Prestige Senior Living High Desert

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

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 12/09/25 at 10:00 am, the facility kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dirt, and black matter was observed on or underneath the following: * Ceilings, walls, doors, and floors throughout the kitchen; * Metal racks and shelving units throughout the kitchen; * Industrial mixer; * Microwave; * Walk-in refrigerator and freezer floors; * Walk-in refrigerator fan; * Ware washing machine; and * Ceiling lights. b. The following areas needed repair; * Holes in walls throughout the kitchen; * Dry storage ceiling tiles with several holes; and * A cracked ceiling light cover. On 12/09/25, the areas in the kitchen which required cleaning and repair were observed and discussed with Staff 1 (ED) and Staff 2 (Dining Services Manager). They acknowledged the findings.

a. Food spills, splatters, debris, dirt, and black matter was observed on or underneath the following: * Ceilings, walls, doors, and floors throughout the kitchen; *Ceilings, walls, doors, floors, to be deep cleaned and all spills, splatter, debris, dirt, black matter to be removed by 1/9/26. Kitchen has implemented a daily, weekly, biweekly, and monthly check-off system. Implemented on 12/10/25. All employees conducting cleaning must sign and date check-off list to hold employees accountable. Dining Service Manager/Executive Director has oversight of these lists and is audited each week. Quality Assurance Program implemented and checked off monthly by Dining Service Manager and/or Executive Director. Facility compliance to be completed by 1/23/26. * Metal racks and shelving units throughout the kitchen; One metal rack replaced on 12/29/25 and all metal racks placed on weekly cleaning schedule. Racks to clean by 1/9/26. DM to delegate. DM is responsible for cleaned racks. * Industrial mixer; Industrial mixer to be cleaned completely after each use, outside of mixer wiped and sanitized. After each use, mixer to be covered. Mixer placed on daily clean schedule and cleaning conducted by cook on duty. Implemented on 12/9/25 * Microwave; Microwave is cleaned after each meal service and placed on daily clean schedule, cleaning conducted by the cook on duty. Implemented on 12/9/25 * Walk-in refrigerator and freezer floors; Walk-in flooring cleaned and placed on weekly cleaning schedule. Cleaning conducted by the cook on duty or DM with DM oversight. Cleaned & implemented on 12/10/25. * Walk-in refrigerator fan; Walk-in fan cleaning conducted by DM and placed on weekly cleaning schedule. Cleaned & implemented on 12/10/25. * Ware washing machine; Ware washing machine placed on daily cleaning schedule and conducted by dietary aid nightly with metal scraper. Cleaned and implemented on 12/9/25. * Ceiling lights Ceiling lights placed on TELS system for Maintenance Director to check monthly. Entered into TELS system 12/10/25. Cleaned on 12/10/25. Also placed on cleaning schedule biweekly to be performed by DM or Maintenance Director. b. The following areas needed repair: * Holes in walls throughout the kitchen; Holes in walls to be plugged with silicone-based caulking to ensure wipeable, cleanable service. Completion date by Maintenance Director: 1/2/26 * Dry storage ceiling tiles with several holes; Dry storage ceiling tiles to be replaced. Maintenance to conduct monthly walk through via TELS reporting system. 1/2/26 * A cracked ceiling light cover Cracked Ceiling light to be replaced by 1/2/26, monitored via TELS reporting system with monthly walkthrough and biweekly clean.

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

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen, food storage areas, food preparation, and food service on 09/26/22 revealed: * Splatters, spills, drips, and debris were observed on: - Storage shelves throughout the kitchen; - Interior flooring of the walk in refrigerator and freezer; - The dishwashing area walls, floors, and equipment; - The sides and the interior of the range, grill, and oven; - Beneath shelving and equipment throughout the kitchen; - Walls and flooring throughout the kitchen; and - Flooring and beneath shelving in the dry storage room. * Dishwashing racks were stored directly on the floor. The areas in need of cleaning were reviewed with Staff 1 (ED) and Staff 5 (Dietary Services Manager) on 09/26/22 and 09/27/22. They acknowledged the findings.

1)Sanitization schedule in place and being followed, weekly and as needed with DSM and ED to monitor for compliance in cleaning and proper storage. 2)Deep cleaning schedule has been posted and put into place with a sign off sheet.   Deep cleaning of all areas then - Each week a deep cleaning task will be completed. 3)This to be monitiored by DSM weekly, monthly by ED Responsible: DSM and ED

Based on interview and record review, it was determined the facility failed to ensure evaluations were performed within the first 30 days of move in for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: Resident 5 was admitted to the facility in 07/2022. There was no documented evidence a review of the evaluation of Resident 5 had been completed within the first 30 days of move in with updates and changes as appropriate. In an interview with Staff 4 (RCC) on 09/26/22, she acknowledged Resident 5's evaluation had not been reviewed within 30 days of move in. The need to ensure 30 day evaluations were completed with changes and updates as appropriate was discussed with Staff 1 (ED) on 09/27/22. She acknowledged the findings.

1)  Service plan due date and change of condition audit completed to identify and correct updating of service plans per OAR   2)   New move in schedule and tracking being followed to support a no more than 30 day review and update of New Move in Evaluation/service plan. 3) Monitored daily during morning Health Services meeting (SMART) and assigned to HSD *Responsible:  HSD, LN and ED to support regular monitoring and tracking

3. Resident 5 was admitted to the facility in 07/2022. There was no documented evidence Resident 5's service plan had been completed within the first 30 days of move in with updates and changes as appropriate. In an interview with Staff 4 (RCC) on 09/26/22, she acknowledged Resident 5's service plan had not been reviewed and updated within 30 days of move in. The need to ensure service plans were reviewed with changes and updates as appropriate within 30 days, was discussed with Staff 1 (ED) on 09/26/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated within 30 days of admission, reflective of residents' needs and provided clear direction to caregiving staff regarding the delivery of services for 3 of 5 sampled residents (#s 1, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2022 with diagnoses including chronic obstructive pulmonary disease and depression. The resident's current service plan and progress notes dated 06/23/22 through 09/26/22 were reviewed. Resident 4 and staff were interviewed and the resident's room was observed. The service plan was not reflective and did not provided clear caregiving instructions in the following areas: * Medications the resident administered; * Evacuation assistance needed; * Activity participation; * Fall interventions; * Interventions for depression; * Assistance needed with the maintenance of an oxygen concentrator; and * Interventions for when the resident was intoxicated. The need to ensure service plans were reflective of the resident's current status and provided clear caregiving instruction was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (Health Services Director) on 09/27/22. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 02/2020 with a diagnosis of schizophrenia. A review of the resident's most current service plan dated 09/15/22 revealed s/he needed assistance with the following: * Physical assist with bathing; * Oxygen at four liters; * Physical assistance with ambulation using four wheeled walker; and * Physical assistance with dressing. An interview with Staff 11 (CG) on 09/27/22 revealed Resident 1 was independent with all the above listed tasks. Staff 11 was unsure why the service plan was updated indicating the resident needed physical assistance. The need to ensure service plans reflected the current care needs of residents was discussed with Staff 1 (ED) on 09/27/22. She acknowledged the findings.

1)   Evaluations and service plans  updated to support resident centered needs through resident involvement, needs and preferences. 2)    Audits of service plans to be completed at time of change of condition, update in preferences or needs, and a minimum of 30 days after move in and quarterly. 3) Monitored daily during Health Services Meeting (SMART) Responsible: HSD, LN, HS Leadership, ED

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, the condition was monitored at least weekly to resolution, and that interventions were re-evaluated to determine effectiveness for 4 of 5 sampled residents (#s 2, 3, 4 and 5) who experienced changes of condition. 1. Resident 2 was admitted to the facility in 02/2018 with diagnoses including diabetes and paraplegia. Observations of the resident, interviews with staff, review of the service plan dated 07/20/22 and progress notes dated 06/26/22 through 09/26/22 were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Toe infection; and * Coccyx break down. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, provided clear, resident-specific directions to staff and that interventions were evaluated for effectiveness was discussed with Staff 1 (ED), Staff 2 (Corporate RN) and Staff 3 (Health Services Director) on 09/27/22. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 01/2017 with diagnoses including diabetes and Parkinson's disease. Observations of the resident, interviews with staff, review of the service plan dated 06/28/22, incident investigations and progress notes dated 06/14/22 through 09/26/22 were reviewed. a. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Blood in the urine; * Low blood sugars; * Vomiting; * Leaking catheter; and * Burn to the thigh. b. An incident investigation dated 09/03/22 indicated the resident sustained a burn to his/her left thigh while refilling his/her lighter. The resident was noted to be alert and oriented and could state what occurred. The investigation indicted no injury was observed at the time of the incident. There was no documentation of a thorough investigation of the burn incident to minimize reoccurrence, develop and implement interventions and to re-evaluate existing interventions for appropriateness and effectiveness. In interviews on 09/26/22 the resident indicated s/he had no concerns with his/her care. The resident denied any mistreatment by staff and indicated the cause of the burn was a "fluke accident." The resident stated s/he had never had any issue filling his lighter up in the past. On this occasion lighter fluid on his/her fingers and pants ignited when s/he tested the lighter. The resident stated s/he was able to put out the fire quickly and sustained a small burn which had been healing well. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, provided clear, resident-specific directions to staff and that interventions were evaluated for effectiveness was discussed with  Staff 1 (ED), Staff 2 (Corporate RN) and Staff 3 (Health Services Director) on 09/27/22. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 07/2022 with diagnoses including stroke and pulmonary embolism. Observations of the resident, interviews with staff and the resident, review of the service plan dated 07/20/22 and progress notes dated 07/20/22 through 09/26/22 were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Emergency room visit; and * Diarrhea. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, provided clear, resident-specific directions to staff and that interventions were evaluated for effectiveness was discussed with Staff 1 (ED) and Staff 4(RCC) on 09/27/22. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 11/2020 with diagnoses including hypertension, Type 2 Diabetes and depression. The resident's progress notes dated 06/23/22 through 09/26/22 and incident reports dated 06/10/22 through 09/25/22 were reviewed. Resident 4 and staff were interviewed. The following short term changes of condition were identified: a. Resident 4 had documentation of the following falls: * 06/10/22; * 06/16/22; * 07/28/22; * 08/14/22; * 08/16/22; and * 08/19/22. There was no evidence the facility determined and documented what interventions were needed for the resident nor was there documented evidence the fall interventions previously implemented were re-monitored for effectiveness. b. The following skin issues were identified: On 08/19/22, Resident 4 fell which resulted in him/her going to the ER and getting stitches. There was no documented evidence the facility monitored the area at least weekly through resolution. During an interview with Resident 4 on 09/26/22 at 2:37 pm, the resident lifted up his/her pant leg to rub his/her shin. There was one quarter sized, dark red scab located on the shin with smaller scabs around the area. There was no documented evidence the facility was aware of these areas or how the resident obtained the scabbing. When questioned, Resident 4 reported having "thin skin" and "it bleeds whenever I run into anything." c. There was a progress note dated 06/26/22 where the resident was quoted, "hates being here" and s/he "feels depressed all the time." There was no documented evidence the feeling of depression was monitored through resolution or the facility determined and documented what interventions were needed for the resident. The need to ensure short term changes of condition were monitored at least weekly through resolution, the facility determined and documented what interventions were needed for the resident, and the interventions were monitored for effectiveness was discussed with Staff 1 (ED) on 09/27/22. She acknowledged the findings.

SPAs (service plan addendum) and skin assessment/evaluations will be completed  a minimum of weekly will occur by LN. 1.Chart review  completed  to identify any system breakdown and areas of improvement.   2. Resident charts to be reviewed to identify any change of condition not previously addressed. Staff inservice to be completed with focus on documentation and identiying and reporting a change of condition. 3) Monitored daily during Heath Services Meeting (SMART) Responsible:  HSD, AHSD, RCC and ED to identify

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to: Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room. Observations of staff during the survey revealed multiple instances where staff failed to wear their face mask properly, exposing their nose, or nose and mouth. The need to ensure staff consistently wore a face mask was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (Health Services Director) on 09/27/22. They acknowledged the findings.

1)Approprately worn face masks and PPE per policy and CDC guidelines will be monitored and compliance obtained through frequent walk throughs, re-review and follow up. 2)Re-training to support appropriate PPE use 3) Monitored always, appointing lead on each shift to ensure masks are worn appropiately during shift Responsible: All Dept Managers

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation and pre-service dementia training was completed prior to beginning job responsibilities for 3 of 3 newly hired staff (#s 8, 9 and 12) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 09/27/22. 1. There was no documented evidence Staff 8 (MT), hired 06/06/22,  Staff 9 (CG), hired 08/12/22, and Staff 12 (CG) hired on 03/30/22, completed the following elements of pre-service orientation: * Infectious disease prevention; and * Fire safety and emergency procedures. 2. There was no documented evidence Staff 12 had completed pre-service dementia training. The need to ensure all newly hired staff completed pre-service orientation, infectious disease training, and pre-service dementia training before providing direct care to residents was discussed with Staff 1 (ED) on 09/27/22. She acknowledged the findings.

1)Audit of pre-service and orientation onboarding to support compliance and training. 2)Training/compentencies to be completed by current staff for missing or past due training. 3)New hire pre-service and training to be reviewed by Office Manager or/and ED prior to providing resident care. Responsible: OM, ED, RCC, HSD

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff (#8) had documented demonstration of competency in all required areas and 2 of 3 (#s 8 and 9) had been trained in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records on 09/27/22 indicated the following: Staff 8 (MT), hired 06/06/22, lacked documented evidence observations and evaluations of competency had been completed within the first 30 days of hire for topics including: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. Staff 8 and Staff 9 (CG), hired 08/12/22, lacked documented evidence of First Aid and abdominal thrust training within 30 days of hire. The need to document demonstrated competency in job duties and to complete First Aid and abdominal thrust training within 30-days of hire was discussed with Staff 1 (ED) 09/27/22. She acknowledged the findings.

1)Competencies and abdominal thrust training will be completed within 30 days of hire by RN and monitored by ED, OM for completion. 2)Audit of all staff competencies and training to be completed by ED and OM  and brought current for any training opportunities. 3)This will be monitored upon hire then with quarterly audit Responsible: ED, OM, and RN/HSD

Based on interview and record review, it was determined the facility failed to have documented evidence the 12 hours of annual in-service training included six hours related to the care of residents with dementia, for 2 of 2 long-term staff (#s 7 and 11) whose training records were reviewed. Findings include, but are not limited to: The annual in-service training records were reviewed on 09/27/22. Staff 7 (MT), hired 09/14/21, and Staff 11 (CG), hired 01/31/18, failed to have documented evidence of completing 12 hours of hours of annual in-service training, including six hours on dementia care. There need to ensure staff completed 12 hours of on-going training, including six hours related to dementia, was reviewed with Staff 1 (ED) on 09/27/22. She acknowledged the findings.

1)Audit of all staff annual  training to be completed by ED and OM  and brought current for any training opportunities.  **OM and ED to impliment training tracking tool to maintain compliance. 2) Posting of monthly trainings to be completed through OCP to ensure compliance. 3) This will be audited quartley and when training through OCP is due.    4)Responsible: ED, OM, HSD

Based on interview and record review, it was determined the facility failed to ensure fire and life safety training and fire drills were conducted on alternating months and that all required fire drill components were addressed. Findings include, but are not limited to: Fire drill records were reviewed from 03/2022 to 09/2022. The following deficiencies were identified: * There was inconsistent documentation the facility was conducting fire drills every other month on alternating shifts; * There was inconsistent documentation the facility was conducting fire and life safety training on alternating months to fire drills; and * The evacuation/drill documentation did not contain information on the escape routes used, problems encountered, evacuation time period needed, and the number of occupants evacuated. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (ED) on 09/27/22. She acknowledged the findings.

1)Evacuation drill schedule in place to include exit route taken and followed per regulatory requirement(s) 2)New tracking sheet completed with evacuation route listed on the sheet 3)Drills to continue being completed monthly and audited monthly by ED Responsible: Maintenance Director and ED

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to: Fire and life safety records revealed the facility lacked documented evidence residents had received annual training in the following areas: * General safety procedures; * Evacuation methods; * Responsibilities during fire drills; and * Designated meeting places inside or outside the building. The need to ensure residents received annual training in fire and life safety requirements was discussed with Staff 1 (ED) on 09/27/22. She acknowledged the findings.

1)Documented training held for all current residents related to fire and life safety to include evacuation methods. New residents will receive fire and life safety education within 24 hours of move in and placed in resident file 2)Done upon move in within 24-hours and done annually with all residents during Town Hall and acknowlegement sheet to be signed.  If resident is unable to attend, visit with the resident individually. 3)Audit of resident files and check off added in move in file that it is completed Responsible: ED, Maintenance Director, Med Aide

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways to the common-use areas in good repair. Findings include, but are not limited to: The exterior walkways of the building were toured on 09/26/22. There were multiple sections of the sidewalk with drop-offs of up to three inches measured from the concrete surface to the planting beds. These drop-offs represented tripping/fall risks for residents. The need to ensure exterior pathways to common-use areas were in good repair was discussed with Staff 1 (ED) on 09/27/22. She acknowledged the findings.

1)River rock to be placed where sidewalk is more than 3in drop off 2)Walk through with Maintenance Director, CRD, and ED to happen monthly.Maintenance Director to ensure outside grounds/sidewalks are kept. 3)Monitored weekly with walk through Responsible: Maintenance Director, ED

Based on observation and interview, it was determined the facility failed to ensure the interior environment was clean and in good repair. Findings include, but are not limited to: A tour of the facility was conducted on 09/26/22 and revealed the following: * Room 101, 105 and 128 had black stains on the carpet throughout high traffic areas; * Room 128 had a large portion of drywall that was damaged; * Toilet in room 155 was broken for over two weeks; and * Room 156 had dirty windows and the exterior light was broken. The need to ensure the facility interior was clean and in good repair was discussed with Staff 1 (ED) on 09/27/22. She acknowledged the findings.

1)  Community will ensure interior physical plant is in good repair through daily and as needed walk through of community and grounds. 2) Maintenance Director will utilize TELS to track work orders and physical plant needs. 3)Monitored weekly with walk through Responsible:  Maintenance Director and ED will monitor and follow up a minimum of weekly to address needs

Based on observation and interview, it was determined the facility failed to ensure 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 09/26/22, the upper portion of the metal fireplace frame in the library was hot to the touch. The temperature was 247.6 degrees F when measured with the surveyor's thermometer. The fireplace was turned off. The need to ensure residents could not come into incidental contact with fireplace elements that exceeded 120 degrees F was discussed with Staff 1 (ED) on 09/26/22. She acknowledged the findings.

1) Guard is to be put in place surrounding the fireplace. 2) Guard will be secured to ensure guard will not be removed. 3) Monitored daily with staff coming/going through this common room Responsible: Maintenance and ED

The findings of the re-licensure survey, conducted 09/26/22 through 09/27/22, 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 OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the revisit to the re-licensure survey of 09/27/22, conducted 01/09/23 through 01/10/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.