistance required with dressing, toileting/incontinence care, and transfers;
* Preference of hospital bed to sleep;
* Use of side rails, hospital bed, and alternating pressure mattress; and
* Frequency of weights.

The need for the facility to ensure residents’ current service plans were reflective of current care needs and status and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:55 pm. They acknowledged the findings.

2. Resident 2 moved into the community in 12/2012 with diagnoses including psoriatic arthritis mutilans and chronic obstructive pulmonary disease.

The resident’s clinical record was reviewed, including the 10/20/25 service plan, observations were made, and interviews were conducted. The following was identified:

The service plan was not reflective of the resident’s current care needs and did not give clear direction to staff in the following areas:

* Fall history;
* Use of walker for ambulation inside the apartment;
* The resident’s inability to self-administer treatments; and
* Hourly safety checks.

The need for the facility to ensure service plans were reflective of the resident’s current care needs and status and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:30 pm. They acknowledged the findings.
Plan of Correction:
1. Resident 1 and Resident 2 Service Plans have been re-reviewed to ensure all information from their evaluation is reflected on their service plans and current care needs.
2. Resident Care Coordinator (RCC) and Registered Nurse (RN) will receive additional education on the New Admission Evaluation and SP steps. The RCC and RN will complete new move in evaluations and then the Administrator will audit to confirm these areas are reflected on the service plans.
3. All New Admission Service Plans, and 3 quarterly service plans will be audited as part of our monthly Quality Audit for 3 months, and if no errors are found then this will be audited quarterly, as well as needed when service plans occur.
4. Resident Care Coordinator, Registered Nurse, and Administrator will all be responsible to ensure completion of the processes and that corrections are monitored.

Citation #2: C0303 - Systems: Treatment Orders

Visit History:
t Visit: 10/29/2025 | Not Corrected
Regulation:
OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the community in 08/2025 with diagnoses including dementia with behavioral disturbance and chronic kidney disease.

Resident 3’s MAR, dated 10/01/25 through 10/27/25, and current physician's orders, dated 09/23/25, were reviewed, and the following was identified:

a. Resident 3 had a physician’s order for polyethylene glycol to give 17 grams by mouth every 24 hours as needed for constipation.

Review of the MAR revealed the polyethylene glycol was scheduled to be given 17 grams by mouth daily.

b. Physician's orders indicated rosuvastatin (calcium) oral tablet 25 mcg to be given by mouth one time a day.

Review of the MAR revealed rosuvastatin was listed twice to be administered at 8:00 pm and 9:00 pm and was initialed as administered twice five times during the 10/01/25 through 10/27/25 period.

In an interview with Staff 2 (Director of Health Services) on 10/29/25 at 9:55 am, she stated it was likely an error with the pharmacy.

The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:25 pm. They acknowledged the findings.

2. Resident 1 moved into the community in 05/2025 with diagnoses including dementia and constipation.

Review of the MAR, dated 10/01/25 through 10/27/25, and current physician's orders, dated 10/27/25, identified the following:

Resident 1 had a physician's order to weigh resident daily on day shift before breakfast.

From 10/01/25 to 10/24/25 and on 10/26/25 and 10/27/25, the MAR was marked as “Other/see nurses notes.” There was no corresponding documentation in the Progress Notes to indicate why resident was not weighed.

In an interview on 10/28/25 at 11:05 am, Staff 2 (Director of Health Services) stated the daily weights should have been discontinued.

The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:50 pm. They acknowledged the findings.
Plan of Correction:
1. Orders have been reviewed for resident 3 and resident 1's primary care providers and orders have been clairified and updated. MARS on these residents were updated to align with Physician orders.
2. New Orders Triple Check system education will happen with the RCC, RN and Med Techs. Additionally,RCC, RN and Med Techs will be educated on how to appropriately document in the progress notes when marking "Other/see nurses notes" and the reason they need to complete the circle of documentation. Registered Nurse will Audit Point Click Care to verify that all "Other/see nurses notes" have follow up in the chart. We will utilize a triple check system where the RN, RCC, and Administrator check that the medication orders are put in correctly.
3. New orders will be audited M-F during our Clinical Meetings for the next month, then audited monthly as part of our Quality Audit.
4. Registered Nurse, Resident Care Coordinator, and Administrator will be responsible to see that corrections and systems are followed and monitored.

Citation #3: C0310 - Systems: Medication Administration

Visit History:
t Visit: 10/29/2025 | Not Corrected
Regulation:
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.
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions were included for PRN medications and failed to ensure the MAR included the correct dosage of medication for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the community in 12/2012 with diagnoses including psoriatic arthritis mutilans and chronic obstructive pulmonary disease.

The resident’s MAR, dated 10/01/25 to 10/27/25, was reviewed, and the following orders were noted:

a. The resident had orders for two PRN medications for pain that did not have parameters for order of administration by unlicensed staff:

* Acetaminophen 500 mg, two tablets every six hours; and
* Hydromorphone HCl 4 mg tablet every four hours.

b. The resident had three orders for PRN medications for constipation that did not have parameters for order of administration by unlicensed staff:

* PEG 3350 powder 238 gm, mix 17 g in liquid;
* Senna 8.6 mg, one tablet daily; and
* Senna 8.6 mg, two tablets if no bowel movement in three days, not to exceed two tablets per day.

In an interview with Staff 15 (MT) on 10/28/25 at 2:35 pm, s/he stated, “I would probably give the Senna,” if the resident complained of constipation, “but actually, I would text the nurse just to make sure.”

The need to ensure resident-specific parameters and instructions for PRN medications were included on the MAR was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:30 pm. They acknowledged the findings.

2. Resident 1 moved into the community in 05/2025 with diagnoses including dementia and constipation.

The resident’s MAR, dated 10/01/25 to 10/27/25, was reviewed, and the following orders were noted:

a. The resident had orders for two PRN medications for pain that lacked parameters for order of administration by unlicensed staff:

* Acetaminophen 325 mg two tablets daily as needed for pain; and
* Morphine sulfate 20 mg/ml 0.25 to 0.5 ml every four hours as needed for pain.

b. The resident had two orders for PRN medications for constipation that lacked parameters for order of administration by unlicensed staff:

* Bisacodyl rectal suppository 10 mg rectally every 24 hours as needed for constipation; and
* Polyethylene glycol 17 grams as needed for bowel care.

c. The following medications lacked the specific dosage to administer:

* Morphine sulfate 20 mg/ml 0.25 to 0.5 ml every four hours as needed for pain; and
* Lorazepam 0.5 to 1 mg every four hours as needed for anxiety or shortness of breath.

In an interview on 10/28/25 at 11:00 am, Staff 2 (Director of Health Services) confirmed the lack of PRN parameters for the pain and bowel medications, as well as the ranges of the dosage of medications on the October MAR.

The need to ensure resident-specific parameters and instructions for PRN medications were included on the MAR and all medications had the correct dosage to administer was reviewed with Staff 1 (Executive Director), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:55 pm. They acknowledged the findings.
Plan of Correction:
1. All errors in parameters related to the bowel meds and to pain meds have been fixed with Resident 1 and Resident 2.
2. The Med Techs will be educated on clear parameters for PRN meds and education if an order is found to not have clear parameters. The Registered Nurse will review PRN orders for accurate Parpameters in MARS as a part of the new order review process.
3. We will audit new PRN medication orders M-F during clinical meetings for 4 weeks, if no issues are found we will audit PRNs monthly as part of our Quality Assurance process.
4. Registered Nurse, Resident Care Coordinator, and Administrator.

Citation #4: C0340 - Restraints and Supportive Devices

Visit History:
t Visit: 10/29/2025 | Not Corrected
Regulation:
OAR 411-054-0060 Restraints and Supportive Devices

Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07
Inspection Findings:
Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, and failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (# 1) who used a supportive device with restraining qualities. Findings include, but are not limited to:

Resident 1 moved into the community in 05/2025 with diagnoses including dementia and unspecified sleep disorder.

Observations of the resident and interviews with staff indicated the resident had a quarter-length side rail on both sides of his/her bed. The side rails were in good repair and flush with the mattress.

There was no documented evidence other less restrictive alternatives were evaluated prior to the use of the device. Staff reported the resident was primarily bedbound and received the hospital bed with side rails from the hospice provider.

On 10/28/25 at 11:25 am, Staff 2 (Director of Health Services) confirmed an assessment of the side rails was not completed prior to survey entry.

The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff 1 (ED), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:55 pm. They acknowledged the findings.
Plan of Correction:
1. Resident 1 assistive devices assessment was completed by Registered Nurse while survey was still in the community.
2. The Registered Nurse and RCC will do full physical walk through to ensure all potentially restrictive devices are identified and have appropriate assessments in place. Moving forward, each new device, including hospital beds, will be assessmented by the Registered Nurse for restraining qualities.
3. Desiginated staff will complete weekly walk through for 1 month for any further assistive devices, and monthly for 1 quarter. The Administrator will pull device audit monthly during QA to ensure all assessments are in place and compliant. If no errors are found in three months, then this will be audited quarterly as part of our Service Plan system.
4. Registered Nurse and Administrator are responsible to verify completion and monitoring of system.

Citation #5: Z0162 - Compliance with Rules Health Care

Visit History:
t Visit: 10/29/2025 | Not Corrected
Regulation:
OAR 411-057-0160(2b) Compliance with Rules Health Care

(b) Health care services provided in accordance with the licensing rules of the facility.
Inspection Findings:
Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 260, C303, C310, and C340.
Plan of Correction:
1. Refer to above C260, C303, C310, C340
2. Refer to above C260, C303, C310, C340
3. Refer to above C260, C303, C310, C340
4. Refer to above C260, C303, C310, C340

Citation #6: Z0164 - Activities

Visit History:
t Visit: 10/29/2025 | Not Corrected
Regulation:
OAR 411-057-0160(2d) Activities

(d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure meaningful activities that promote or help sustain the physical and emotional well-being of residents and activities were person centered and available during residents ' waking hours for sampled residents (#s 1 and 3) and multiple unsampled residents, and failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 2 sampled residents (#s 1 and 3) who resided in the memory care unit. Findings include, but are not limited to:

1. Observations were made throughout the survey in the memory care unit and revealed a lack of meaningful activities for the residents.

On 10/28/25 during observations in the memory care unit, an activity was scheduled at 11:00 am titled “Music Hour.” In an interview with Staff 10 (CG) at 11:15 am on 10/28/25, he stated “typically” during music hour they will put music on the television for the residents to listen to together. Observations at 11:15 am revealed a cat show on the television with two residents watching and another resident looking at a magazine in the common area. The scheduled activity did not take place.

An interview with Staff 12 (CG) on 10/28/25 at 2:40 pm confirmed care staff were primarily responsible for conducting activities. Staff 12 stated there will be an activity title on the calendar “like reminiscing time”; however, she stated they did not have instructions on how to do the activity.

The following activities were scheduled for 10/29/25 in the memory care unit:

* 10:00 am – Reminiscing Time
* 11:00 am – Card Game
* 1:00 pm – Relaxation Afternoon

Observations made on 10/29/25 revealed that none of the above activities took place as scheduled.

Throughout the survey residents were observed remaining in their rooms or sitting at tables in the common area of the memory care unit coloring and/or watching television.

The need to ensure the facility provided meaningful activities that promote or help sustain the physical and emotional well-being of residents, and to ensure that activities were person centered and available during residents' waking hours was discussed with Staff 1 (ED), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:30 pm. They acknowledged the findings.

2. Resident 1 and 3’s current service plans, dated 09/04/25 and 09/15/25, respectively, and “Activity Evaluation” questionnaires were reviewed. There was no documented evidence the facility had evaluated and developed individualized plans based on each resident’s:

* Past and/or current interest;
* Current abilities and skills;
* Emotional and social needs and patterns;
* Physical abilities and limitations; and
* Adaptations necessary for the resident to participate; and
* Identification of activities for behavioral interventions.

The need to ensure each resident was evaluated for activities and an individualized activity plan was developed was discussed with Staff 1 (ED), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:25 pm. They acknowledged the findings.
Plan of Correction:
1. Activity calendar will be audited for implementation of resident directed activities. Staff has been educated on the importance of following through on the activities on the calendar and Resident Care Coordinator and Activities Director are checking for execution of the activities.
Resident 1 and Resident 3's activity evaluations have been updated to reflect past/current interest, current ability and skill, emotional and social needs and patterns, physical ability and limitations and adaptations necessary for the resident to participate and identification of activities for behavioral intervention.
2. Staff education on the importance and method of completing each activity with checks by the Resident Care Coordinator, Administrator, or Activities Director occurring daily. Regional Director has come and taught staff about our Radiance program and how to implement and execute activities. Activity Director and Administrator audited all memory care activity evaluations to ensure they match each resident. Each new resident's Activity Evaluation will be completed by the Activity Director and double checked by Administrator.
3. Activity program execution will be evaluated as part of Quality Assurance each month, as well as spot checks completed daily by the Activities Director.

New move in and quarterly activity evaluations will be completed by Activity Director and Administrator will review to ensure accuracy for 6 months. Then audited quarterly during Quality Assurance and Activity Focused audits.
4. Activities Director, Administrator, Resident Care Coordinator, Caregivers, and Medication Techs.

Survey WO1W

0 Deficiencies
Date: 1/4/2024
Type: State Licensure, Other

Citations: 1

Citation #1: C0000 - Comment

Visit History:
1 Visit: 1/4/2024 | Not Corrected
Inspection Findings:
The findings of the kitchen inspection, conducted 01/04/24, 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.

Survey 36S5

2 Deficiencies
Date: 11/29/2022
Type: Complaint Investig., Licensure Complaint

Citations: 3

Citation #1: C0010 - Licensing Complaint Investigation

Visit History:
1 Visit: 11/29/2022 | Not Corrected
Inspection Findings:
Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 11/29/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Citation #2: C0361 - Acuity-Based Staffing Tool

Visit History:
1 Visit: 11/29/2022 | Not Corrected

Citation #3: C0550 - Wiring Systems

Visit History:
1 Visit: 11/29/2022 | Not Corrected

Survey H1ZD

0 Deficiencies
Date: 10/3/2022
Type: Complaint Investig.

Citations: 1

Citation #1: C0010 - Licensing Complaint Investigation

Visit History:
1 Visit: 10/3/2022 | Not Corrected
Inspection Findings:
Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the unannounced complaint investigation conducted 10/03/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.

Survey 68Q4

13 Deficiencies
Date: 6/21/2022
Type: Validation, Change of Owner

Citations: 14

Citation #1: C0000 - Comment

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Not Corrected
Inspection Findings:
The findings of the re-licensure survey conducted 06/21/22 through 06/23/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. 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 re-visit to the re-licensure survey of 06/23/22, conducted 09/13/22 through 09/14/22, 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.

Citation #2: C0240 - Resident Services Meals, Food Sanitation Rule

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
2. Two sampled residents who were interviewed during the survey reported not liking the food. One of the residents went on to state, "It all tastes pre-made. There isn't a lot of fresh fruits and vegetables. [The facility] has gone with the cheapest supplier and I can taste it." A test tray was requested from Staff 5 (Dietary Manager) on 06/22/22 at 11:35 am.The test tray was served to the surveyor team at 11:57 am. The meal was served uncovered and consisted of a soft shelled beef taco, corn with tomatoes and peppers, Spanish rice and banana pudding. The ground beef used in the soft shelled taco did not taste seasoned and the beef had overcooked pieces which made it dry, crunchy and chewy. The Spanish rice did not taste seasoned and was overcooked to a mechanical soft like texture. The need to ensure the meals served were palatable was discussed with Staff 1 (Administrator), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure nutritious and palatable meals and snacks were provided in accordance with the United States Department of Agriculture (USDA) guidelines, and facility kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:1. The kitchen was toured on 06/21/22 with Staff 5 (Dietary Manager). The following was observed to be in need of cleaning or repair: * The tile flooring underneath the warewashing machine had deep grooves and gouges;* The tile baseboard underneath the warewashing machine had fallen off the wall and was lying on the floor;* The floor tile had black matter build up;* The tiles along food prep and stove were cracked; * The ceiling tile above the hood range had a gouge exposing raw material;* The green exit door in kitchen had scuffs and rust colored spots;* The cabinets in coffee bar had scuffs and scrapes across the front; and * The ceiling tiles in dry storage above shelves had black scuff marks. The need to ensure the kitchen was clean and in good repair was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.
Plan of Correction:
1. Kitchen cleaning and damage repair to noted area of tile, kitchen door, coffee bar cabinet and ceiling tiles above hood and storage will take place.Meals will be prepared using the new recipes and menu guides, and will be sampled for quality control to ensure residents are served palatable meals2. Dietary staff will use the work order system for repairs, cleaning schedules and weekly walk throughs to ensure ongoing compliance. ED/designee to sample meals to ensure quality of meals, and resident feedack to be obtained via weekly dining comment cards and monthly Dining Committee for the previous 3 months.3. ED and Dietary Manager to conduct weekly kitchen walk throughs to ensure complianceED/designee to sample 2 meals weekly and provide feedback to dietary manager. Dining Committee shall meet monthly ongoing as a part of the QA process.4. ED, RDO, Dietary Manager, Maintenance

Citation #3: C0260 - Service Plan: General

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, updated with changes, and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 05/2021 with diagnoses including history of stroke and major depressive disorder.Review of the current service plan, dated 06/12/22, observations of the resident and interviews with the resident and caregiving staff indicated the service plan lacked the following information:* Clear instruction to staff regarding compression stocking use, including use of lotion and treatments; and* Instruction to staff regarding care needs after tooth extraction.2. Resident 4 was admitted to the facility in 04/2015 with diagnoses including rheumatoid arthritis.Review of the current service plan, dated 03/08/22, indicated handwritten changes regarding side rail use and instructions to staff were not dated and initialed. The need to ensure service plans were reflective of the residents' status, updated, and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction:
1. Resident #2 and #4 SP updated to reflect missing resident specific items and SP conference to be held. 2. ED to conduct inservice with staff on the proper service planning process and to review OAR with the service planning team. Evaluation tool in PCC was updated to cover OAR areas and to feed directly to the service plan 3 . As part of the monthly internal QA process, community will audit 2 SPs for accuracy 4. RN and ED or designee are responsible

Citation #4: C0270 - Change of Condition and Monitoring

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
2. Resident 3 was admitted to the facility in 02/2019 with diagnosis including diabetes and cognitive impairment.The resident's medical record was reviewed and interviews were conducted. The following lacked documented evidence of monitoring through resolution:a. On 06/02/22, a progress note stated Resident 3 had returned from the hospital after sustaining a fall out of bed that resulted in rib fractures and a pelvic fracture. The resident did not need surgical interventions for the fractures. Per the facility's "alert charting and audit tool", a return admission from the hospital would constitute 72 hours of monitoring. The facility lacked documented evidence the return from the hospital and Resident 3's fractures had been monitored through resolution.b. On 06/07/22, the resident had an increase in Hydrocodone (for pain). There was no documented evidence the change in medication had been monitored through resolution.The need to ensure residents' short term changes of condition had documentation of weekly monitoring through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to determine what actions or interventions were needed for short term changes of condition, communicate those changes to staff on each shift and failed to monitor changes through resolution for 2 of 3 sampled residents (#s 2 and 3) who were reviewed with changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2021 with diagnoses including stroke and major depressive disorder.Resident 2's medical record was reviewed. Multiple changes of condition were identified with the following deficiencies:a. No actions or intervention developed, no communication to staff on each shift or evidence of monitoring for the following changes of condition:* Tooth extraction; and * Urinary tract infection. b. Lack of weekly monitoring for:* Left ankle wounds;* Wound under left knee;* Red rash to bilateral legs; and* Red rash/burn to top of both hands.c. Lack of monitoring through resolution for:* New medication on alert charting 04/01/22; and* Skin abrasion to forehead.The need to ensure all changes of condition were evaluated, had interventions developed, were communicated to staff on each shift and monitored weekly for effectiveness through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction:
1. Resident #2 and #3- Change of Condition were reviewed and documentation completed reflecting the changes and SP to be updated as needed. 2. 24 hour process will be reviewed and retraining as needed will be provided to Med Techs and RN to ensure that communication from staff regarding visualized changes are being documented for further follow up. RN, ED will review in clinical meeting and address/document accordingly.3. Review of 24 hour binder and audit tool will be conducted M-F during clinical meetings. Monthly QA Audit of the 24 Hour process will be conducted ongoing as a part of conitnued compliance.4. ED and RN or designee are responsible

Citation #5: C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers for 1 of 2 sampled residents (#2) who received services from outside providers. Findings include, but are not limited to:Resident 2 was admitted to the facility in 05/2021 with diagnoses including history of stroke and major depressive disorder.Review of outside provider communications in the resident's record indicated the following recommendations were made:* 03/31/22: "Adaptive handle for motorized chair so s/he can reach lever to rotate chair for transfers," recommended by HHPT on Health Professional Communication form;* 05/09/22: "Edema can be treated with ...restriction of dietary sodium intake and diuretics," on Patient Handout from dermatology Nurse Practitioner;* 06/02/22: "Monitor bilateral circulation," recommended by HHRN on Health Professional Communication form; and* 06/08/22: "Please remove Unna boot in 4 days - on 06/12/22 and apply Triamcinolone cream thereafter 1 time a day under compression socks," from dermatology Nurse Practitioner handwritten note on day of service.There was no documented evidence these recommendations were communicated to staff or implemented as appropriate.The need to ensure coordination between the facility and outside service providers was reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction:
1. Resident #2 home health notes have been reviewed and documentation completed reflecting outside provider reccomendations. Staff have been made aware of changes, via tsp and service plan to be updated as needed. Resident # 2 was reassessed with no negative outcome. 2. 24hr process to be reviewed with staff to ensure communication regarding New outside provider notes or reccomendations. RN and ED will review any outside provider notes M-F in clinical meetings. 3. Review of outside provider binder, including audit, will be conducted Monday through Friday during clinical meeting ongoing. 4. RN and ED responsible

Citation #6: C0303 - Systems: Treatment Orders

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 2 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to:Resident 2's signed physician orders and 06/01/2022 through 06/21/22 MAR/TAR were reviewed. The following orders were not carried out as prescribed: * Triamcinolone cream - one time a day under compression socks was ordered on 06/08/22. The facility failed to implement the new order, continuing to administer Triamcinolone cream bid;* Mupirocin 2% ointment - "apply to wounds on legs every day until resolved" was ordered on 04/29/22. Leg wounds were resolved 05/09/22 per progress note and Staff 2 (RN) interview. The 06/01/22 through 06/21/22 TAR indicated Mupirocin was still being administered; and* Six treatments lacked documented evidence of administration on the 06/01/22 through 06/21/22 TAR. The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction:
1. Comprehensive physican's order review was conducted for resident #2, in addition 10 residents physican orders will be reviewed for accuracy by date of compliance 2. Inservice all facility Med Techs on order processing and review 3. Audit new Physician orders alongside the MAR weekly for 6 weeks and then monthly after during 24 hour review process. Bring any findings to internal QA meeting monthly 4. ED and RN responsible

Citation #7: C0305 - Systems: Resident Right to Refuse

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to medication and treatment orders for 1 of 1 sampled resident (#2) who had documented treatment refusals. Findings include, but are not limited to:Resident 2's 06/01/22 through 06/21/22 MAR/TAR was reviewed. The record showed 10 instances of treatment refusal.There was no documented evidence the facility notified the physician each time the resident refused to consent to orders.The need to ensure the facility notified physicians of medication and treatment refusals was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction:
1. Resident #2 orders to be updated to reflect MD preference for notifcation when medication is refused. 2. Inservice Med Techs on proper notification of refused medications. 3. Lead Med Tech/RN/ED or designee to check for refused medications M-F and ensure proper notifications were made x4 weeks and then spot check 2 times per month as part of internal QA process. Bring findings to monthly internal QA meetings4. ED, RN and Lead Med Tech or designee responsible

Citation #8: C0310 - Systems: Medication Administration

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included medication specific instructions including significant side effects and when to call the prescriber or nurse and failed to ensure resident-specific parameters for PRN medications for 2 of 3 sampled residents (#s 2 and 3) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 02/2019 with diagnoses including diabetes and cognitive impairment. The resident's 06/01/22 through 06/21/22 MAR and TAR was reviewed and revealed the following:* Two PRN bowel medications to treat constipation lacked parameters on when to initiate treatment and what medication to administer first; and * Scheduled and PRN blood glucose monitoring was lacking resident specific instructions on when to notify the prescriber or nurse relating to high blood sugar readings. There was an entry on Resident 3's TAR to notify the prescriber monthly of any medication refusals. There was an entry on 06/13/22 which prompted to "Other / See Nurse Notes." There was no documented evidence of a corresponding nurse note.The need to ensure residents' MARs and TARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 05/2021 with diagnoses including history of stroke and major depressive disorder. The resident's 06/01/22 through 06/21/22 MAR/TAR was reviewed and the following deficiencies were identified.a. The medication record contained no medication specific instructions, if applicable, including significant side effects. Resident 2 was on alert charting beginning 04/30/22 for new medications, including Doxycycline. A progress note dated 05/13/22 stated "resident is on alert for red rash/burn to the top of both hands, right hand appears to be swollen. Resident is complaining of pain and states that it burns. Resident believes that the Doxycycline is what's causing the redness to [resident's] hands."b. There were no parameters for two PRN pain medications: acetaminophen and hydrocodone/APAP; andc. There were 36 entries on TAR that indicated either "Hold/See Nurse Notes" or "Other/See Nurse Notes." There was no documented evidence of corresponding nurse notes.The need to ensure MARs/TARs were complete and accurate was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction:
1 - Resident #3 medications reviewed to include specific instructions for staff. Resident #2 medications were reviewed and corrected to address parameters. All resident orders to be reviewed and ensure resident specific instructions and/or parameters are in place2 - Training to be provided to health services team regarding order confirmation, clarification of orders and proper parameters 3 - Audit orders for parameters and instructions as new orders are received during the clinical meeting, and 2 at random monthly as a part of QA process 4 - Lead Med Tech, RN, ED or designee responsible

Citation #9: C0370 - Staffing Requirements and Training – Pre-Serv

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents for 3 of 3 newly-hired direct care staff (#s 9, 10 and 14). Findings include, but are not limited to: The facility's training records were reviewed on 06/22/22 and 6/23/22.Staff 9 (CG), hired 12/09/21, Staff 10 (CG), hired 01/18/22, and Staff 14 (CG), hired 04/05/22, lacked documented evidence they had completed the required pre-service dementia training prior to providing direct care to residents. The need to ensure all newly hired, direct care staff had the required pre-service dementia training prior to providing care to residents was reviewed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/23/22. They acknowledged the findings.
Plan of Correction:
1. All employee files to be audited for the presence of all required preservice dementia training. 2. New employee onboarding process to be reviewed/ completed with ED to ensure that new hire checklist is completed and accurate for all new employees with documented evidence. 3. Employee Training Grid to be used to track all employee pre-service dementia training. ED to audit 3 files/month for accuracy and completeness. Audit findings to be brought to internal QA meeting 4. ED, RDO responsible

Citation #10: C0420 - Fire and Life Safety: Safety

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure fire and life safety instructions to staff was provided on alternate months and failed to ensure written fire drill records included all required components. Findings include, but are not limited to: On 06/22/22 fire and life safety records for 12/21/2021 through 05/15/2022 were reviewed. 1. Fire and life safety training was not consistently being provided to staff on alternating months of fire drills. 2. The facility was not consistently evacuating or relocating residents during fire drills. Fire drill documentation was lacking or incomplete regarding:* Escape route used;* Evacuation time-period required;* Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. The need to ensure staff received all required fire and life safety training and fire drills included all required components was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.
Plan of Correction:
1. Fire drill form with appropriate Fire Life Safety requirements to be reviewed with maintenance director with immediate corrections and will be in compliance by compliance date. Documented evacuations that include residents, as well as alternating saftey training will be adequately documented with clear instructions on routes and procedures.2. Fire drills, evacuations and staff safety training to be conducted on company standardized forms which address all needed requirements per OAR to include resident/ staff training, involvment and adequate documentation with proper filing. 3. Fire drills/training to be reviewed during internal QA meeting monthly to ensure compliance. 4. ED responsible

Citation #11: C0422 - Fire and Life Safety: Training For Residents

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:On 06/22/22 at 10:48 am, Staff 6 (Maintenance) confirmed the facility had not been providing annual fire and life safety training to residents. The need to ensure fire and life safety instruction was provided to residents at least annually was reviewed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.
Plan of Correction:
1.Facilty has implemented and scheduled annual fire evacuation training that will be conducted before 8/22/22. 2. All residents to be trained on fire safety, fire roles and responsibities, and evacuation upon move in and annually per the new schedule. 3. Fire drills/training to be reviewed during internal QA meeting to ensure compliance monthly 4. ED responsible

Citation #12: C0610 - General Building Exterior

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure the exterior pathways and accesses to the facility common use areas, entrance and exit ways were maintained in good repair. Findings include, but are not limited to: The facility grounds and sidewalks were observed on 06/21/22 and the following was identified:* Outside the facility entrance the green wicker chair left arm rest was fraying;* The enclosed eaves to the left of the front door had a hole;* Drop-offs at approximately three to seven inches in height along sidewalks; and * The walkway next to mechanical room had hole measuring approximately 20 inches by 30 inches and was deep enough that the surveyor was unable to visualize the bottom. The hole was covered with wood creating an uneven surface. The drop-offs and hole created potential tripping hazards for residents. The need to ensure the exterior pathways and accesses to the facility common use areas was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.
Plan of Correction:
1. Wicker chair was removed and hole in eave and sidewalk drop offs in back of communiity, have been scheduled for repair. Project completion estimated for 08/22/22. While awaiting completetion, caution tape has been put into place to prevent resident access. 2. All staff to be inserviced to the workorder process for repairs and maintenance. 3. ED and Maintenance Director to conduct weekly walk throughs, as well as internal QA meetings to review building maintenance audits. RDO to complete quarterly building walk through 4. RDO, ED, Maintenance Director responsible

Citation #13: C0613 - General Building: Doors-Walls, Cleanable

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
Based on observation and interview, it was determined the facility failed to keep all interior and exterior surfaces clean and in good repair. Findings include, but are not limited to:The interior and exterior of the building were toured on 06/21/22. The following areas needed cleaning or repair:a. Facility Wide * Multiple resident rooms, facility doors and door frames had scuffs, scratches and gouges; * The carpet throughout the facility had stains; and* Multiple walls throughout the facility had gouges and scuffs. b. First Floor * The front desks left corner was chipped exposing wood underneath; * The elevator panels had gouges and scuff marks; and* The carpet baseboard was fraying where it attached to wood baseboard in dining room next to the salon and staff lounge. c. Housekeeping / Hopper Room* The corner had a gouge in wall exposing material underneath; * The hopper had debris around the rim and sides; and* The power outlet plate was broken next to the door. d. Laundry Room * The vinyl tiles were broken and missing underneath the left dryer exposing wood; * The ceiling tiles had rust color stains and one was missing; * The cabinets had scuff marks along the front; and* The chair seat on the brown chair had white and black stains.e. Dining Room * The pillar had gouges and scuff marks; * The screen was bent in the left window; and* The vinyl flooring was cracked and did not connect around the gold floor cleanout cover creating a hole. f. Ice Cream Bar * The grout to tile countertop had black debris build up; and * The baseboards had black debris on the top. g. Second Floor * The carpet was fraying at the second-floor threshold into the elevator; * The black tables in the Activity Room had gouges exposing wood; and* The carpet baseboard had white debris on it in the Activity Room. The areas needing cleaning and repair were shown to and discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22 at 1:05 pm. They acknowledged the findings.
Plan of Correction:
1. Interior and Exterior deficiencies noted in the 2567 will be reviewed and repaired.2. All staff to be trained on utilizing work order system to ensure needed repairs are addressed timely. 3. ED and Maintenance Director to conduct weekly walk throughs, as well as monthly QA meeting audits. RDO to complete quarterly communitiy walk though to ensure compliance. 4. RDO, ED and Maintenance Director

Citation #14: C0640 - Heating and Ventilation

Visit History:
1 Visit: 6/23/2022 | Not Corrected
2 Visit: 9/14/2022 | Corrected: 8/22/2022
Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure that covers, grates, or screens of wall heaters did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:During an environmental walk-through on 06/21/22, the following was identified: Fireplaces were observed turned off during the survey. * The Surveyor turned on the lobby fireplace via a wall timer at 1:50 pm. The surveyor measured the front glass covering at 1:54 pm, it measured 212 degrees F with the surveyor's thermometer. * The Surveyor turned on the Activity Room fireplace via a wall timer at 2:22 pm. The surveyor measured the front glass covering using the surveyor's thermometer at 2:28 pm, it measured 174 degrees F. The need to ensure residents could not come into incidental contact with fireplace elements that exceeded 120 degrees F was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.
Plan of Correction:
1. Immediate action was taken for the safety of our residents. The fireplaces were turned off and disabled until the new fireplace screens arrived that week. screens were secured in place.2. Ongoing checks to ensure the screens are in place and to ensure the residents cannot come in contact with the hot surface. 3. ED and Maintenance Director to ensure proper placement of safety screens weekly during walk throughs and monthly temps will be conducted. 4. ED and Maintenance Director are responsible

Data sourced from Oregon Long-Term Care Licensing

Report generated: 2025-12-12T15:16:14.532Z