Bayberry Commons Assisted Living

Based on interview and record review, it was determined the facility failed to ensure direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, adequate staffing to meet fire safety and evacuation standards on night shift, and a minimum of two care staff available whenever a resident required the assistance of two or more staff for scheduled and unscheduled needs for 1 of 1 sampled resident (#6) and four unsampled residents. It was determined staffing levels on the night shift posed a threat of harm to residents, in the event of an evacuation. Findings include, but are not limited to:

The facility was licensed as an ALF with two floors. During the acuity interview on 09/15/25, the consensus was confirmed at 46 residents, with five residents identified as needing two-person assistance for transfers and/or ADL cares.

The facility’s posted staffing plan and staffing schedule from 09/08/25 through 09/14/25 were reviewed. The following was identified:

The posted staffing plan for the facility was as follows:

* Day shift: 3 CG, 2 MT;
* Swing shift: 3 CG, 2 MT; and
* Night shift: 1 CG, 1 MT.

Interviews with staff on 09/18/25 identified Resident 6 as requiring three to four staff to perform ADL cares, repositioning, and transfers. The resident was receiving hospice services and was described as “bed-ridden,” reportedly having not been out of bed for over a week. Interview statements obtained between 2:05 pm and 2:35 pm on 09/18/25 included the following:

* Staff 11 (CG) stated, “Three people are needed to perform changes and repositioning in bed. Two people would not be able to get [him/her] out of bed.”;
* Staff 13 (MT/CG) stated, “The only way we could get [him/her] out in an emergency would be a blanket lift, with one person on each corner.”; and
* Staff 17 (MT/CG) stated, “[S/he] always requires three to four staff to reposition or change [him/her]. It would take more to get [him/her] out of the building.”

With the number of residents requiring two-person transfers and/or care, in addition to Resident 6 who required the assistance of three to four staff for transfers, the facility failed to have staff sufficient in number to meet the scheduled and unscheduled needs of the residents on the overnight shift, as well as to meet fire safety and evacuation standards, when only two direct care staff were scheduled. It was determined the current staffing levels on night shift were inadequate and posed a threat to the safety and well-being of the resident.

On 09/19/25 at 10:05 am, the survey team spoke with Staff 1 (ED) about the safety concerns around staffing issues on the overnight shift. A written plan to increase staff on the overnight shift was requested.

On 09/19/25 at 11:43 am, Staff 1 presented the survey team with a proposed plan of correction to increase staffing on the overnight shift.

At 12:51 pm, the survey team spoke with Staff 1 to request additional information, and at 1:10 pm, Staff 1 presented the updated plan to the survey team, and it was accepted.

On 09/19/25 at 2:20 pm, the need to ensure adequate staffing to meet the residents’ scheduled and unscheduled needs and fire safety and evacuation standards was discussed with Staff 1, Staff 2 (Regional Director of Operations), and Staff 3 (Oversight RN). They acknowledged the findings.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

(Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:

The facility was toured on 09/16/25 at 9:15 am. The following was identified:

* Scratches and scrapes were observed on the doors and door frames of Resident Rooms 111, 112, 211, 228, 242, and restroom near dining room;
* There was chipped plaster and paint on walls near Resident Rooms 232, 233, 234, and first floor laundry room;
* There were tears or gaps in the fabric base boards throughout the building’s second floor;
* Carpet stains were observed in common areas, near Resident Rooms 180, 206, 208, 227, and 239; and
* The carpet in Resident Room 213 was heavily soiled with dark stains and emitted a pervasive urine odor that did not dissipate through multiple days of survey.

On 09/19/25 at 2:20 pm, the need to ensure all interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), and Staff 3 (Oversight RN). They acknowledged the findings.

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

(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.

This Rule is not met as evidenced by:

Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main facility kitchen occurred on 04/16/25 from 10:45 am thru 1:30 pm revealed the following deficient practices.

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

* Pipes, drain, walls and flooring behind/underneath of the dish machine.
* Kitchen drains.
* Flooring in corners, edges, under and between equipment.
* Industrial mixer.
* Exterior of soup kettle.
* Walk in cooler floors under racks.
* Walk in freezer floors.
* Walk in cooler stationary racks.
* Tall movable metal rack located in walk in cooler.
* Open shelving under steam line.
* Black utility carts.
* Insulated food transportation carts.
* Light fixtures
* Sprinkler heads.
* Cabinet under sink by beverage service station.
* Flooring between steam line and ovens.
* Stove top and grill top.

b. The following areas needed repair:

* Large gap/hole in wall where gas line inters/exits wall next/near large industrial mixer
* Reach in cooler with broken/cracked door seal.
* Multiple areas in ceiling where paint/ceiling pealed/chipped or damaged.
* Two small holes in ceiling
* Wall in dry storage with damage behind racks
* Right oven damaged and didn’t work
* Steamer not operational.
* Sections of tile flooring missing grout
* Section of shelving in janitor closet area with porous wood.

c. Both sanitizer buckets found with zero parts per million of sanitizing agent. Staff was not sure when the bucket was last made. Both containers of strips were noted to be expired as of Jan 1 2019.

d. Staff 2 (Dining Services Manager) was observed to serve cooked to order grilled hamburgers without checking that the temperature of the food product was safe or palatable.

e. Facility did not have a thin prob diameter thermometer probe available for checking temperatures of thin foods.

f. Multiple food contact surfaces of single use plates, etc were noted stored open to potential contamination.

g. Staff 1 was noted to not change gloves after handling potential contaminated items before touching ready to eat food products.

h. Dish washing racks were observed stored on the floor.

i. Multiple cutting boards were observed damaged/stained or heavily scored and in need of replacement.

j. The main dining room was noted to have silverware for the Noon meal set on tables at 10:45am and were not covered or inverted as required.

On 04/16/25 at 1:15 pm, staff 1 (Executive director) was interviewed and acknowledged the above areas in need of correction.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

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

This Rule is not met as evidenced by:
Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:



Observation of the main facility kitchen occurred on 6/17/25 from 11:08 am through 3:00 pm revealed the following:



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

* Pipes, drain, walls and flooring above the sink and behind/underneath of the dishwashing area and dish machine;
* Flooring in corners, edges, under and between equipment;
* Industrial mixer;
* Walk in cooler floors under racks;

* Walk in cooler stationary racks;
* Tall movable metal rack located in walk in cooler;

* Walk in freezer floors;

* Insulated food transportation carts;
* Cabinet under sink by beverage service station;

* Flooring between steam line and ovens;

* Stove top and grill top; and

* Inside of steamer.

b. The following areas needed repair:


* Active leak under the sink in the dishwashing area;
* Large gap/hole in wall where gas line enters/exits wall next/near large industrial mixer;
* Walk-in cooler with broken door handle and door not sealing properly;
* Left side of oven not heating food evenly;
* Steamer not operational; and
* Section of shelving in janitor closet area with porous wood.



c. Multiple items in the walk-in freezer were open and uncovered.



d. Multiple items in the walk-in cooler were not dated/labeled as required.



The need to ensure the facility maintained the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000, was reviewed with Staff 1 (ED) and Staff 3 (ED in training) on 06/17/25 at 3:15 pm. They acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

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

This Rule is not met as evidenced by:

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

Refer to C 240.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

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

This Rule is not met as evidenced by:

Based on interview and record review, conducted during a site visit on 05/17/24, it was confirmed the facility failed to ensure service plans were updated quarterly for 1 of 1 sampled resident (#2), whose service plan was reviewed. Findings include, but are not limited to:A review of Resident 2's service plan indicated the most recent update was on 11/01/23 with a review date of 01/29/24. In an interview on 05/17/24, Resident 2 stated his/her last care plan meeting was in March 2023 and s/he had not been asked to sign or talk about a new one since.In an email on 05/21/24, Staff 6 (ED) reported that the nurse had done a care plan update with Resident 2, however, s/he did not document it and was no longer working at the facility.The findings were reviewed with and acknowledged by Staff 1 on 05/21/24.It was confirmed the facility failed to ensure service plans were updated quarterly.Verbal plan of correction: ED will be talking with the team right away to come up with a plan to get everyone's service plans updated and make sure residents and families are invited to care plan meetings.

Based on observation, interview, and record review, it was confirmed the facility failed to ensure that all interior materials and surfaces were kept clean, and all equipment were kept in good repair. Findings include, but are not limited to:Compliance specialist observed the following on 05/17/24:· Dining room lights were working and not flickering on and off,· Red and black stains on the carpet next to the bed in Resident 1's room,· Dark colored stains on the carpet at the door and by the window and air conditioner in Resident 2's room.Reviewed invoice dated 01/26/24 indicating an electrician was out to repair lights on 01/11/24.In an interview with Resident 1 and Witness 1, they stated the floors had not been shampooed since Resident 1 moved there in October 2023.In an interview with Resident 2, s/he stated the carpets were last cleaned in August 2023. S/He stated they requested the carpets be cleaned two weeks ago when maintenance was walking by.The findings were reviewed with and acknowledged by Staff 6 (ED) on 05/21/24 via email.It was confirmed the facility failed to ensure that all interior materials and surfaces were kept clean, and all equipment were kept in good repair.Verbal plan of correction: Carpet has been replaced in dining room and common areas, facility will address any concerns about carpet or stains when reported and has been transitioning to hardwood floors in the rooms.

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 01/11/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily 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

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 01/11/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily 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

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 01/11/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily 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

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 11/15/2022. 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

Based on interview and record review, it was confirmed that the facility failed to provide 3 daily nutritious, palatable meals to the residents, including fresh fruits and vegetables. Findings include:Compliance Specialist (CS) reviewed the menu for 11/13/22-11/19/22, requested food temperature logs, and food meeting minutes. The kitchen staff are not logging the food temperatures and they have not had any recent food meetings with the residents. There wasnt any fresh fruit listed on the menu for 11/15/22.In an interview with Staff #1 on 11/15/22, they stated that they do have concerns about the food quality and food sanitation in the kitchen. The staff are taking food temperatures; however, they have not been documenting them. They need a lot of training and cleaning to be done in the kitchen. They just had a new dining director start about 3 or 4 days ago.Witness #1 reported that the facility has no concerns for the food quality they are putting out. The other day breakfast was rubber scrambled eggs, a piece of toast, and a prepackaged Danish and the resident is diabetic.The above information was discussed with Staff #1 on 11/15/22.Plan of correction:The facility will be working with the dining manager and staff on training and documenting food temperatures.

Based on interview and record review, it was confirmed that the facility failed to ensure that the service plans are getting updated quarterly. Findings include:CS reviewed Resident #2 ' s Service Plan dated 10/06/22 and it was determined that they are not being updated quarterly. Resident #2 moved in on 04/13/22 and only had the one service plan update since move in.The above information was shared with Staff #1 on 11/15/22, who acknowledged the findings.In interviews with Staff #1 and #4 on 11/15/22, they stated that they are aware that the facility has been behind on the service plans, and it is part of their condition that they are working on.In a phone interview with Witness #1 on 11/17/22, they stated that they never had a service plan update since Resident #1 moved in. They have requested the information, but nothing was given to them.Plan of correction:Facility is working on getting all resident service plans updated.

Based on interview, observations, and record review, it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include:CS reviewed the posted staffing plan, Acuity Based Staffing Tool (ABST), service plans and progress notes for Resident #1-2, and call light response times for 10/22/22-10/23/22. There were multiple call light response times between 20-39 minutes. The ABST does not have all of the residents, or their information entered into the tool.CS observed the call light monitor on 11/15/22 and observed a call light going off at 11:32am which was not responded to for 28 minutes.In separate interviews on 11/15/22, Staff #1-4 stated that they are not always staffed per the posted staffing plan. They try to use agency staff and they have requested assistance from the Nurse Crises Team. Staff #1 stated that office staff and the nurse have been working the floor to cover shifts. They just lost their business office manager yesterday, and the new administrator has been out. Staff # 2-3 stated that there is not enough staff. Residents are not getting toileted enough, hospice residents are not getting enough attention, showers are not getting done on swing shift, and call lights are taking a long time to get to.The above information was discussed with Staff #1 on 11/15/22.

Based on interview, observation, and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:CS reviewed posted staffing plan, ABST, and service plans and progress notes for Resident #1-2. The ABST is not updated with all the residents listed on the census. Resident # 2 does not have accurate care needs entered on the ABST per their service plan dated 10/06/22. 49 out of the 57 residents are entered into the ODHS ABST.CS observed that the facility has 5 staff members working on the floor (including staff from nurse crises team) on 11/15/22. The nurse was not at the facility as they worked the NOC shift the night before. CS observed a call light going off at 11:32 am that was not responded to until 28 minutes later.The above information was shared with Staff #1 on 11/15/22, who acknowledged the findings.In an interview on 11/15/22, Staff #1 stated that there are currently about 57 residents in the assisted living facility. They have been working on ABST and updating service plans per their condition.

Based on interview and record review, it was confirmed that the facility failed to issue 30-day written notification to the resident or residents ' legal representative and follow the Oregon Administrative Rules when requesting an involuntary move out from the facility. Findings include:Compliance Specialist (CS) reviewed Resident #2s service plan dated 10/06/22, Progress notes for June-November 2022, and Resident Evaluations/Assessments from June-September 2022, email and 30-day move out notice dated 11/15/22. Nothing was documented about interventions that were taken with family or discussions regarding finding placement for Resident #1 due to the facility not being able to provide care. Resident moved in on 04/13/22 and there wasn ' t a quarterly service plan update until 10/06/22 even though behaviors were being documented in the progress notes back in June 2022. Nothing noted by the facility about providing additional care for the residents safety until placement can be found.In separate interviews on 11/15/22 with Staff #1 and 4, stated that they were not aware of any move out notices being issued, however, they have only been at the facility for a couple of days and the administrator is out.In a phone interview on 11/17/22 with Witness #1, they stated that they had a meeting with the interim administrator and new administrator on 10/28/22. At this meeting they were told that Resident #1 needed memory care placement and they didn ' t have any open rooms in the memory care so they would need to immediately take the resident home or pay for 24-hour care as they couldn ' t provide the care for them. They did not give them a written 30-day move out notice. Witness #1 stated that they contacted a lawyer who told them that the facility cannot evict without notice, so they declined to take the resident home. They have recently found placement on their own at a memory care for the resident in December. Up until this point, the facility had communicated with the family regarding behaviors and needing memory care, but they were never given an updated service plan or a move-out notice.Plan of correction:Facility emailed a 30-day move out notice to the policy analyst on 11/15/22 and left a message to go over it.

The findings of the re-licensure survey, conducted 10/10/22 through 10/13/22 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 Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a dayThe findings of the first re-visit to the initial survey of 03/30/22, conducted 08/22/22 through 08/23/22, 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.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules.

The findings of the first revisit to the re-licensure survey of 10/13/22, conducted 08/15/23 through 08/16/23, 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 for 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 revisit to the re-licensure survey of 10/13/22, conducted 11/08/23, 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 for 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 third revisit to the re-licensure survey of 10/13/22 conducted 01/04/24 are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the re-licensure survey, conducted 10/10/22 through 10/13/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.Refer to the deficiencies identified in the report.

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors, and available for inspection. Findings include, but are not limited to:A tour of the facility conducted on 10/10/22 identified the facility lacked the following postings:* The name of administrator or designee in charge, posted by shift;* The facility staffing plan; and * A copy of the most recent survey, including revisits and plans of correction.The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (Administrator) on 10/12/22. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the preservation of resident records for 6 of 7 sampled residents (#s 1, 3, 4, 5, 6, and 7) who experienced changes of condition. Findings include, but are not limited to:Residents 1, 3, 4, 5, 6, and 7 all experienced changes of condition. Staff were asked for interim service plans (ISPs) for these changes and reported their process was to resolve ISPs with an entry in the resident's progress notes, then shred the ISP form. Monitoring and resolution of changes of condition were documented in the progress notes, but any instructions to staff about monitoring was not documented anywhere in the resident's record. This resulted in incomplete records for the six residents.The need to preserve all resident records according to rule was discussed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure 1 of 7 sampled residents (#7) was treated with dignity and respect and was free from neglect. Findings include, but are not limited to: Resident 7 was admitted to the facility in 09/2021 with diagnoses including osteoarthritis. During the acuity interview on 10/10/22, Staff 22 (MT) stated Resident 1 believed s/he was going to marry Resident 7. Resident 1 had hit Resident 7 within the past month, and had followed him/her to the parking lot the previous week. Resident 7 lived with his/her spouse in the facility. On 10/10/22 during the lunch meal, Resident 7 was observed seated at a table in the dining room. A facility staff was standing between Resident 7 and Resident 1. Resident 1 was yelling. During interviews, conducted 10/10/22 through 10/13/22, Staff 20 (RA), Staff 16 (MT), and Staff 22 (MT) stated staff had frequently intervened in the dining room when Resident 1 attempted to approach Resident 7 and that staff interventions often led to Resident 1 yelling, hitting staff, and yelling at Resident 7. Resident 1 repeatedly stated s/he was going to marry Resident 7.A progress note, dated 08/19/22 stated "Resident came into RCC office concerned about an ongoing issue with [Resident 1]." [Resident 7] is requesting that [his/her] family have a meeting about how to take care of the behaviors shown by [Resident 1]. Assured resident that we would do whatever we are able to help with the situation." During an interview 10/11/22, Resident 7 stated s/he felt that s/he was being "stalked" and did not "know what to do." Resident 7 further stated Resident 1 repeatedly verbalized his/her intention to marry Resident 7, followed him/her, wrote him/her love letters, tried to sit with him/her in the dining room and told Resident 7's spouse they were getting married. Resident 7 stated the behaviors happened almost daily, and that staff interventions were ineffective, often resulted in Resident 1 yelling at him/her and striking staff. Resident 7 stated the situation had been going on for "three or four months," felt like the facility was not responding appropriately, and s/he "did not matter." Resident 7 confirmed a meeting had been held, which included his/her family members, Resident 1's daughter, and the previous facility RCC. S/he reported nothing had changed as a result of the meeting. During interviews on 10/12/22 and 10/13/22, Staff 1 (Administrator) and Staff 3 (MCC) confirmed they were aware of the situation, had met with Resident 7 the week prior, and acknowledged Resident 1's behaviors towards Resident 7 were ongoing. The facility's failure to ensure Resident 7 was treated with dignity and respect, and to ensure Resident 1's behaviors did not infringe on the rights or safety of others, resulted in a violation of Resident Rights, and is considered neglect. The need to ensure residents were treated with dignity and respect and were free from neglect was discussed with Staff 1 and Staff 3 on 10/13/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure incidents of abuse or suspected abuse were investigated and reported to the local AAA when abuse was not reasonably ruled out for 2 of 2 sampled resident (#s 1 and 7) whose facility records were reviewed. Resident 1 was found wandering unsupervised outside the facility. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility 04/2022 with diagnoses including dementia. The resident's 07/10/22 through 10/11/22 progress notes, and the 09/29/22 quarterly evaluation and service plan were reviewed. Facility staff were interviewed. a. Resident 1's quarterly evaluation, dated 09/29/22, indicated the resident was unsafe to leave the building unsupervised. The quarterly service plan, also dated 09/29/22, instructed staff to redirect the resident if s/he tried to leave the building, secondary to a history of wandering. Progress notes dated 09/26/22, 09/27/22, and 10/08/22 stated the resident was observed "wandering" on the grounds of the facility unsupervised. A progress note dated 09/30/22 stated the resident went for a walk outside with another resident. The failure of the facility to follow the service plan and provide the necessary services to maintain the safety of the resident put the resident at risk for serious harm and was reported to the local AAA by survey on 10/21/22 at 1:56 PM.b. A progress note dated 09/23/22 stated the resident went out for a walk and "staff were later notified that a stranger saw (Resident 1) laying in the grass on Pioneer Parkway."During an interview with Staff 1 (Administrator), he stated "rumor had it" the resident was brought back to the facility by the concerned citizen. There was no documented evidence the facility investigated the incident to rule out abuse, including:*Time, date, place and individuals present;*Description of the event as reported; *Staff response at the time of the event;*Follow up action; and *Administrator's review. The incident was reported to the local AAA by survey on 10/21/22 at 1:56 PMc. During the acuity interview on 10/10/22, Staff 22 (MT) stated that Resident 1 struck Resident 7 sometime within the last month. A 09/15/22 progress note, indicated to be a late entry for 09/14/22, stated Resident 1 was in the dining room, had walked up to Resident 7, and "began shouting at (him/her) and threatening (him/her). A staff member tried to intervene and in the process, resident hit the staff member and the other resident." A 09/14/22 "Internal Incident Report" was completed for the incident, but lacked information related to Resident 1 threatening and hitting another resident. There was no documented evidence the facility investigated the incident or reported the abuse to the local AAA. The facility was instructed to report the incident to the local AAA on 10/11/22. The facility provided a fax confirmation the incident was reported on 10/11/22 at 5:15 PM. Upon further review of the "Internal Incident Report" following the survey, it was noted that the facility had circled Resident 1's left forearm on a diagram and indicated the resident had sustained an injury. Survey reported the injury sustained during the incident to the local AAA on 10/21/22 at 1:56 PM. 2. Resident 7 was admitted to the facility in 09/2021 with diagnoses including osteoarthritis. During the acuity interview on 10/10/22, Staff 22 (MT) stated Resident 1 believed s/he was going to marry Resident 7. Resident 1 had hit Resident 7 within the past month, and had followed him/her to the parking lot the previous week. On 10/11/22, Resident 7 stated s/he felt that s/he was being "stalked" and did not "know what to do." On 10/12/22 and 10/13/22, Staff 1 (Administrator) and Staff 3 (MCC) confirmed Resident 1's behaviors towards Resident 7 were ongoing. There was no documented evidence the facility investigated the incidents or reported the abuse to the local AAA. The facility was instructed to report the incident to the local AAA on 10/12/22. The facility provided a fax confirmation the incident was reported that day. Refer to C200 The need to provide basic care and services necessary to maintain the health and safety of the resident, to thoroughly investigate all incidents of abuse or suspected abuse, and to report to the local AAA when abuse was not reasonably ruled out was discussed with Staff 1 on 10/13/22. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and that food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchens, food storage areas, food preparation, and food service on 10/10/22 through 10/12/22 indicated the following deficiencies:1. The facility's main kitchen was toured on 10/10/22 and showed the following:* Dried food debris on the meat slicer and the stand mixer whisk;* Gray, greasy film on microwave, microwave stand, and ware washer, including temperature gauges, rendering them unreadable; * Food debris on floor, underneath racks in dry storage room, and a peanut butter cookie was on top of a storage bin;* Gray matter on blue cup racks;* Food debris on side of grill;* Dark matter and dust on grill hood;* Multiple food packages were open in the dry storage room, and the lid was off the oatmeal storage bin;* Gallon of honey mustard dressing in the walk-in cooler was expired;* Multiple items in the walk-in cooler were not dated;* Weekly menu included eggs cooked to order, and eggs in the cooler were not pasteurized;* Paper signs were throughout the kitchen, creating uncleanable surfaces;* Garbage cans throughout kitchen did not have lids; and* Back door had multiple areas of chipped and worn paint, creating an uncleanable surface.2. Observation of meal service during lunch in the dining room on 10/11/22 and in the kitchen on 10/12/22 showed the following: * Caregiving staff assisting with meal service in the kitchen and dining room were not wearing aprons;* Staff 21 (Dishwasher) was observed dishing up food in the kitchen and transporting food to the memory care unit. Staff 21 reported he did not have a Food Handlers Card; and* Staff 20 (Resident Assistant) was observed dishing up food in the kitchen and training another Resident Assistant how to dish up food. Staff 20 reported she did not know if her Food Handlers Card was current, but that "it probably isn't." Food Handlers Cards were requested on 10/12/22 from Staff 4 (Marketing Director) for the four caregivers observed helping with meal service during lunch on 10/11/22. He said he would ask his colleagues at their upcoming meeting. No further documentation was provided.These findings were reviewed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 sampled resident (#4). Findings include, but are not limited to:Resident 2 was admitted to the facility in 06/2022 with diagnoses including chronic pain syndrome. Review of the resident's move-in evaluation, dated 06/29/22, identified the following elements were not addressed:* Customary routines, including sleeping, eating, and bathing;* Spiritual, cultural preferences and traditions;* Physical health status, including list of diagnoses, list of medications and PRN use, and visits to health practitioner(s), emergency room, hospital, or nursing facility in the past year;* Effective non-drug interventions for mental health issues;* Personality, including how they cope with change or challenging situations;* Ability to understand and be understood;* How they express pain and discomfort;* Fluid preferences;* Complex medication regime;* History of dehydration or unexplained weight loss or gain; and* Environmental factors which impact behavior, including noise, lighting, and room temperature.The need to ensure all required elements were addressed in the move-in evaluation was discussed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings.

2. Resident 3 was admitted to the facility in November 2018 with diagnoses including diabetes and low back pain. Observations and interviews with the resident, interviews with staff and review of the care plan dated 09/30/22, showed the care plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * One person assist with ambulation using a walker;* Wheel chair use as needed;* Transfer assistance;* Dressing, grooming, hygiene and toileting assistance;* Incontinence;* Outside provider services including Home Health PT and Palliative Care;* Use of a bed cane;* Heating pad use, with instructions for staff; and* Ability to evacuate. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator) on 10/12/22. He acknowledged the findings.
3. Resident 1 was admitted to the facility in 04/2022 with diagnoses including dementia. The resident's 09/29/22 service plan and 07/10/22 through 10/11/22 progress notes were reviewedThe quarterly service plan, dated 09/29/22, instructed staff to redirect the resident if s/he tried to leave the building secondary to a history of wandering. Progress notes dated 09/27/22, and 10/08/22 stated the resident was observed "wandering" on the grounds of the facility unsupervised. A progress note dated 09/30/22 stated the resident went for a walk outside with another resident. The need to ensure the resident's service plan was followed for his/her safety was discussed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings. 4. Resident 2 was admitted to the facility in 02/2021 with diagnoses including diabetes. Review of the resident's 09/30/22 service plan and interviews and observations of the resident revealed the service plan was not reflective of the resident's current status and care needs in the following areas:*Hearing loss;*Glasses;*Weight loss;*Assistance to dining room;*Recent loss of spouse; and *Skin tear.The need to ensure the resident's service plan was reflective of the resident's status and care needs was discussed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, reflective of residents' current status and care needs and/or provided clear direction to staff regarding the delivery of services for 5 of 6 sampled residents (#s 1, 2, 3, 5, and 7). Findings include, but are not limited to:1. On 10/10/22 Staff 22 (MT) reported resident service plans, including service plan for Residents 1, 2, 3, 5, and 7, were kept in the locked MT room, therefore not readily available to direct care staff.The need to ensure service plans were readily available to all caregivers was discussed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, and/or were implemented for 2 of 3 sampled residents (#s 8 and 9). This is a repeat citation. Findings include, but are not limited to:1. Resident 9 was admitted to the facility in March 2021 with diagnoses including hypertension and glaucoma. The service plan dated 06/27/23 was not reflective of the resident's status, lacked clear direction to staff, and/or was not implemented in the following areas:* Adaptive cup use;* Eating routine;* Finger foods;* Pressure mattress instructions;* Frequency of repositioning;* Shower schedule; and* Pain scale use.On 08/16/23, the need to ensure service plans were reflective of resident needs, provided clear direction to staff, and were implemented, was discussed with Staff 23 (ED) and Staff 24 (Consultant RN). They acknowledged the findings.
2. Resident 8 was admitted to the facility in February 2022 with diagnoses including polyneuropathy and obesity. The service plan dated 06/27/2023 was not reflective of the resident's status and lacked instruction to staff in the following areas:* Assistance needed to sit up at edge of bed;* Use of urinal at night;* History of significant weight gain;*Assistance with dressing; and* Hygiene assistance after toileting.On 08/16/23, the need to ensure service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 23 (ED) and Staff 24 (Consultant RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who provided services, for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to:The current service plans for Residents 1, 2, 3, 4, 5 and 7 lacked documented evidence they had been developed by a service planning team.On 10/13/22 the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Administrator). He acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the RN when needed, interventions were determined, documented, communicated to staff on all shifts, and monitored for effectiveness, and the changes monitored at least weekly through resolution for 2 of 6 sampled residents (#s 1 and 2). Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/13/22 with diagnoses including dementia. The resident's 07/10/22 through 08/11/22 progress notes and incident investigations, and the 09/29/22 quarterly evaluation and service plan were reviewed. Staff were interviewed. a. Progress notes from 08/01/22 through 10/11/22 revealed almost daily documentation Resident 1 was on alert for "inappropriate behaviors" related to his/her behavior toward Resident 7, who s/he believed s/he was to marry. There were numerous progress notes related to behaviors which included Resident 1 yelling and hitting staff, yelling at Resident 7, and one instance of Resident 1 threatening and hitting Resident 7. A progress note dated 08/08/22 referenced an 08/01/22 interim service plan which instructed staff to seat Resident 1 and Resident 7 at separate tables. The 09/29/22 service plan instructed staff to "Keep (him/her) away from (Resident 7) to try to prevent the agitation and aggression." There was no documented evidence the facility monitored the interventions for effectiveness during the time frame reviewed or developed new interventions to address the resident's behavior when the behavior continued. b. A 09/23/22 progress note indicated Resident 1 had told staff s/he was going for a walk and staff were later notified "a stranger saw (Resident 1) laying on the grass on Pioneer Parkway." There was no documented evidence the facility evaluated the resident upon his/her return, determined and documented what actions and interventions were needed for the resident, communicated them to staff on all shifts, and monitored the resident after the incident. The need to ensure the resident was evaluated following changes of condition, with actions and interventions determined, documented, communicated to staff on all shifts, and interventions monitored for effectiveness was discussed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings. 2. Resident 2 was admitted to the facility in 02/2021 with diagnoses including diabetes. The resident was identified to have had a recent decline in mobility and ADLS during the acuity interview on 10/10/22.The resident's 09/30/22 service plan, 07/16/22 through 10/10/22 progress notes, 08/02/22 through 10/05/22 weight records, 09/01/22 through 10/10/22 MAR/TAR, and incident investigations were reviewed. Interviews with staff and observations of the resident were conducted. The resident experienced the following changes of condition: * 08/13/22: Fall with subsequent resident complaints and staff observations of weakness and a significant decline in mobility and ADL status;* 08/18/22: Quarter size wound on back;* 08/23/22: Non-injury fall.* 08/24/22 Fall with skin tear to left elbow;* 08/22/22: Confusion;* 09/05/22: Resident 2 was sent to local ED with complaints of left arm pain, extreme weakness, and resident report that s/he stated, "I'm sick." Resident returned to the facility the same day with diagnoses including UTI and hypomagnesemia. The resident was prescribed Cephalexin (antibiotic) and magnesium (supplement);* 09/04/22: Resident weight records indicated s/he weighed 192.3 on 08/04/22. The resident's weight on 09/05/22 was 179.2. This represented a significant weight loss of 13.1 pounds or 6.81%. The resident's recorded weight on 10/05/22 was 187.4; and* 10/03/22: Resident experienced a fall with injury to his/her left elbow.The RN was unavailable for interview during the survey. Interviews with multiple staff confirmed the resident experienced a decline with increased need for assistance for mobility and ADLs over the last few months. They reported s/he regularly had meals in the dining room and had a good appetite. The resident was observed to be transported to the dining room in a wheelchair on 10/11/22 and observed to eat independently. There was no documented evidence the facility ensured Resident 1's changes of condition were evaluated and referred to the RN when needed, interventions were determined, documented, communicated to staff on all shifts, and monitored for effectiveness, and the changes monitored at least weekly through resolutionResident 2's short-term and significant changes of condition were discussed with Staff 1 (Administrator) on 10/13/22. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure residents who experienced significant changes of condition were assessed by the RN for 1 of 1 sampled resident (#2) who had a significant change of condition. Findings include, but are not limited to: Resident 2 was admitted to the facility in 02/2021 with diagnoses including diabetes. The resident was identified to have had a recent decline in mobility and ADLS during the acuity interview on 10/10/22Resident's 09/30/22 service plan, 07/16/22 through 10/10/22 progress notes, and 08/02/22 through 10/05/22 weight records were reviewed. Interviews with staff and observations of the resident were conducted. 1. A progress note dated 08/13/22 indicated Resident 2 had an unwitnessed non-injury fall. A second progress note that date indicated the resident was "having a hard time standing up out of chairs." Staff observations and resident reports documented in progress notes included the following:08/14/22: "Hard time walking to dinner tonight and an RA had to grab a wheelchair";08/15/22: "Noticeable weakness to the lower extremities";08/16/22: "Having a hard time walking to/from the dining room for meals. He mostly struggles with lifting his left foot to walk, as it shuffles on the ground";08/17/22: "MT called family requesting they get [resident] some new pants. Preferably sweatpants due to resident's decline in ADLs";08/18/22: "Resident did not come down for dinner because they stated they could not walk or stand by themselves"; and8/18/22: Resident "does state that (s/he) is feeling a lot weaker";On 08/19/22, the RN documented in a progress note "Alert charting being discontinued related to the non-injury fall that occurred on 08/13. (S/he) denies pain, has no visible bruising or wounds related to his fall. Resident does report feeling weak. Alert charting will be started related to decline in ADLs."2. Resident 2's recorded weight on 08/04/22 was 192.3 lbs. The resident's weight on 09/05/22 was recorded to be 179.2 lbs. This represented a significant weight loss of 13.1 lb or 6.81% of his/her body weight in one month. There was no documented evidence an RN completed an assessment when the resident experienced the significant weight loss. The RN was unavailable for interview during the survey. The resident's weight was recorded to be 187.4 on 10/05/22. The resident was observed eating independently on multiple occasions during survey.The failure of the facility to ensure the RN completed thorough assessments of the resident when s/he experienced significant changes of condition related to weight loss and a decline in mobility and ADLS was discussed with Staff 1 (Administrator). He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 2 of 2 sampled residents (#s 2 and 3) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.During the acuity interview on 10/10/22, Residents 2 and 3 were identified to be administered insulin injections by non-licensed staff.1. Resident 3's insulin administration record and MARs, reviewed from 09/01/22 through 10/10/22, revealed insulin had been administered by Staff 16 (MT), Staff 18 (MT) and Staff 22 (MT) on multiple occasions.a. The most recent periodic inspection, supervision and re-evaluation of the delegation for Staff 18, completed 09/01/22, and Staff 22, completed 09/08/22, lacked documentation in the following areas:* Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable; and* Date of subsequent re-evaluation to be completed.b. The initial delegation for Staff 16 was completed on 06/29/22. There was no documented evidence a re-evaluation was completed within 60 days of the initial delegation.2. Resident 2's insulin administration record and MARs, reviewed from 09/01/22 through 10/10/22, revealed insulin had been administered by Staff 18 (MT) and Staff 22 (MT) on multiple occasions.a. The most recent periodic inspection, supervision and re-evaluation of the delegation for Staff 18, completed 08/20/22 and Staff 22, completed 09/19/22, lacked documentation in the following areas:* Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable; and* Date of subsequent re-evaluation to be completed.The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Administrator) on 10/11/22. He acknowledged the findings. Staff 2 (RN) began the delegation process over for all MT staff on 10/12/22.

Based on observation and interview, it was determined the facility failed to ensure it had a trained Infection Control Specialist and to consistently comply with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:1. In an interview on 10/11/22, Staff 1 (Administrator) reported the facility did not currently have a designated Infection Control Specialist who had completed the required specialized, Department-approved training in infection prevention and control protocols.2. 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 a mask or wear a mask properly, covering both the nose and mouth.The need to ensure the facility had a designated Infection Control Specialist who had completed all required training, and that staff consistently wore a face mask, was reviewed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were followed as written and physician orders for all medications and treatments were in the resident's record for 1 of 7 sampled residents (#2). Findings include, but are not limited to:Resident 2 was admitted to the facility in 02/2021 with diagnoses including diabetes. A review of the resident's 09/01/22 through 10/12/22 MARs and physician orders revealed the following:a. The MAR revealed the resident was being administered Travoprost 0.004% eye drops (for glaucoma) every day, one drop in each eye at bedtime. There was no physician order for this medication in the resident's record.b. The resident had a prescription for Lantus Solostar (insulin), 10 units every day. There was no documented evidence the resident received insulin injections on the following dates:* 09/09/22 - the MAR indicated the resident was out of the facility;* 09/17/22 - there were no initials indicating the insulin was administered, nor was there any documentation regarding whether or not the insulin was administered; and* 10/09/22 - a note on the MAR indicated the staff passing medications at that time was not delegated to perform injections for the resident.In an interview on 10/12/22, Staff 3 (MCC) indicated she was passing medications on 10/09/22 and did not administer the insulin for Resident 2 because she was no longer delegated to do so. She reported to her knowledge no other staff administered the resident's insulin on 10/09/22. No documentation showing the resident was administered insulin on 10/09/22 was provided.c. Staff reported they were administering wound care to a skin tear on the resident's left elbow. There was no order for the wound care in the resident's chart, nor was wound care treatment listed on the MAR.d. Physician orders signed 01/31/22 included orders for the following:* Anti-diarrheal 2 mg tabs PRN;* Weekly weights for monitoring; and* Fax weekly weights to PCP monthly.These orders were not on the MAR.e. The resident had an order dated 3/31/22 to monitor blood pressure 1-2 times a week. The MAR indicated the resident's blood pressure should be checked one time per month.The need to have signed physician orders in the chart for all medications and treatments the facility was responsible to administer, and to follow the orders as prescribed, was discussed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings.

2. Resident 2 was admitted to the facility in 02/2021 with diagnoses including diabetes. A review of the resident's 09/01/22 through 10/12/22 MAR revealed the following:* There were four PRN bowel care medications listed on the MAR, with no instructions regarding the sequence in which they should be administered by staff.* A PRN order for an enema (for constipation) was listed on the MAR, but there was an order dated 02/05/21 discontinuing this medication.* There was no reason for use listed for 20 medications on the MAR.The need to have an accurate MAR was discussed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings.3. Resident 4 was admitted to the facility in 06/2022 with diagnoses including edema and chronic pain syndrome. A review of the resident's 09/01/22 through 10/12/22 MAR revealed the following:* There was no reason for use listed for 14 medications.* There were two PRN bowel care medications listed on the MAR, with no instructions regarding the sequence in which they should be administered by staff.The need to have an accurate MAR that included reasons for use and parameters for PRN medications was discussed with Staff 1 (Administrator) on 10/12/22. He acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included reasons for use for all medications and included clear instructions for all medications and treatments the facility was responsible to administer for 3 of 7 sampled residents (#s 2, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:l. Review of Resident 5's 09/01/22 through 10/11/22 MAR revealed the following: a. The MAR indicated duplicate medication administration on six occasions:* Tramadol: 09/07 marked given in PM and at 8 pm; and* Gabapentin: 10/08 and 10/09 marked given in AM and at 8 am, 10/08 and 10/09 marked given in "afternoon" and at 2 pm, and 10/08 marked given in PM and at 8 pm. Staff 19 (MT) reported that she would initial the 2 pm MAR, for instance, if she saw the dose had been given and recorded in the "afternoon" row by another MT. Staff 22 (MT) reported that the MTs who were initialing to indicate the resident had already been given the medication by another MT needed training in the correct process: marking "not given" and utilizing the drop-down reason as "time change."b. The following medications lacked reasons for use: * Gabapentin; and* Tramadol. The need to ensure a resident's MAR was accurate and included reason for medication use was reviewed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings.
3. Resident 8 was admitted to the facility in February 2022 with diagnoses including venous insufficiency and polyneuropathy.Resident 8's physician orders and 08/01/23 through 08/15/23 MARs were reviewed during the survey and showed the following:* Furosemide 40 mg every morning;* Primidone 500 mg twice daily; and * Vitamin B-12 500 mcg every day. There was no reason for use listed on the MAR for these medications.The need to ensure the resident's MARs included reason for use for all medications being administered was discussed with Staff 23 (ED) and Staff 24 (Consultant RN) on 08/16/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a physician or other legal prescriber and for which the facility was responsible to administer for 3 of 3 sampled residents (#s 8, 9, and 10). This is a repeat citation. Findings include, but are not limited to:1. Resident 10 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease and hypertension.The resident's 08/01/23 through 08/15/23 MAR and physician orders were reviewed, and inaccuracies were identified.* Three medication orders were transcribed onto the MAR incorrectly; and* Nine medications lacked reasons for use.The need for MARs to be accurate was discussed with Staff 23 (ED) and Staff 24 (Consultant RN) on 08/16/23. They acknowledged the findings.
2. Resident 9 was admitted to the facility in March of 2021 with diagnoses including hypertension and glaucoma.The resident's 08/01/23 through 08/16/23 MAR, current signed physician orders, and last three months of weights were reviewed. The following was identified:a. Resident 9 had orders for the facility to obtain monthly weights on the fifth day of the month. The facility failed to document why the monthly weight was not obtained in June or August. b. Two PRN bowel medications, Miralax and Milk of Magnesia, lacked specific parameters of use.c. Parameters for MD notification of systolic blood pressure were unclear: "Notify MD if systolic blood pressure is 90 ...".d. Parameters for Miralax were conflicting: "Take by mouth as needed for no bowel movement in 3 days. Please notify hospice if [h/she] hasn't had a bm in 2 days and refuses to take miralax [sic]."The need to ensure MARs were accurate, including directions that require no discretion by unlicensed caregivers, was discussed with Staff 23 (ED) and Staff 24 (Consultant RN) on 08/16/23. They acknowledged the findings.

Based on interview, observation and record review, it was determined the facility failed to ensure all treatments provided to residents were documented on the TAR for 1 of 1 sampled resident (#2). Findings include, but are not limited to: Resident 2 was admitted to the facility in 02/2021 with diagnoses including diabetes. Review of the resident's 09/01/22 through 10/09/22 MAR and progress notes revealed the following: There were multiple progress notes entered which referenced a bandage on the resident's left arm. On 10/12/22, Resident 2 was observed in the dining room with a bandage on his/her left arm above the elbow. Review of the 09/01/22 through 10/010/22 TAR revealed there was no documentation staff had treated the wound. In an interview with Staff 22 (MT), she indicated she wrote the date the bandage was changed on a white board in the medication room, but did not initial it on the TAR.The need to ensure treatments provided by the facility were documented on the TAR was discussed with Staff 1 (Administrator) on 10/13/22. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 10, 12, 14 and 15) completed all elements of pre-service orientation, 3 of 4 newly hired staff (#s 12, 14 and 15) completed all pre-service dementia training in the required time frame, and 2 of 2 long-term staff (#s 8 and 23) completed infectious disease prevention training by 07/01/22. Findings include, but are not limited to:Staff training records were reviewed 10/12/22 and revealed the following:1. There was no documented evidence Staff 10 (Resident Assistant), Staff 12 (Resident Assistant), Staff 14 (MT), or Staff 15 (Resident Assistant, hired 04/23/22, 08/16/22, 05/02/22, and 07/08/22, respectively, completed one or more of the following pre-service orientation topics before performing any job duties:* Resident rights and values of CBC care;* Abuse reporting requirements;* Infectious disease prevention;* Fire safety and emergency procedures; and* Written job description.2. There was no documented evidence Staff 12, Staff 14, or Staff 15 completed pre-service dementia training prior to providing care to residents in one or more of the following topics:* Dementia disease process, including progression, memory loss, and psychiatric and behavioral symptoms;* Techniques for understanding, communicating, and responding to behaviors; reducing the use of antipsychotics;* Strategies for addressing social needs and engaging them in meaningful activities; and* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and use of the person-centered approach.3. There was no documented evidence Staff 8 (Kitchen Staff) or Staff 23 (Maintenance Director) completed infectious disease prevention training by 07/01/22.The need to ensure new staff complete pre-service orientation prior to beginning any job responsibilities and pre-service dementia care training prior to providing care to residents, as well as to have had all staff complete infectious disease prevention training by 07/01/22, was discussed with Staff 1 (Administrator) and Staff 7 (Business Office Manager) on 10/13/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 26, 28, and 30) completed all pre-service orientation topics and pre-service dementia training. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 08/16/23 and revealed the following:1. There was no documented evidence Staff 26 (MT/Resident Assistant), Staff 28 (MT/Resident Assistant), and Staff 30 (MT/Resident Assistant), hired 05/17/23, 05/19/23, and 06/08/23, respectively, had completed one or more of the following pre-service orientation topics:* Resident rights and values of CBC care;* Abuse reporting requirements;* Infectious disease prevention;* Fire safety and emergency procedures; and* Written job description.2. There was no documented evidence Staff 26, Staff 28, and Staff 30 completed the required pre-service dementia training.The need to ensure newly hired staff completed pre-service orientation and training as required was discussed with Staff 23 (ED) and Staff 24 (Consultant RN) on 08/16/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired direct care staff and 2 of 4 long term staff completed the required infectious disease prevention training during pre-service orientation and failed to ensure all staff were trained by 07/01/22, as required. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 11/08/23. The following was identified:a. There was no documented evidence Staff 33 (MT), hired 10/06/23, completed infectious disease prevention training as part of their pre-service orientation prior to performing any job duties. b. There was no documented evidence Staff 31 (Receptionist), hired 06/15/18, and Staff 20 (CG), hired 09/08/09, had completed infectious disease prevention training by 07/01/22, as required. The need for all staff to complete infectious disease prevention training during pre-service orientation and by 07/01/22, as required for all staff was discussed with Staff 23 (ED) and Staff 30 (Director of Operations) on 11/08/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired direct care staff (#s 10, 12, 14 and 15) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 10/12/22.a. There was no documented evidence Staff 10 (Resident Assistant), Staff 12 (Resident Assistant), Staff 14 (MT), or Staff 15 (Resident Assistant), hired 04/23/22, 08/16/22, 05/06/22 and 07/08/22, respectively, demonstrated competency within 30 days of hire in one or more of the following areas:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition;* Conditions which require assessment, treatment, observation, and reporting;* General food safety, serving and sanitation;* Other duties as applicable (med pass, treatments); and* First Aid/Abdominal Thrust.b. There was no documented evidence Staff 14 demonstrated competency in medication passing job duties within 30 days of hire. In an interview on 10/13/22, Staff 16 (MT) reported they had a process they followed to train new staff related to administering medication, they just didn't document their demonstration of competency. Staff 22 (MT) verified this information.The need to document all direct care staff demonstrated competency within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 7 (Business Office Manager) on 10/13/22. They acknowledged the findings.On 10/13/22, at the request of survey, Staff 1 provided a plan for how the facility would observe and document competency in assigned job duties for all staff administering medications to residents.
Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 26, 28, and 30) demonstrated competency in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 08/16/23.There was no documented evidence Staff 26 (MT/Resident Assistant), Staff 28 (MT/Resident Assistant), or Staff 30 (MT/Resident Assistant), hired 05/17/23, 05/19/23, and 06/08/23, respectively, demonstrated competency in one or more of the following areas:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition;* Conditions which require assessment, treatment, observation, and reporting;* General food safety, serving, and sanitation;* Other duties as applicable (med pass, treatments); and* First aid/abdominal thrust.The need for new staff to demonstrate competency in all assigned job duties within 30 days of hire was discussed with Staff 23 (ED) and Staff 24 (Consultant RN) on 08/16/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure long-term employees completed 12 hours of annual in-service training, including at a minimum 6 hours related to the provision of service and 6 hours related to dementia care, for 4 of 4 long-term staff (#s 11, 16, 17 and 20) whose training records were reviewed. Findings include, but are not limited to:Staff training records were reviewed on 10/12/22.There was no documented evidence Staff 11 (Resident Assistant), Staff 16 (MT), Staff 17 (MT), or Staff 20 (Resident Assistant), hired 07/02/12, 03/22/13, 10/20/15, and 09/08/09, respectively, had completed the required number of hours of annual in-service training, related to both the provision of care in CBC and dementia care.The need to ensure staff completed the required annual training in the specified time frames was discussed with Staff 1 (Administrator) and Staff 7 (Business Office Manager) on 10/13/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff (#s 11 and 20) completed the required annual infectious disease prevention training. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 08/16/23.There was no documented evidence Staff 11 (Resident Assistant), hired 07/02/12, or Staff 20 (Resident Assistant), hired 09/08/09, had completed infectious disease prevention training as part of their annual in-service training.The need for all staff to complete infectious disease prevention training annually was discussed with Staff 23 (ED) and Staff 24 (Consultant RN) on 08/16/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternate months as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and life safety records were reviewed on 10/11/22.There was no documented evidence the facility provided fire and life safety training instruction to staff on alternating months from fire drills.In an interview on 10/11/22, Staff 23 (Maintenance Director) verified the facility was not providing fire and life safety instruction to staff.The need to provide instruction to staff in accordance with the OFC was discussed with Staff 1 (Administrator) and Staff 7 (Business Office Manager) on 10/13/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 260, C 310, C 370, C 372, C 374 and C 613.
Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C370 and C613.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:Observations of the facility on 10/10/22 and 10/11/22 showed the following areas were in need of cleaning or repair:* Numerous dark stains were noted on the carpet in the common areas. Stains were observed on the carpets in the dining room, TV room, hallways, doorways and inside multiple resident rooms on the first and second floor. * Multiple residents interviewed during the survey, and Staff 23 (Maintenance Director) reported that the carpets were cleaned often, but the stains would always come back;* A large black, burnt-looking area was observed on the carpet in front of the fireplace on the second floor;* One black chair in the TV room had a split in the seat cushion material approximately 3 inches long; * Multiple doors and door frames had black streaks and/or scrapes;* Multiple walls and corners had chips, scrapes or dings;* Multiple windows and screens had a build up of dirt, cobwebs and bugs;* Multiple ceiling lights in the hallways had visible dead bugs and debris; and* There was missing plaster along the bottom edges of the walls of the entire stairway leading to the second floor.The areas in need of cleaning and/or repair were shown to and/or discussed with Staff 1 (Administrator) on 10/12/22. He acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. This is a repeat citation. Findings include, but are not limited to:Observations of the facility on 08/15/23 and 08/16/23 showed the following areas were in need of cleaning or repair:* Numerous dark stains were noted on the carpet across the dining room and on the stairs going from the first to second floor of the facility. * There were frayed seam lines on the dining room carpet approximately five to six feet long.* Multiple windows and screens had a build up of dirt, cobwebs, and bugs.During an interview with Staff 25 (Maintenance Director), he stated he was aware of the stains on the carpets and that no floor cleaning had been effective to remove the stains.The areas in need of cleaning and/or repair were shown to and/or discussed with Staff 23 (ED) and Staff 24 (Consultant RN) on 08/16/23. Staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to:Observations of the facility on 11/08/23 showed the carpeting in the dining room was dirty, damaged, covered with hard water deposits, and in need of cleaning and/or repair.Staff 23 (ED) provided three commercial floor covering quotes dated 01/13/23, 09/15/23, and 10/05/23. However, no security deposit was made by the facility, and no project start date has been determined. The areas in need of cleaning and repair were shown to and discussed with Staff 25 (Maintenance Director) and Staff 23 on 11/08/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or surfaces of baseboard 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 10/11/22 with Staff 23 (Maintenance Director), it was revealed that the metal grate surface on the wall heaters located in apartments with one or two bedrooms and in the bathroom off the dining room exceeded 120 degrees F when turned on.The need to ensure residents could not come into incidental contact with wall heater grates that exceeded 120 degrees F was discussed with Staff 1 (ED) and Staff 23 on 10/11/22 and 10/12/22. They acknowledged the findings. Staff 23 disconnected power to all 27 wall heaters prior to survey exit on 10/13/22.

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 09/20/2022. 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

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 9/20/2022. 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

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 09/20/2022. 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.

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 08/18/2022. 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.

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 09/20/2022. 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

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 08/04/2022. 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

Based on interview and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:In review of the ODHS ABST tool on 08/04/22, the facility has not updated or entered any resident information into the tool. The above information was shared with Staff #1 on 08/04/22, who was in agreement with the findings.In an interview on 08/04/22, Staff #1 that their current census is 46 residents. They have not implemented an ABST tool at this time. They are going to be using the ODHS tool, however, they have not entered any resident information. They are currently staffing per their resident acuity and no needs are being missed due to staffing. They will start working on implementing the ABST tool.