Bonaventure of Salem Assisted Living

OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law.

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 06/08/26 at 12:42 pm, identified the facility failed to post in a conspicuous location the following required postings: * Resident Rights and Protections, including the LGBTQIA2S+ Rights and Protections; and * Ombudsman poster. The need to ensure all required postings were displayed in an accessible and conspicuous location for the public was discussed with Staff 1 (ED) and Staff 8 (Maintenance) on 06/09/26 at 10:27 am, and Staff 1, Staff 2 (Regional Operations Officer) and Staff 3 (Chief Operating Officer) on 06/10/26 at 3:50 pm. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents’ needs and provided clear direction to staff for 2 of 5 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2025 with diagnoses of chronic kidney disease and an unspecified fracture of the upper end of right humerus. Observations were made of the resident's care on 06/08/26 and 06/09/26, interviews with the resident and facility staff were conducted, and the 02/01/26 service plan was reviewed. Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions regarding the resident’s speech impairment; * Instructions from home health provider for wound care; * Use of TED hose (compression socks for edema); * Instructions for bathing; * Preferred meal service; * Bladder continence status; and * PRN medication orders. In interviews on 06/08/26 at 12:15 pm and 06/09/26 at 11:20 am, Resident 2 stated that s/he did not wear TED hose, required assistance to bathe all areas except his/her face, ate lunch and dinner in his/her room, was not incontinent of bladder and had a home health nurse who treated his/her wounds, all of which were not reflected as such on the resident’s service plan. In interviews on 06/08/26 at 12:15 pm and 06/09/26 at 11:20 am, Resident 2 showed evidence of speech impairment that was not identified on the service plan. Interviews with Staff 16 (CG) and Staff 19 (CG) on 06/09/26 at 9:12 am and 06/10/26 at 2:30 pm respectively, confirmed that the resident could sometimes be difficult to understand and had to be asked to repeat him/herself for clarification. The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 06/10/26 at 4:20 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 04/2024 with diagnoses including rib fracture. The resident was subsequently admitted to hospice on 10/26/25 with an admitting diagnosis of multiple sclerosis. Observations were made of the resident's care on 06/09/26 and 06/10/26. Interviews with the resident and facility staff were conducted, and the 03/23/26 service plan was reviewed. Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions for behaviors related to verbal and physical aggression towards residents and staff; * Behavioral problems and effective non-drug interventions; * Number of staff needed to assist with activities of daily living; * Hearing status and instructions to staff for providing care to the resident with significant hearing impairment; * Physician Orders for Life Sustaining Treatment status; * Instructions for what types of skin impairments to report and to whom; * Instructions for perineal and skin care; * Transfers; * How Resident 4 expressed memory loss; and * Incorrect reference to information that the resident was able to utilize the call system independently. Staff 11 (MT/CG) was interviewed on 06/09/26 at 11:33 am and stated “when [Resident 4] gets into aggravated mood, we always have to use two people [to provide care] for safety. [S/he] yells but can also swing.” The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 06/10/26 at 3:50 pm. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

Based on observation, interview and record review, it was determined the facility failed to determine, document and communicate to staff what action or intervention was needed for a resident following a change of condition with weekly progress noted until the condition resolved, for 2 of 4 sampled residents (#s 1 and 5) with documented changes of condition related to wounds. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2024 with diagnoses including adult failure to thrive and aortic valve stenosis. The resident was receiving hospice services. The resident's service plan dated 03/11/26, incident report/investigation, progress notes and temporary service plans dated 03/08/26 to 06/08/26 were reviewed, observations were made, and interviews with staff and the resident were conducted. The following was identified: Resident 1 experienced multiple short-term changes related to skin conditions that lacked documentation of what action or intervention was needed, and weekly documentation on the progress of each wound until resolution: * 03/31/26 - Wound to right buttock and redness to upper inner thighs; * 05/05/26 – “New sores to coccyx;” * 05/09/26 – Skin tear to coccyx; and * 05/26/26 – Bruising to right lower leg. During an interview on 06/09/26 at 09:55 am, Staff 1 (ED) acknowledged the lack of monitoring progress for the changes of condition and reported that the nurse was responsible for weekly skin monitoring and determining actions or interventions as needed. Observation of the skin conditions completed on 6/09/26 at 10:15 am with Staff 4 (Regional RN) revealed the redness to upper inner thighs was resolved, the bruising to the left lower leg remained discolored, and all other wounds were not resolved. The need to ensure short-term changes of condition had monitoring of progress noted at least weekly, and actions or interventions that were determined were documented and communicated to staff, was discussed with Staff 1, Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) at approximately 2:00 pm on 05/10/26. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 04/2026 with diagnoses including diabetes and deep post-operative wound infection. The resident's service plan dated 04/16/26, progress notes and temporary service plans dated 04/18/26 to 06/08/26 were reviewed, observations were made, and interviews with staff were conducted. The following was identified: The following short-term changes of condition related to wounds identified in the progress notes lacked weekly documentation on the progress of each wound until resolution: * 04/18/26 – Right ankle shearing to skin; * 04/18/26 – Surgical wound bottom right foot; and * 04/18/26 – Pressure ulcer right heel. During an interview on 06/09/26 at 09:55 am, Staff 1 (ED) acknowledged the lack of documented monitoring of progress for changes of condition through resolution and reported the nurse was responsible for weekly skin monitoring and determining actions or interventions as needed. The need to ensure all changes of condition were monitored, with progress noted at least weekly to resolution was discussed with Staff 1 and Staff 2 (Regional Director of Operations), and Staff 3 (Chief Operating Officer) on 06/10/26 at approximately 2:00 pm. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

Based on observation, interview and record review, it was determined the facility failed to ensure a facility nurse, physical therapist or occupational therapist conducted a thorough assessment of a supportive device with restraining qualities, instructed direct care staff on the correct use and precautions related to the use of the device and documented the use of the device in the resident service plan, for 3 of 3 sampled residents (#s 2, 3 and 5) who used a supportive device with restraining qualities. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2025 with diagnoses of chronic kidney disease and an unspecified fracture of the upper end right humerus. On 06/08/26 at 12:15 pm, bilateral half-length side rails were observed on the resident’s hospital bed. The resident stated they did not restrict his/her movement while in bed and s/he used the rails to assist with transfers in/out of bed. The current service plan, dated 02/01/26, indicated the resident used bed rails for assistance in and out of bed and the device required an assessment by an RN, PT or OT. The assessment of the device that was provided by the facility was dated 06/08/26. In an interview on 06/10/26 at approximately 1:00 pm, Staff 4 (Regional RN) stated the facility had not conducted an assessment of the device prior to 06/08/26 and she wasn’t aware of when the resident received the device. In an interview on 06/09/26, Staff 19 (CG) stated she had not received any instruction on the correct use and precautions related to the use of devices with restraining qualities. The need to ensure a facility nurse, physical therapist or occupational therapist conducted a thorough assessment of a supportive device with restraining qualities and documented the use of the device in the resident service plan was reviewed with Staff 1 (ED), Staff 2 and Staff 3 (Chief Operating Officer) on 06/10/26 at 4:20 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2025 with diagnoses including Parkinson’s disease and stage 5 kidney failure. The resident was receiving dialysis. On 06/09/26 at 1:35 pm, the resident was observed to utilize a bed cane device on one side of his/her bed. The device was stationary and did not raise or lower. It was positioned near the head of the bed, and the resident stated it did not interfere with his/her ability to exit the bed. The resident stated s/he used the device to steady him/herself during transfers. The resident also stated s/he had used the device since moving to the facility. The current service plan, dated 04/12/26, indicated the resident did not use a bed rail or any other device. However, “1/2 rail cane for mobility” was hand-written on the service plan that was provided to the surveyor on 06/09/26. The updated information regarding the device use was not dated. The assessment of the device that was provided by the facility to the surveyor was dated 06/08/26. In an interview on 06/10/26 at 9:45 am, Staff 2 (Regional Director of Operations) confirmed the facility had not conducted an assessment of the device until 06/08/26. The need to ensure a facility nurse, physical therapist or occupational therapist conducted a thorough assessment of a supportive device with restraining qualities and documented the use of the device in the resident service plan was reviewed with Staff 1 (ED), Staff 2 and Staff 3 (Chief Operating Officer) on 06/10/26 at 3:30 pm. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 04/2026 with diagnoses including diabetic foot infection. The resident recently had surgery on his/her feet. On 06/09/26 at 10:40 am, the resident was observed to utilize a bed cane device on both sides of his/her bed. The devices were stationary and did not raise or lower. They were positioned near the head of the bed and the resident stated they did not interfere with his/her ability to exit the bed. The resident stated s/he used the devices to hold onto when staff assisted him/her with transfers. The use of the devices was included in the resident’s initial service plan, dated 04/16/26. The assessment of the device that was provided by the facility to the surveyor was dated 06/08/26. In an interview on 06/10/26 at 9:45 am, Staff 2 (Regional Director of Operations) confirmed the facility had not conducted an assessment of the device until 06/08/26. The need to ensure a facility nurse, physical therapist or occupational therapist conducted a thorough assessment of a supportive device with restraining qualities was reviewed with Staff 1 (ED), Staff 2 and Staff 3 (Chief Operating Officer) on 06/10/26 at 3:30 pm. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

Based on interview and record review, it was determined the facility failed to complete, update and review the acuity based staffing tool (ABST) evaluation for each resident before a resident moved in and no less than quarterly and corresponding with residents’ service plan updates for 2 of 5 sampled residents (#s 4 and 5) and used the results of the ABST to develop and update the facility’s staffing plan. Findings include, but are not limited to: ABST data was captured on 06/08/26 at 9:30 am just shortly after beginning the survey. 1a. On 06/10/26 at 3:30 pm, Staff 1 (ED) confirmed Resident 5 moved into the facility on 04/28/26. The resident’s ABST evaluation was not created until 05/02/26. b. Resident 4’s most recent service plan was dated 03/23/26. The resident’s ABST evaluation was last reviewed on 12/27/25. 2. The ABST indicated the facility needed the following number of direct care staff to meet the scheduled and unscheduled needs of all the residents in the facility: * Day shift: 4.87 direct care staff; * Swing shift: 4.35 direct care staff; and * Night shift: 1.53 direct care staff. The posted staffing plan, dated 04/18/26, indicated the facility staffed as follows: * Day shift: 4 direct care staff; * Swing shift: 4 direct care staff; and * Night shift: 2 direct care staff. The facility staffing plan did not meet the staffing requirements indicated by the ABST. The need to ensure the ABST was maintained as required and used to develop and update the facility’s posted staffing plan, was reviewed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 06/10/26 at 2:45 pm. They acknowledged the ABST evaluations had not been created or reviewed as required and the staffing plan did not meet the ABST results.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

Based on interview and record review, it was determined the facility failed to conduct and document fire drills according to the Oregon Fire Code (OFC) with all required elements. Findings include, but are not limited to: On 06/10/26, fire drill records from 01/2026 through 06/2026 were reviewed, and the following was identified: a. The facility did not conduct unannounced fire drills at different times of the day, evening and night shifts. b. The facility did not consistently document the following: * Escape route used; * Evacuation time-period needed; and * Problems encountered and comments relating to residents who resisted or failed to participate in the drills. In an interview on 06/10/26 at 9:32 am, Staff 1 (ED) acknowledged the facility had not performed fire drills on night shift and had not consistently documented the time-period needed for evacuation or escape route used. c. Staff 1 reported the facility had not practiced the evacuation of bedbound residents during its fire drills. Therefore, there was no evidence the facility could meet the evacuation standards for the building. The need to ensure the facility conducted and documented fire drills according to the Oregon Fire Code (OFC) with all required elements was reviewed with Staff 7 (Maintenance) and Staff 8 (Maintenance) on 06/10/26 at 11:10 am, and Staff 1 and Staff 2 (Regional Director of Operations) on 06/10/26 at 4:20 pm. They acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and at least annually thereafter. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (ED) on 06/10/26 at 9:50 am. There was no documented evidence that residents were provided fire and life safety training within 24 hours of admission and re-instructed at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire. In an interview on 06/08/26 at 12:15 pm, Resident 2 stated s/he had not been provided with fire and life safety training since moving into the facility in 09/2025. The need to provide fire and life safety instruction to residents within 24 hours of admission and re-instructed at least annually was discussed with Staff 1, Staff 2 (Regional Director of Operations) and Staff 3 (Chief Operating Officer) on 06/10/26 at 4:20 pm. 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.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and free from unpleasant odors. Findings include, but are not limited to: Observations of the facility between 06/08/26 and 06/10/26 revealed the following: * Odor of urine throughout room 236; and * Odor of urine was apparent throughout the hallway on the second floor near rooms 224, 231, and 235. The area in need of cleaning was shown to and discussed with Staff 2 (Regional Operations Officer) and Staff 3 (Chief Operating Officer) on 06/10/26 at 5:24 pm. They acknowledged the findings.

OAR 411-054-0300 (5) Resident Units (5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: The facility was toured on 06/08/26 at 12:42 pm. Common area windows on the second and third floors opened vertically, and windowsill heights were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls. The lack of a mechanism to prevent accidental falls was discussed with Staff 1 (ED) and Staff 3 (Maintenance) on 06/09/26 at 10:27 am, and Staff 1, Staff 2 (Regional Operations Officer) and Staff 3 (Chief Operating Officer) on 06/10/26 at 3:50 pm. They acknowledged the findings.

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted.

Based on observation and interview, it was determined the facility failed to post the LGBTQIA2S+ Rights and Protections in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to: Refer to C 152.

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

Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen was completed 06/09/26, from 10:15 am through 1:45 pm, and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter was visible on or underneath the following: * Floors under equipment/counters in beverage service area; * Interior of beverage cooler in service area; * Drip tray of soda machine; * Interior of ice machine; * Floors under/near ice machine; * Flooring and walls under and around dish machine area; * Clean side of dish washing area; * Kitchen drains; * Floors under steam table; * Ceiling above steam table; * Ceiling and vent above clean section of dish pit; * Metal pole extending from service line to ceiling; * Interior of microwave; * Handheld mixer base; * Industrial mixer; * Flooring under and in between large equipment and behind oven/range/grill; * Handle of steamer; * Range top; * Interior of convection oven; *Interiors of conventional ovens; * Walk-in freezer floor; * Can rack in dry storage; * Movable metal speed rack outside walk-in cooler; * Metal racks in walk-in cooler; * Fan blades and cages in walk-in cooler; * Interior of plate warmer bases; * Cord for plate warmer; * Removable hood vents; * Stainless steel shelving above baking area; and * Floor grout lines in multiple heavy use areas. b. The following areas were in need of repair: * Seal for beverage cooler in service area torn/damaged; * Small gap in ceiling by sprinkler as you exited the door to independent dining room; * Larger gap around electrical conduit near the ceiling in the back prep area; * Multiple areas in the floor with grout missing or worn, collecting excess food debris; and * Multiple downspout drains reaching inside floor drains, not creating adequate air gaps during a backup/drain clogged event. c. Multiple food items found in reach-in cooler without proper labels and/or prepared/opened or use-by dates as required. Multiple food packages found open in walk-in freezer, exposing food products to potential contamination. Multiple items found open/uncovered and without proper labels/dates in deli cooler. d. A large bulk container of powdered sugar was observed with a scoop stored inside the product, with the handle touching the food product. e. Multiple kitchen staff observed making/serving/handling food or clean dishes/equipment without effective hair or beard/facial hair restraints. f. Multiple staff members were observed not to change gloves when potentially contaminated as required. One staff was observed to potentially contaminate his gloves when he left the service line, took dirty dishes to the dish area, handled the sprayer and dirty side of dish machine handle, then returned to serving food on the service line without changing his gloves. The staff then touched ready-to-eat food with the contaminated gloves. Surveyor intervened and had the facility discard the contaminated food. g. Multiple staff were observed not performing hand washing prior to donning gloves or when changing gloves, as required. One staff member was observed handling dirty dishes then starting to put away clean dishes without a hand hygiene step. h. A large quantity of dirty dishes was stacked/piled up directly next to the “clean” side of the dish machine area. Multiple racks of “clean” dishes were sitting on an area with visible food debris from the dirty side of the stacked dishes. There was no clear separation between clean and sanitized dishes and dirty dishes, causing cross contamination potential. i. Multiple dish washing racks were observed stored on the floor. j. The white service board on the deli cooler was observed heavily scored and stained. Multiple portable cutting boards were also found stained and/or heavily scored with deep grooves/pits and in need of repair or replacement. Sauté and saucepans were also observed damaged and/or protective coating worn or scraped off. k. A large quantity of delivered food was observed stored on the floor in the walk-in cooler, walk-in freezer, and dry storage area. The food was delivered the day before. Staff 2 (Executive Chef) was interviewed at approximately 12:45 pm, and acknowledged the items should have been put away the day of delivery. l. A box of fresh bell peppers was observed placed directly next to a large rack used for defrosting raw meats. There was a bag of raw chicken defrosting inches away from the fresh produce, with visible blood/juices dripping from the bag on to the pan nearly touching the box of produce. At 1:30 pm, identified areas were reviewed with Staff 1 (Executive Director) and Staff 2, who acknowledged the areas of concern.

1. All accumulation of food, spills, splatters, loose food and trash debris, dirt, dust, greast, and/or black matter has all been thoroughly cleaned, scrubbed, washed, and sanitized on and around every floor surface, countertops, dish washing station, walls, drains, steam tables, prep areas, ceilings, piles, mixers and all other equipment, range top, interior of ovens, walk-in freezer, walk-in cooler, dry storage, vents, hoods, shelves, racks, salad bar, soup bar, ice machine, and both beverage stations. Repairs have been completed for the following: seal for beverage cooler, both gaps in ceiling, downspout inside floor drain replaced, and grout on kitchen floor is being scheduled for repair/replacement as soon as possible. Food items have been covered and dated, and in-service conducted with all staff. Utensil removed from container and in-service conducted. Kitchen staff have hair restrained and in-service conducted. Staff in-serviced about contamination and importance of hand hygeine and changing out gloves. Aprons have been ordered as well. In-service for staff about keeping clean and dirty dishes separated to avoid cross-contamination. All cutting boards and the white service board have been replaced, all deliveries have been put away and staff in-serviced on the standard of putting items away immediately upon delivery. Staff in-serviced about the importance of keeping raw meat and other foods separate to avoid any cross-contamination. 2. All areas from ceiling to the floor, walls, floors, drains, vents, hoods, appliances, dish area, steam tables, dry storage, and walk-in freezer/cooler have been added to a daily and/or weekly cleaning schedule. Tasks are to be marked off upon completion and audited by Executive Chef. Task list will be adjusted accordingly if certain areas require more or less attention. Multiple in-services will be conducted with staff to go over cleaning expectations and task list, cross-contamination of raw food, proper food labeling and storage, and hand hygiene and clean gloves and aprons, 3. Surface cleaning, floors, walls, drains, dish area, range top, dry storage, salad bar, soup well, both beverage stations, and prep areas will be cleaned daily. Walk-in cooler/freezer, vents, hoods, shelves, racks, dry storage, and equipment will be cleaned weekly. However, all surfaces of kitchen will be monitored for cleanliness daily. 4. The Executive Chef and lead cook will be responsible for ensuring the kitchen maintains cleanliness and all repairs are done in a timely manner to stay in compliance.

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

Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen was completed 07/14/25 from 10:20 am through 11:45 am and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease and/or black matter was visible on or underneath the following: * Juice machine * Hand washing sink edges/corners * Floors under equipment/counters in beverage service area * Interior of ice machine * Edges of flooring in dry storage * Flooring and walls under and around dish machine area * Kitchen drains * Floors under steam table * Flooring under and in between large equipment and behind oven/range/grill * Stainless steel shelving holding clean dishes by service line * Knobs of ranges/ovens/grill and steam table * Flooring in under and around dishwashing area * Walk in freezer floor * Can rack in dry storage * Metal racks storing clean dishes * Stainless steal service area on tray line b. The following areas were in need of repair: * Small gap in ceiling by sprinkler c. Multiple food items found in walk in cooler without proper labels and/or prepared/opened or use by dates as required. Multiple food packages found open in walk in exposing food products to potential contamination. Multiple items found open/uncovered and without proper labels/dates in deli cooler. Multiple items found in walk in cooler that were past 7 days from prepared date and should have been discarded. d. Facility did not have test strips to verify/validate surface sanitizing chemicals were at appropriate levels for sanitizing as required. Staff 2 (Dining Services Manger) was not aware of the type of chemical dispensing from the wall for 3 compartment sink and surface sanitizer buckets needed different test strips. The chemical contained lactic acid and the facility had quaternary ammonia strips. The facility did not have a system to regularly test the concentration of that solution to ensure at appropriate sanitizing levels. e. Multiple kitchen staff observed without hair or beard/facial hair restraints. f. Reach in cooler for beverages including items that were potentially hazardous/protein rich did not have a thermometer to ensure items were stored at appropriate temperatures for cold holding. Staff 2 verified they could not locate a thermometer. At 11:30 am the above items were reviewed with Staff 2 who acknowledged areas needing correction. On 07/15/25 at 2:00 pm, identified areas were reviewed with Staff 1 (Executive Director) and Staff 2 who acknowledged the areas of concern.

1. a. accumulation of all food splatter, dirt, and grease has been thoroughly cleaned from literally every surface in the kitchen, drink stations, floors, walls, dish machine, ice machine, ranges, ovens, and steam table. b. repairs for the small gap in the ceiling sprinkler has been repaired on 7/24. c. ALL food items have been properly covered and dated. All staff have been re-educated about proper food handling/storage. Dietary Manager following up and managing staff to ensure consistency. d. all the correct test strips have been purchased and all staff have been trained on how to utilize test strips, when to change out the sanitation bucket, and which strips are used for what purpose. e. all staff have been reminded about hair restraints and instructed that if they show up for their shift without their hair properly restrained, they'll be sent home. f. there is now a working thermometer in the reach-in cooler, and all staff are aware of where it is and what the purpose is for. There is also a checklist to document temps. 2. a. daily cleaning task list will be completed, signed and turned in to the Dietary Manager who will audit for cleanliness and efficiency. b. maintenance have on their schedule to inspect and clean sprinkler heads and vents once a month, unless there is a need before. c. Dietary Manager will audit food inventory throughout the day to ensure all food items and beverages are properly covered and dated. Staff will be closely managed to ensure they are remembering to properly dated and covered. If staff continue to go against policy, they will receive a written warning and be required to retake the Food Handler's course. d. Dietary Manager will do daily audits of all sanitizing buckets throughout the day to ensure proper use and testing system is in place, in addition to staff documenting each time they do testing and changing out bucket. e. all staff have signed hair restraint policy and will be held accountable if they do not comply. f. confirming presence and accuracy of thermometer will be added to daily checklist. 3. a. a detailed daily cleaning task list, weekly deep cleaning task list, monthly "cleaning party" to be scheduled, managed, and documented. Dietary Manager will follow up to ensure quality and effiency. b. monthly maintenance checklist for cleanliness and/or repair of sprinkler heads and vents. Dietary Manager will alert maintenance if it needs attention sooner. c. daily audit to ensure all food items are always covered and dated. d. daily audit of sanitation testing checklist to ensure it is being completed according to schedule. e. daily observation of staff to ensure hair is restrained. f. daily audit to ensure thermometer has been checked off and signed that it is present and accurate. 4. a. Dietary Manager and Executive Director b. Dietary Manager, Executive Director and Maintenance c. Dietary Manager and Executive Director d. Dietary Manager e. Dietary Manager and Executive Director f. Dietary Manager

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

Based on observation and interview, it was determined the facility failed to maintain the kitchen in 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 facility main kitchen was completed on 09/24/25. The following was identified: An accumulation of food spills, splatters, loose food debris, dirt, dust, grease, and/or black residue was observed on and/or underneath the following: * Hand washing sink edges/corners; * Floors under equipment/counters in beverage service areas; * Edges of flooring in dry storage; * Flooring and walls under and around dish machine area; * Floor drains; * Floors under steam table; * Flooring under and in between large equipment and behind oven/range/grill; * Stainless steel shelving holding clean dishes by service line; * Knobs of ranges/ovens/grill and steam table; * Flooring in, under, and around dishwashing area; * Metal racks storing clean dishes; * Stainless steel service area on tray line; * Interior of drawers; and * Wall behind trash can. The need to ensure the kitchen was kept clean was discussed with Staff 1 (Executive Director) and Staff 2 (Dining Services Manager) on 09/24/25. They acknowledged the findings.

1. accumulation of all food splatter, dirt, and grease has been thoroughly cleaned from literally every surface in the kitchen, including but not limited to floors, walls, ranges, ovens, steam table, surface areas, racks, walk-in cooler and freezer, dry storage, drink stations, ice machine, and dishwashing station. 2. detailed cleaning task list will be completed, signed, and turned in to Dietary Manager on a consistent basis. Dietary Manager will audit for cleanliness and efficiency. Task lists will be divided and assigned to staff #1, 2, 3 to prevent any confusion on who is responsible for what tasks. This will also assist management in holding staff accountable and/or provide further training opportunities. 3. daily, weekly, monthly. 4. Dietary Manager, Assistant Executive Director, Executive Director.

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

Based on observation and interview, it was determined the facility failed to maintain the kitchen in 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 facility main kitchen was completed on 12/31/25 from 10:00 am through 11:15 am. The following was identified: An accumulation of food spills, splatters, loose food debris, dirt, dust, grease, and/or black residue was observed on and/or underneath the following: * Hand washing sink edges/corners in beverage area; * Floors under equipment/counters in beverage service areas; * Flooring and walls under and around dish machine area; * Floor drains in beverage area, under steam table, under dish machine and under back prep sink; * Interior of bottom cabinet under steam table; * Floors under steam table; * Stainless steel shelving holding clean dishes by service line; * Stainless steel shelving above baking prep area; * Knobs hand handles of ranges/ovens/grill and steam table; * Range top spiders and area under; * Removable drip pan under stove top; * Interior and exterior of convection oven; * Flooring in, under, and around dishwashing area; * Metal racks storing clean dishes; * Interior of drawers holding clean utensils; and At 11:00 am, the need to ensure the kitchen was kept clean was discussed with Staff 1 (Executive Director) and Staff 2 (Executive Chef) on 12/31/25. They acknowledged the findings.

1. ALL areas of kitchen, beverage service areas and dishwashing area have been thoroughly deep cleaned of all food splatters, loose food debris, dirt, dust, grease, and/or black residue including but not limited to: hand washing sinks, floors under equipment and counters, all beverage service areas, all drains, floors, walls, steam tables, cabinets, shelving, knobs and handles of range/oven, drip pan, and all metal racks. 2. A detailed cleaning check list has been updated which includes daily, weekly, and monthly duties to ensure cleanliness is being maintained on a consistent basis. ALL kitchen staff have been in-serviced about cleaning expectations and accountibility if not completed. Executive Chef will audit kitchen and cleaning lists daily to ensure compliance is up to par and maintainted. Executive Director and Executive Chef will meet weekly to review task lists, audits, and discuss any changes/modifications needed. 3. Cleaning will be done and audited on a daily basis. 4. Executive Director and Executive Chef will be responsible to see that corrections are being implemented and monitored.

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

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

Based on observation and interview, 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 C240.

1. PLEASE REFER TO C240 2. PLEASE REFER TO C240 3. PLEASE REFER TO C240 4. PLEASE REFER TO C240

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

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

1. PLEASE REFER TO C240 2. PLEASE REFER TO C240 3. PLEASE REFER TO C240 4. PLEASE REFER TO C240

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

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair, in a sanitary manner or have a qualified person in charge in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:   Observation of the facility ALF kitchen was completed 05/08/24 from 9:45 am through 2:30 pm and again on 05/09/24 from 9:45 am thru 11:00 am and the following was identified:     a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease and/or black matter was visible on or underneath the following:   * Dining room floors near tables, table bases; * Ceiling vents above beverage service area; * Ceiling vents above prep and service areas; * Juice machine; * Outlets and light switches; * Floors throughout kitchen and beverage service area; * Interior of ice machine; * Walls throughout kitchen; * Multiple utility carts; * Exterior of robot coupe; * Fans and metal cages of fan by serving area; * Open shelving throughout kitchen and beverage service area; * Large metal pan holding bag of onions; * Interior and exterior of microwave; * Exterior of bulk food bins; * Cover for baking (Go) racks; * Baking (Go) racks; * Interior and exterior of convection ovens; * Exterior and interior of steamer; * Range top, grill top; * Knobs of ranges/ovens/grill and steam table; * Metal shelves storing pots/pans/dishes; * Steam table wells; * Industrial can opener and housing; * Steamer interior and exterior; * Industrial mixer; * Interior and exterior of reach in deli cooler; * Door thresholds with food debris/splatter; * Plate warmer; * Interiors and exteriors of stainless steal drawers; * Flooring in under and around dishwashing area; * Walk in cooler fans and cages; * Walk in cooler ceiling; * Metal racks in walk in cooler; * Kitchen and beverage area drains. * Three compartment sink area; * Can rack in dry storage; * Metal racks storing clean dishes; and * Stainless steal service area on tray line. b. The following areas were in need of repair:   * Corners of walls with chips, nicks and gouges; * Multiple tile pieces upon entry to kitchen with cracks with visible debris build up; * Caulking behind three compartment sink with black debris build up; and * Approximate one inch gap observed by ceiling vent by prep area. c. Staff 2 was observed to prepare hamburger and sandwich with lettuce that was not washed. Staff was observed to leave the line, walk into walk in cooler, and remove green leaf lettuce from box, exit walk in and put directly on to hamburger that was served to resident. Lettuce was then put in deli fridge. Surveyor returned to walk in and reviewed box lettuce which indicated the product needed to be washed and trimmed before service/use. Surveyor immediately informed Staff 2 that lettuce was to be washed prior to service per the box instructions. Staff 2 stated that they usually did not wash that product as it "looks very clean and looked prewashed." Surveyor reiterated that the box indicated it needed to be washed and trimmed. Staff 2 verbalized understanding but did not remove lettuce and wash or trim as directed and was observed placing it on a deli sandwich and served to residents. d. Staff 2 was observed during tray line to leave line several times and touch door handles, and other items including a rag with sanitizer solution with gloved hands. Staff 2 did not change gloves or wash hands, when switching tasks or potentially contaminating gloves and preceded to handle ready to eat foods such as garlic bread, hamburger buns, and make deli sandwiches. e. Staff 2 was observed to wipe several plates with a rag stored on the tray line counter. Staff wiped the counter with this rag as well as other plates. The rag was then placed in sanitizer bucket and taken back out to be used to wipe plates and surfaces during tray line. f. Multiple food items were found in walk in cooler without proper labels and/or prepared/opened or use by dates as required. Multiple food packages were found opened in walk in, exposing food products to potential contamination. Multiple items found open/uncovered and without proper labels/dates in deli cooler. g. Multiple food packages were found opened in dry storage without open dates. Multiple food items found not securely closed and/or open to potential contamination in dry storage. h. Staff 2 was observed to not check temperature of service line products including scrambled eggs. Surveyor intervened before delivery and asked staff to check the temperature which was found to be at required levels. i. Multiple kitchen staff were observed without hair or beard/facial hair restraints. Staff 2 was alerted of the need however staff continued to not restrain hair while working with food and clean equipment per rule. j. Dining room was observed with preset tableware that was not covered or inverted and exposed to potential contamination.   k. Staff 2 was not able to demonstrate adequate person in charge knowledge for prevention of cross contamination, kitchen employee hygienic practices, proper temping of food items, handling of potential hazardous food items, and proper cleaning methods/procedures. On 05/08/24 at approximately 12:30 pm, surveyors reviewed above areas with Staff 1 (Executive Director) and Staff 5 (Memory Care Administrator), who acknowledged the findings. On 05/09/24 from 9:45 am to 10:45 am,  the surveyors observed that significant cleaning had occurred with also noted improvements in other identified areas from previous days observations. Staff 4 was interviewed and was able to verbally demonstrate adequate knowledge in most areas with the exception of employee illnesses for exclusion and reporting. Staff 3 (Dining Service Manager) was interviewed on 05/09/24 at 10:00 am. S/he said areas identified in kitchen review were not at their standards of what they would expect the designated Person In Charge to maintain. Staff 3 stated s/he had not at been at facility consistently in PIC role since November 2023. On 05/09/24 at approximately 10:45 am, completed survey findings were reviewed with Staff 1 and Staff 5. They acknowledged the areas in need of correction.

1. Dining manager and team will be completing the following: a.  thorough cleaning of kitchen, which will include floors, vents, ceilings, appliances, walls, utility carts, shelves, bins, countertops, coolers, freezer, sinks, steam tables, juice machines, drink station, and any other area not mentioned. b.  repairs of chipped corners, cracked tile on floor, caulking behind sinks, and any other area not mentioned. c.  Inservice for all dietary staff reviewing infection control, cross contamination, proper glove use, proper hand washing, proper washing of produce, proper labeling of food items, proper temperature checks, and proper hair restraints. d.  All kitchen staff are to re-do and complete food handler's card. e.  Designated kitchen manager while Dietary Services Manager is away. f.   Cleaning party done weekly (Thursdays) for the next 30 days and then done once monthly. g.  Management present during each meal service for the next 30 days to ensure compliance and good practice. 2. Management present during all meals to ensure compliance and good practice. b. Retraining for staff/inservice regarding infection prevention, hand washing, food handler 3. Evaluation of kitchen will be done daily 4. Dietary Service Manager, Executive Director, and Person in Charge will oversee compliance and good practice.

The findings of the kitchen inspection, conducted 05/08/24 through 05/09/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 05/08/24, conducted on 07/18/24, are documented in this report. The facility was determined to be in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents for 2 of 2 sampled residents (#s 1 and 4) who used call pendants. Findings include, but are not limited to: During the survey process, 12/12/23 through 12/14/23, the following was identified: a. Resident 4 was admitted to the facility in 09/2021 with diagnoses including high blood pressure. Record review and interviews revealed the following: Resident 4 experienced a fall on 11/18/2023 at 3:45 am. In an interview on 12/13/23, Witness 2 (Family member) reported Resident 4 had pressed his/her call pendent for assistance after a fall and had waited approximately 30 minutes for assistance. When staff did not come, Resident 4 called a family member for assistance. The family member called the facility's front desk who had caregiving staff respond and assist Resident 4 off the floor. The resident's fall on 11/18/23 was discussed with Staff 5 (Health and Wellness Director) on 12/14/23. He explained the reason why staff did not come sooner to assist the resident when s/he used the call pendant was that either Resident 4 did not push it hard enough or the pendant's battery was not functional. Staff 5 was not able to provide evidence the call pendant was checked by staff to indicate if the pendant was in working order following the fall. He was unable to report how often call light pendants and batteries were checked and tested for functionality, but stated it was a maintenance task. There was no documented evidence Resident 4's call pendent was tested to determine functionality after experiencing a fall and pressing his/her call pendant. b. Resident 1 was admitted to the facility in 09/2023 with diagnoses including history of subdural hematoma and high blood pressure. The resident's move-in evaluation, dated 09/22/23, stated the resident would "utilize a pendant for safety" and identified three times that the resident had previously fallen. The resident experienced an unwitnessed fall in his/her room at 5:10 pm on 10/29/23. The occurrence report stated the resident "had to scoot to the wall to call us since [his/her] wrist button wasn't working." In an interview on 12/14/23, Staff 3 (Assisted Living Director) reported that after the fall, she replaced the battery on Resident 1's wrist pendant. She stated she was not aware of a current process for monitoring or checking call pendant batteries, though she believed this was performed by the maintenance team. During an interview on 12/14/23, Staff 7 (Maintenance) stated he was not aware of a current system or process in place to check call light pendants and batteries. He stated that at this time, he only replaces single batteries or pendants as needed when a caregiver notifies him that one has not worked when a resident called for help. The facility lacked documented evidence that there was a system in place for monitoring the effectiveness of residents' call pendants. On 12/14/23, the need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 3 and Staff 5. They acknowledged the findings.

1. All residents with call pendants will have them monitored monthly for operational status. This will include testing for funtional ability and replacement of batteries. This will be completed by the maintenance director. 2. Resident ability to activate call pendants will be assessed quarterly at service plan update meeting to ensure that resident is still able to activate call pendant appropriately. 3. Resident preference will be assessed quarterly at service plan update meeting to determine how resident would prefer to wear call pendant, either as a necklace style pendant or as a wrist watch style call pendant. 4. All residents issued a new pendant, either being a new move in to the community or an existing resident choosing to utilize a pendant will be instructed on how to properly activate their pendant and when to notify the community if it does not appear to be functioning correctly. This will be documented in the resident chart. 5. Items mentioned in steps 2-5 will be completed by the Assisted Living Director. 6. The Executive Director will review these items weekly for completion.

3. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia. Resident 5's Charting Notes from 09/18/23 through 12/04/23, service plans, Temporary Care Plans (TCP), and Alert Charting records were reviewed during the survey. Interviews were conducted with caregiving staff and the resident. The current service plan, dated 12/07/23, lacked information regarding Resident 5's private caregiver including: * Name and contact information for the home health agency providing the service; * The name of the private caregiver; * The private caregiver's schedule; and * Instructions for providing additional care, if necessary, at times when the private caregiver was not on-site. The lack of information about the private caregiver and instructions for facility caregivers for ensuring care was provided when the private caregiver was not on-site was reviewed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the information lacking from the service plan.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services for 3 of 5 sampled residents (#s 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2022 with diagnoses including artherosclerotic heart disease, hypertension, and shortness of breath. The resident's 09/27/23 service plan, 09/29/23 through 12/04/23 Charting Notes, and Resident Temporary Care Plans were reviewed. Staff were interviewed and observations were made of the resident. The following areas of the service plan were not reflective of the resident's current care needs and did not provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided: * Continuous positive airway pressure (CPAP) use including assistance needed with the mask and water, and what to do if staff noticed it was in disrepair; * Pacemaker placement; * Outpatient PT services; * Short-term memory loss; * Interventions relating to cognition deficits; * Personalized interventions for behaviors; * What triggered the resident's behaviors; * Environmental factors that impact the resident's behavior; * Activities of interest both in the facility and independently; * Assistance needed for dressing; * Cueing needed for personal hygiene tasks; * Toileting assistance and brief use; and * Staff to monitor for bruising relating to a blood thinning medication. The need for service plans to accurately reflect residents' current needs and provide clear instructions to staff was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 07/2023 with diagnoses including Parkinson's disease and spinal stenosis. The resident's current service plan, dated 09/09/23, was reviewed, observations were made, and interviews with staff were conducted. Resident 3's service plan was not reflective of the resident's status in the following areas: * Modified diet texture; and * Home Health therapies. In addition, Resident 3's service plan did not provide instructions to caregivers on the correct use of side rails and precautions related to their use. The need to ensure service plans reflected the residents' needs and provided clear direction to staff was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

1. Service plans for residents 2, 3, & 5 have been updated. 2. Resident service plans will include detailed information on outside providers being utilized by residents such at PT/OT, home health, private caregivers, medical supply services, who to contact for repairs to resident equipment, etc. 3. Pre-move in evaluation tool will be updated to reflect resident use of devices and services not clearly defined in current tool. 4. Resident service plans will clearly outline a detailed description of what service is to be provided, by whom, when, how and frequency with which the service will be provided. 5. Resident service plans will be reflective of resident preferences, resident specific plans to address needs. 6. All service plans will be completed by the Assisted Living Director. 7. Staff will be inserviced weekly to ensure they understand the need to provide services to residents in  a manner than respects and upholds their independence and dignity. This training will be conducted by the Health & Wellness Director. 8.  The Executive Director will review these items weekly for completion.

Based on interview and record review, it was determined the facility failed to determine, document, and communicate to staff what action or intervention was needed for a resident in response to a short-term change of condition, and failed to document weekly progress until the condition resolved, for 2 of 5 sampled residents (#s 1 and 5) who experienced changes of condition requiring monitoring. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia. Resident 5's Charting Notes from 09/18/23 through 12/04/23, service plans, Temporary Care Plans (TCPs), and Alert Charting records were reviewed during the survey. The resident experienced the following changes of condition: * 09/18/23, 10/11/23, and 11/15/23: Significant weight gains; and * 11/27/23: Change in behavior including increased confusion, fearful, wanting to leave building, and grasping his/her cat unsafely. The following deficiencies were identified: a. The facility wrote a TCP in response to each weight increase. Each TCP included the following interventions: * Offer or encourage healthier choices at meals; and * Encourage more physical activity such as walking around the facility. The facility failed to include instructions for staff as to what to monitor and document. There was no documented evidence the facility monitored whether the interventions were attempted by caregivers, whether the resident was agreeable to trying the interventions, or whether the interventions were effective in meeting the treatment goal. b. The facility instituted its alert charting process in response to the change in behavior on 11/27/23 by creating an Alert Charting entry electronically. Review of the Alert Charting entry with Staff 5 (Health and Wellness Director) on 12/14/23 indicated the entry lacked resident-specific instructions for staff as to what behaviors staff should monitor and report or document on. The need to ensure the facility provided resident-specific instructions for what exactly to monitor and document following a resident's change of condition was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 on 12/14/23. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including history of subdural hematoma and osteopenia. Observations of the resident, interviews with staff, and review of the resident's most recent service plan, dated 11/08/23, Shift-to-Shift Communication Logs, Temporary Care Plans, Occurrence Reports, physician communications, and Charting Notes from 09/12/23 through 12/11/23 were completed. The facility record lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution for the following short-term changes of condition: * 10/04/23: New medication: Coumadin (blood thinner); * 10/22/23: Missed medication: metoprolol (for high blood pressure); and * 10/29/23: Unwitnessed fall with injury. The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and changes of condition were monitored through resolution, was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

1. Staff will be inserviced weekly on the proper use of temporary service plans (TSP's). This training will be conducted by the Health & Wellness Director. 2. TSP's will include clear directions to staff on what happened to said resident, interventions to reduce the risk of harm to the resident in the immediate moment as well as interventions to prevent future reoccurrences from happening. 3. TSP's will include specific information for staff to identify what to observe and report on pertaining to the specific event. 4. Staff will be inserviced  weekly on the alert charting process to include making proper opening and closing alert charting notes. This training will be conducted by the Health & Wellness Director. 5. Alert charting will contain more resident specific directions for staff to identify what to report and document on when being placed on alert charting. This will be completed by the medication aids when placing a resident on alert charting. 6. The Executive Director will review these items weekly for completion.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols during meal service. Findings include, but are not limited to: During lunch service on 12/12/23 and 12/13/23 multiple care staff, who performed duties including resident ADL care, were observed assisting with meal service, which included entering the kitchen to obtain food for the residents. Though the kitchen staff were wearing aprons, care staff did not don aprons or some other barrier to prevent potential cross contamination when assisting with meal service. The need to establish and maintain infection prevention and control protocols, including protocols to prevent the development and transmission of communicable diseases, was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

1. Staff will be inserviced weekly on infection control policy and preceedure to include proper handwashing. This training will be conducted by the Health & Wellness Director. 2. Care staff will wear an apron at all times when acting as a server in dining room between duties as a caregiver. Care staff will place dirty aprons in the garbage can specified in the AL drink station for dirty aprons. 3. These aprons will be laundered by the facility daily to ensure cleanliness. Laundry will be completed daily by the NOC care staff. 4.The Executive Director will review these items weekly for completion.

Based on interview and record review, it was determined the facility failed to ensure adequate professional oversight of the medication administration system. Findings include, but are not limited to: During the re-licensure survey, conducted 12/12/23 through 12/14/23, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following area: * C 303: Medication and Treatment Orders. On 12/14/23, the delays in updating the MAR with new orders, obtaining new prescriptions, and administering medications as ordered was reviewed with Staff 5 (Health and Wellness Director). When asked to explain the current process for auditing resident MARs, he stated the MARs were audited once per month. On 12/14/23, Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 were informed the oversight of the medication administration system was determined to be inadequate based on the medication type and potential impact on the resident and the extended length of time the facility was administering medications to residents which did not align with the current physician orders. They acknowledged the findings.

1. MAR reviews will be conducted twice monthly by the Health & Wellness Director to increase frequency of quality control checks for accuracy. 2.The Executive Director will review these items weekly for completion.

2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including history of subdural hematoma and osteopenia. The resident's MARs, dated 10/01/23 through 12/11/23, and all physician orders were reviewed. a. The resident had a physician's order dated 10/18/23, with a fax stamp indicating the facility received the order on 10/18/23 at 10:10 am, for changes to Coumadin (blood thinner) administration, to be followed until new orders were received. The MAR was not updated between 10/14/23 and 10/30/23, resulting in the resident receiving an incorrect dosage of Coumadin on the following dates: * 10/18/23; * 10/20/23; * 10/25/23; and * 10/27/23. b. The facility did not carry out prescribed physician orders for metoprolol (for high blood pressure), resulting in the resident not receiving medication on: * 10/21/23; and * 10/22/23. c. The facility did not carry out prescribed physician orders for Coumadin from 10/31/23, resulting in the resident receiving 2.5 mg instead of 5 mg on 10/31/23. d. The facility did not carry out prescribed physician orders from 11/04/23 indicating the resident should receive 5 mg of Coumadin daily. The MAR was blank, with no documented evidence the resident received Coumadin on the following dates: * 11/05/23; * 11/06/23; and * 11/07/23. e. Medications and a treatment on 12/06/23 were not provided per physicians orders, including metoprolol, Coumadin, lidocaine patch (for pain management), and wound care to the right forearm. The MAR exception stated "medication given late," but in an interview on 12/12/23 Staff 9 (MT) stated the resident did not receive the medications and treatment. The need to ensure all orders were carried out as prescribed was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 5 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 07/2023 with diagnoses including Parkinson's disease and spinal stenosis. Review of the resident's physician orders included an order dated 10/18/23, with a fax stamp indicating the facility received the order on 10/19/23, for midodrine (for Parkinson's disease) increased from 2.5 mg three times a day to 5 mg three times a day. The 11/2023 MAR listed the 2.5 mg order stop date as 11/03/23, and the 5 mg order origination date as 11/03/23, with documentation of 2.5 mg given through 11/02/23 and increased to 5 mg on 11/03/23. There was no documented evidence the medication started on 10/19/23, per physician's orders. Staff 4 (RN) reported in an interview on 12/13/23 that she did not know why the medication had not been increased to 5 mg until 15 days after the order was received. The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 3 (Assisted Living Director), Staff 4, and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

1. Staff will be inserviced weekly on properly entering a physician order, the 4 step approval process,what constitutes a legal written physician order. This training will be conducted by the Health & Wellness Director. 2. Daily review of medications availability by the Assisted Living Director and Health & Wellness Director will occur to ensure that all resident medications are received in a timely manner and communicated to residents providers. 3.The Executive Director will review these items weekly for completion.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility administered for 3 of 3 sampled residents (#s 7, 8 and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 01/2023 with diagnoses including dementia and congestive heart failure . The resident's MAR, dated 02/01/24 through 03/18/24, and physician's orders were reviewed and revealed the following: * On 02/05/24 a decreased dose of Lisinopril to 20 mg a day was ordered for a duration of 30 days; and * Furosemide 20 mg a day was ordered for 30 days. The MAR indicated both medications were administered starting on 02/06/24 and should have stopped after the 03/06/24 administration. The Lisinopril 20 mg and Furosemide continued to be administered after the 30 days through 03/18/24 when the surveyor notified Staff 4 (RN). The RN acknowledged the findings and reported she would contact the physician immediately for further orders. * On 03/06/24 Bacitracin-neomycin-polymyxin ointment was ordered to be applied to the skin twice daily (wound right forearm). The MAR revealed the facility was documenting administration of the ointment one time daily, not twice daily as was ordered. The need to ensure physician's orders were carried out as prescribed was discussed with RN and Staff 6 (Director of Health Services) on 03/18/24, and Staff 2 (ED), Staff 5 (Previous Health and Wellness Director) and Staff 17 (Regional Director of Operations) on 03/19/23. They acknowledged the findings. 2. Resident 8 was admitted to the facility in 05/2022 with diagnoses including dementia, type 2 diabetes and hypertension. The resident's MAR, dated 02/01/24 through 03/18/24, charting notes from 02/14/24 through 03/18/24, and physician's orders were reviewed and revealed the following: The resident was administered sulfamethoxazole-trimethoprim 800-160 mg (for urinary tract infection) between the dates of 02/15/24 through 02/20/24. Charting notes from 02/15/24 stated the medication was dropped off at the facility by the resident's daughter. The facility was unable to provide any documentation that a physican's order was received for this medication. The need to ensure signed physician's orders were documented in the resident's record for all medications the facility administered was discussed with Staff 2 (ED), Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations) on 03/18/24 and 03/19/24. No additional information was provided, and they acknowledged the findings. 3. Resident 9 was admitted to the facility in 01/2022 with diagnoses including congestive heart failure and type 2 diabetes. The resident's MAR, dated 02/01/24 through 03/18/24, and physician's orders were reviewed and revealed the following: The resident had a physicians order, dated 01/15/24, for ergocalciferol 5,000 unit tablet (for severe vitamin deficiency) to be given once every week for eight weeks, then switched to 1,000 unit tablets daily thereafter. The resident's MAR showed that the facility was continuing to administer the 5,000 unit tablet after the ordered eight weeks had been completed. The facility had also been simultaneously administering the 1,000 unit dose daily throughout the look-back period. The need to ensure all medication orders were carried out as prescribed was discussed with Staff 2 (ED), Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations) on 03/18/24 and 03/19/24. No additional information was provided, and they acknowledged the findings.

1) R#7:  Bacitracin order was re-written correctly.  Fax sent to MD to clarify longevity of orders for Lisinopril and Furosemide dosing.   R#8:  Request sent to MD for copy of antibiotic order.  R#9:  MAR corrected for documentation error on the vitamin suppliment.  A MAR audit of remaining residents conducted to verify accuracy in order transcription and utilization.  Re-education for MT staff on proper order transcription process will be provided by 4/12/24. 2) Weekly MT meetings with a focus on routine audit findings will be conducted for 30 days then will resume monthly or more as need identified.  ALD/MCD will conduct daily order transcription review for new incoming orders and twice monthly MAR audits to assure accuracey. 3) Daily order transcription review and twice monthly MAR audits 4)  ALD/MCD with ED/Designee oversight

3. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia. Resident 5's Charting Notes from 09/18/23 through 12/04/23, service plans, Temporary Care Plans (TCP), Alert Charting records, and the resident's ABST data were reviewed during the survey. Interviews were conducted with caregiving staff and the resident. Resident 5 had a private caregiver who provided ADL care for approximately four hours per day on Monday thru Friday. No private caregiving was scheduled on the weekends. The following ADL elements were not reflective of the time it would take for facility staff to complete the task or the frequency for which the care was provided. Examples include: * Assisting with ambulation, escorting to and from meals or activities; * Supervising, cuing or supporting while eating, including tray delivery and pick-up; * Cuing or redirecting due to cognitive impairment or dementia; * Ensuring non-drug interventions for behaviors; and * Monitoring behavioral conditions or symptoms. The need to ensure Resident 5's ABST data was accurate to develop the facility's staffing plan was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 09/2022 with diagnoses including artherosclerotic heart disease, hypertension, and shortness of breath. The resident's 09/27/23 service plan, 09/29/23 through 12/04/23 progress notes, Resident Temporary Care Plans, 11/01/23 through 12/11/23 MARs, and Resident 2's ABST data was reviewed. Staff were interviewed and observations were made of the resident. a. The following ADL elements were not reflective of the time it would take for facility staff to complete the task or the frequency for which the care was provided. Examples include: * Personal hygiene; * Responding to call lights; * Leisure activities; * Non-drug interventions for behaviors; * Redirecting due to cognitive impairment or dementia; * Passing out medications; * Escorting to and from meals or activities; * Helping with bowel and bladder management; and * Grooming. During multiple observations on 12/12/23 and 12/13/23, the resident requested or required staff's assistance with responding to call lights, escorting to and from meals or activities, interventions for behaviors, and redirecting due to cognitive impairment. However, either no staff time, or an insufficient amount of staff time, was assigned to these elements in Resident 2's ABST. b. There were no minutes assigned for the "NOC" shift (from 10:00 pm to 6:00 am); however, there was documented evidence the resident received PRN medications and staff were providing Resident 2 care and companionship during the shift. The need to ensure resident's ABST data was accurate to develop the facility's staffing plan was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to develop an acuity-based staffing tool (ABST) that reflected an accurate time frame needed for each component to generate an accurate staffing plan for 3 of 5 sampled residents (#s 2, 4, and 5) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 09/2021 with diagnoses including high blood pressure and hypertension. The resident's 12/01/23 service plan, 11/15/23 through 12/12/23 progress notes, Resident Temporary Care Plans, and ABST data was reviewed. Staff were interviewed and observations were made of the resident. The following ADL elements were not reflective of the time it would take for facility staff to complete the task or the frequency for which the care was provided. Examples include: * Providing treatments (e.g. skin care, wound care); * Transferring in or out of bed or a chair; * Helping with bowel and bladder management; * Dressing and undressing; and * Additional care services such as pet care. On 12/14/23, the need to ensure resident's ABST data was accurate to develop the facility's staffing plan was discussed with Staff 3 (Assisted Living Director) and Staff 5 (Health and Wellness Director). They acknowledged the findings.

1. ABST tool will be updated upon resident move in, residents sent out to the hospital or skilled nursing facilities (SNF), quarterly service plan updates or change of condition. This will be performed by the Health & Wellness Director. 2. The Health & Wellness Director will update the ABST tool weekly with all resident updates from quaterly service plan updates. 3. The Health & Wellness Director will ensure all new move ins are entered into the ABST tool prior to move in to the community. 4. The Health & Wellness Director will ensure that all residents are updated in the ABST tool when out of the community in the hospital or a SNF. 5.The Executive Director will review these items weekly for completion.

Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) assessment for two unsampled residents and update the ABST after a significant change of condition for 1 of 2 sampled residents who experienced a significant change of condition (#8). This is a repeat citation. Findings include, but are not limited to: 1. The facility's ABST was reviewed upon survey entrance on 03/18/24. Two unsampled residents did not have minutes entered to reflect their care needs. 2. Resident 8 was admitted to the facility in 05/2022 with diagnoses including dementia and type 2 diabetes. Review of the resident's ABST showed it was last updated on 01/06/24. On 02/29/24, the resident returned to the facility from a hospital stay. A significant change of condition assessment was completed by Staff 4 (RN) on 03/01/24 and described the resident's increased level of confusion, generalized weakness, and need for increased assistance from staff including "monitoring resident frequently" and "offer assistance to meals." The ABST was not updated to reflect the resident's care needs following the significant change of condition. The need to ensure an ABST assessment was completed for all residents and updated after significant changes of condition was reviewed with Staff 2 (ED), Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations). They acknowledged the findings, and no additional information was provided.

1) Sampled residents were immediately added to the ABST tool.  ABST tool was reviewed for sampled R#8 to assure accuracy.  A review of the ABST tool for residents with changes of condition in the last 14 days will be conducted to assure accuracy. 2) Training on the ABST tool and review protocol was provided to the Executive Director and new Assisted Living Director and new Wellness Director to assure understanding.  ABST tool will be reviewed at least twice monthly and/or with new admits/discharges and those with changes to care needs. 3) At least twice monthly and/or with new admits/discharges and those with changes to care needs 4) ALD/Wellness Director/ED or Designee

Based on interview and record review, it was determined the facility failed to ensure direct care staff completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting for 2 of 2 long-term staff (#s 9 and 15) whose training records were reviewed and failed to ensure all staff completed annual training on infectious disease outbreak and infection control for 1 of 2 non-care staff (#16) whose training records were reviewed. Findings include, but are not limited to: Training records were reviewed with Staff 1 (ED) on 12/13/23. The following deficiencies were identified: 1. Based on review of training records, the facility conducted monthly in-service training for all staff which included training on topics related to the provision of care for persons in a community-based care setting, but did not document the portion of time specifically spent on such topics. As a result, Staff 9 (MA), hired 03/2022, and Staff 15 (CG), hired 11/2022, failed to have documented evidence of completing 12 hours of required annual in-service training, based on their anniversary date of hire. 2. Based on review of training records, Staff 16 (Housekeeping), hired 10/2012, failed to have documented evidence of completing annual training on infectious disease outbreak and infection control. The facility provided evidence that Staff 16 completed the training on 12/12/2023 while the survey team was on site. The need to ensure direct care staff completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting and ensure all staff completed annual training on infectious disease outbreak and infection control was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 12/12/23. They acknowledged the findings. No further information was provided.

1. All staff training will have amount of time dedicated to each specific topic indicated on signature sheet. 2. All staff will complete annual infection control and infectious disease outbreak training annually as determined by facility. 3. All staff will complete this training by being scheduled monthly throughout the course of the year to ensure compliance with annual expiration dates. 4. All staff training will be managed by the Assistant Executive Director. 5.The Executive Director will review these items weekly for completion.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: On 12/12/23, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed: 1. Staff did not evacuate or relocate residents during all fire drills. Therefore, fire drill records did not include information on: * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. 2. There was no documented evidence the facility provided fire and life safety training to staff on alternate months. The need to ensure the facility conducted unannounced fire drills according to the OFC and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 12/12/23. They acknowledged the findings. No further information was provided.

1. Facility will document each month the escape route used, problems or issues encountered during the course of the drill, residents who refused to participate in the drill, what is the plan to encourage future participation, the time needed to evacuate and the number of eople evacuated. 2. The facility will provide fire and life safety training to staff on alternating months. The community has created a schedule which dictates which months will be designated for training and which topic will be discussed as well as which shift a fire drill will be executed on each month. 3. Fire drills and training will be provided monthly and documented by the maintenance director. 4.The Executive Director will review these items weekly for completion.

Based on interview and record review, it was determined the facility failed to document all required elements on fire drill documentation, per the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to: Fire and life safety records dated 02/14/24 through 03/18/24 were reviewed on 03/18/24. Fire drill documentation did not include one or more of the following required elements: * Time of fire drill; * Location of simulated fire origin; * Problems encountered, comments relating to residents who resisted or failed to participate in the drill; * Evacuation time-period needed; and * Number of occupants evacuated. The need to follow all OFC requirements for fire drills and documentation was discussed with Staff 2 (ED), Staff 17 (Regional Director of Operations), Staff 6 (Director of Health Services), and Staff 5 (Previous Health and Wellness Director) on 03/19/24. They acknowledged the findings. No additional information was provided.

1) Information missing to the reviewed fire drill were added.  Retraining provided to the Maintenance Director to assure understanding of proper completion of the fire drill documentation was completed. 2) Executive Director will review fire drill documents weekly with Maintenance Director to assure all elements are addressed as per regulations for each fire drill conducted. 3) Weekly 4) Executive Director/Maintance Director

Based on interview and record review, it was determined the facility failed to re-instruct each resident, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire and failed to keep a written record of fire safety training. Findings include, but are not limited to: On 12/12/23, Staff 2 (Assistant ED) stated prior to each fire drill all residents were given a handout with instructions regarding what to do during a fire drill. However, Staff 2 was unable to produce a copy of the handout. Also, the facility had no written record of fire safety training, including content of the training sessions and the residents attending. The need to ensure residents were re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places and the facility kept a written record of fire safety training was discussed with Staff 1 (ED) and Staff 2 on 12/12/23. They acknowledged the findings.

1. The community will ensure that all residents understand what to do in the event of a fire by reviewing the fire safety proceedure with residents upon move in during contract signing. This will be done by either the Assistant Executive Director or the Executive Director. 2. The community will ensure ongoing resident fire safety education by scheduling annual fire safety re-orientation and documenting attendance with a resident signature sheet along with attached training content. This training will be conducted by the maintenance director. 3. All residents not in attendance at the annual orientation will receive one-on-one instruction from the maintenance director and will be documented on the annual orientation signature sheet. 4.The Executive Director will review these items weekly for completion.

Based on observation and interview, it was determined the facility failed to ensure exterior pathways were maintained in good repair and all chemicals were maintained in a locked storage unit. Findings include, but are not limited to: On 12/12/23, during a tour of the exterior and interior of the facility, the following were identified: * Exterior pathways in the courtyard and around the perimeter of the building contained multiple drop-offs up to approximately four inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents; and * Cabinets in the second floor kitchenette were unlocked and contained toxic chemicals. On 12/13/23, the exterior drop-offs and the unlocked interior chemicals was toured and reviewed with Staff 2 (Assistant ED) and Staff 7 (Maintenance). They acknowledged the findings.

1. All exterior pathways surrounding the community and courtyard have been brought level with sidewalks with the addition of bark mulch. 2. These walkways will be monitored weekly for continued comliance by the maintenance director. 3. Bark mulch will be added to any walkways as needed to prevent uneven surfaces and potential for fall hazards. This will be completed as needed by the mainteance director. 4. All chemicals in the 2nd floor kitchenette have been removed. This will be completed by the Assistant Executive Director. 5. Chemicals will not be stored in the 2nd floor kitchenette. 6.The Executive Director will review these items weekly for completion.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: On 12/12/23, the facility interior was toured. Multiple vertically opening windows above the first floor, with window sills lower than 36 inches from the floor, lacked a system which limited how far the window could be opened to prevent accidental falls. On 12/13/23, the lack of a mechanism to prevent accidental falls from upper floor windows was discussed with Staff 2 (Assistant ED) and Staff 7 (Maintenance). They acknowledged the findings.

1. All windows above the 1st floor will have a device installed to limit how far the window is able to be opened so as to prevent a human body from falling out of the window. 2. These devices will be installed by the maintenance director. 3.The Executive Director will review these items weekly for completion.

Based on observation and interview, it was determined the facility failed to ensure the stove in the activity room had a keyed remote switch or safety device to ensure staff control. Findings include, but are not limited to: The interior of the facility was toured on 12/12/23. The stove in the activity room, located on the second floor and accessible to all residents, was able to be turned on without the use of a key, remote switch, or other safety device to ensure staff control. On 12/13/23, the need to ensure a safety device was used for the stove when staff were not present was discussed with Staff 2 (Assistant ED) and Staff 7 (Maintenance). They acknowledged the findings.

1. The stove in the activity room on the 2nd floor will have a timer installed to deactivate the power to the stove after a specified amount of time. 2. The maintenace director will arrange for a licensed electrician to install this timer device. 3.The Executive Director will review these items weekly for completion.

Based on observation and interview, it was determined the facility failed to ensure that when washing soiled linens and soiled clothing washing machines had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant was used. Findings include, but are not limited to: During a tour of the facility laundry rooms on 12/12/23 and 12/13/23, it was observed the facility washed all linens and clothing in residential washers. There was no documented evidence the washers had a minimum rinse temperature of 140 degrees Fahrenheit to sanitize the soiled items. Interviews with Staff 14 (Housekeeping) and Staff 13 (CG), stated they washed soiled linens and soiled clothing, respectively, in accordance with instructions posted by the facility in each laundry room. The instructions did not include direction to use a chemical disinfectant when washing soiled linens and clothing. The need to ensure facility staff used a chemical disinfectant when washing soiled linens and clothing in a washing machine that did not have a minimum rinse temperature of 140 degrees F was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 12/12/23. They acknowledged the findings. No further information was provided.

1. Staff will be inserviced weekly on the proper way to handle laundry soiled with bodily fluids. This training will be conducted by the Health & Wellness Director. 2. Facility will provide documentation that the soap used to launder resident laundry contains sanitizing agents appropriate to clean and sanitize washing machines after use. This documentation will be provided by the Assistant Executiove Director. 3. Facility will post proper signage instructing staff on the proper procedure for handling of soiled laundry. This signage will be posted by the maintenance director. 4.The Executive Director will review these items weekly for completion.

Based on observation and interview, it was determined the facility failed to ensure that when washing soiled linens and soiled clothing washing machines had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant was used. This is a repeat citation. Findings include, but are not limited to: During a tour of facility laundry rooms on 03/18/24 and 03/19/24, it was observed that facility staff washed linens and clothing in residential washers on floors one through three. There was no evidence the washers had a minimum rinse temperature of 140 degrees Fahrenheit to sanitize soiled items. When asked how soiled linens and soiled clothing were washed, staff reported they used the resident's personal laundry detergent, and if they did not have one, they would then use the facility-provided powdered detergent. The detergent was provided to staff in a glass bowl with a small plastic cup inside. There was no marking on the cup or instructions posted to indicate how much of the detergent to use or that it should be used for soiled linens and soiled clothing. There was no posted signage in any of the laundry rooms which described the need to use a chemical disinfectant when washing soiled linens and clothing. Posted in the second floor laundry room, there was a hand-written sign which stated "Before putting soiled laundry in machine first rinse thoroughly in residents shower put in trash bag to get it to laundry room then put in machine cold water cycle." During interviews with Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations), they stated the soiled linen handling policy had been reviewed at an employee in-service on 12/28/23 and 01/04/24. They acknowledged that the current posted soiled laundry policy did not include information about use of a chemical disinfectant. The need to ensure facility staff used a chemical disinfectant when washing soiled linens and clothing in a washing machine that did not have a minimum rinse temperature of 140 degrees F was reviewed with Staff 2 (ED), Staff 6 and Staff 17 03/19/24. They acknowledged the findings, and no additional information was provided.

1) Proper detergent was placed in all laundry rooms during the visit. Re-education on purpose and expected use of this detergent was provided to all applicable staff by 4/12/24. 2) Ongoing oversight of the laundry rooms for adequate detergent available and proper use of hopper rooms. 3)  Weekly 4) Executive Director/Designee

Based on 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 303, C 361, C 420 and C 630.

Immediate corrections to the findings noted during the survey were initiated and completed during the survey visit. see individual plans of correction under each tag Executive Director will review POC weekly with applicable department heads to assure execution Executive Director

The findings of the re-licensure survey, conducted 12/12/23 through 12/14/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL:   activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC: Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day

The findings of the first revisit to the re-licensure survey of 12/14/23, conducted 03/18/24 through 03/19/24 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, OARs 411 and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second revisit to the re-licensure survey of 12/14/23, conducted on 05/14/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on record review and interview, it was confirmed that the facility failed to ensure that the service plans are getting updated quarterly. Findings include: A review of Resident #2 (R2) service plan showed that the facility did not update quarterly. The service plan is dated 12/31/2022. On 04/19/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: S1 will update service plan to reflect resident's current needs.

Based on interview, observation, and record review it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include: During separate interviews 04/03/2023, Resident #5 (R5) stated call lights take a long time for staff to respond especially during meals times. During an unannounced site visit on 04/03/2023, Compliance Specialist (CS) entered the facility at 10:30 AM and did not observe any med techs or caregivers until 11:30AM. A review of the staff schedule for February and March 2023, call light logs from 03/20/2023-3/24/2023, and the acuity-based staffing tool (ABST). The call light log showed 12 occurrences where they call lights exceed the facility's 10-minute response time, with 2 exceeding 20 minutes. Both schedules show multiple days were the facility had open shifts not filled. The facility ABST is not updated correctly, not showing the correct staffing levels reflective of all resident's needs. On 04/03/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: Not provided.

Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During separate interviews on 04/03/2023, Staff #1-3 (S1, S2, and S3) stated that their current staffing levels are 1 Med Tech (MT) and 2 Caregivers (CG) for day and swing shift and 1 MT and 1 CG for NOC shift. During an unannounced site visit on 04/03/2023, Compliance Specialist (CS) observed 1 MT and 2 CG working. A record review of the posted staffing plan, staff schedule for February- March 2023, resident roster updated on 04/01/2023, Resident #1-2 (R1 and R2) service plans dated 12/31/2022 and 02/24/2023, progress notes from 01/03/2023 - 04/03/2023, and the breakdown of their care on the facility's ABST. R2 service plan had not been updated quarterly. The exported data in the ABST showed 38 of the 45 residents entered in the tool to not have been evaluated quarterly with last updated dates ranging from 07/08/2022-01/02/2023. Matching the roster with the ABST showed that the ABST has 45 residents entered in the tool while the resident roster has 48 residents listed. On 04/03/2023, these findings were reviewed and acknowledged by S1.

Based on record review and interview, the facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned. Findings include: During separate interviews 04/03/2023, Staff #1 (S1) stated that competencies should have been verified by a med tech and a nurse, as per their policy. A review of training records for Staff #3-5 (S3, S4 and S5) revealed that S4 hired on 03/21/2023 did not complete the safety and health program which includes reporting protocols, accident prevention plan, OSHA requirements, employee focused- resident safe handing, proper body mechanic/safe transfers and the use of a camel. On 04/03/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: Not provided.

Based on interview and record review it was confirmed the facility failed to provide records to the Department upon request. Findings include: Compliance Specialist (CS) requested documentation from the facility for an investigation conducted on 04/03/2023 and did not receive them. Reviewed email request dated 04/05/2023 following up on the request for additional documentation to Staff #1 (S1). The facility did not provide the documentation requested. On 04/19/2023 CS informed S1 about documentation not being provided upon request. Plan Of Correction: S1 will be providing documentation upon site visit.

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 04/03/2023.  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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview and record review it was confirmed the facility failed to provide personal and other laundry services. Findings include: During separate interviews on 03/01/2023, Witness #1 (W1) and Resident #1 (R1) stated that housekeeping services have not been done in a while. A review of Resident #1-3 (R1, R2, and R3) service plan, resident council notes for 02/21/2023, and the housekeeping checkoff binder for February 2023. The housekeeping binder showed that housekeeping had only been completed 2 out of the 4 weeks in February for all residents. The individual check off sheet for R2 showed that their bed sheets had not been washed all month. The review of their service plans stated all 3 residents are to received weekly housekeeping services. On 03/01/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: The facility has hired a new housekeeper and will do training on housekeeping and completing housekeeping sheets.

Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During separate interviews on 03/01/2023, Staff #1-4 (S1, S2, S3 and S4) stated that their current staffing levels are 1 Med Tech (MT) and 2 Caregivers (CG) for day and swing shift and 1 MT and 1 CG for NOC shift. During an unannounced site visit on 03/01/2023, Compliance Specialist (CS) observed 1 MT and 2 CG working. A record review of the posted staffing plan, staff schedule for February 2023, resident roster, Resident #1-3 (R1, R2 and R3) service plans, progress notes, and the breakdown of their care on the facility ' s ABST. The exported data in the ABST showed 40 of the 49 residents entered in the tool to not have been evaluated quarterly with last updated dates ranging from 07/08/2022-12/18/2022. Matching the roster with the ABST showed that Residents #3-6 (R3, R4, R5 and R6) had not been entered into their tool. R3 moved into the facility on 02/15/2023, R4 moved in on 02/04/2023, and R5 and R6 moved in on 02/23/2023. On 03/01/2023, these findings were reviewed and acknowledged by S1.

Based on interview, observation, and record review it was confirmed the facility failed to keep clean all interior and exterior materials and surfaces. Findings include: During separate interviews on 03/01/2023, Witness #1 (W1) and Resident #1 (R1) stated that housekeeping services have not been done in a while. Staff #1 and 4 (S1 and S4) stated that Resident #3 (R3) is a newer resident and the belongings stacked in the hallway by their room belonged to R3. During an unannounced site visit on 03/01/2023, Compliance Specialist (CS) observed many boxes of belongings stacked in a hallway. A review of Resident #1-3 (R1, R2, and R3) service plan, resident council notes for 02/21/2023, and the housekeeping checkoff binder for February 2023. The housekeeping binder showed that housekeeping had only been completed 2 out of the 4 weeks in February for all residents. The individual check off sheet for R2 showed that their bed sheets had not been washed all month. The review of their service plans stated all 3 residents are to received weekly housekeeping services. R3 service plan showed R3 moved into the facility on 02/15/2023. On 03/01/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: The facility has hired a new housekeeper and will do training on housekeeping and completing housekeeping sheets. S4 stated that they will call R3 ' s power of attorney to remove the belongings from the hallway.

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 03/01/2023.  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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 01/11/23 at 10:30 am the kitchen was observed to need cleaning in the following areas: * Vents above stove/grill/deep fat fryer; * Black matter on floor and around drain under steamer; * Four food storage bin lids under prep counter; * Front and sides of grill/ovens; * Vents above salad prep area; * Doors on the outside of the sandwich refrigerator; and   * Front of bread drawer under toaster. The garbage can next to plate warmer and near the steam table was uncovered when not in use. The above areas were discussed with Staff 2 (Executive Director) on 01/11/23. The findings were acknowledged.

Facility has created cleaning task list that includes daily, weekly and monthly cleaning tasks to address kitchen cleanliness in all areas. Staff will be required to initial and date each task as it is completed. Task list will address as needed cleaning tasks with a separate area for staff to sign and date the task completed as needed between scheduled cleanings. Task list will be completed daily and turned into the Dining Services Manager and the Executive Director. Weekly task lists will be discussed at weekly meetings between the Dining Services Manager and the Executive Director, as well as planning of monthly cleaning parties to address deep cleaning needs that cannot be address during hours the kitchen is in use. Task list will address the following items at a minimum: * Air vents - cleaned weekly *Floors & floor darins - cleaned daily * Food storage bin lids - to be stored in proper storage area at all times throughout the course of the day * Grill - all areas including front and sides to be cleaned daily * Doors on sandwich refrigerator - cleaned daily & as needed during service throughout the day * Bread drawer under toaster - will be cleaned out after each meal service is completed. * Garbage cans - all garbage cans will be covered by lids when in the kitchen

Based on observation, record review and interviews, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 3/22/23 at 11:30 am the main kitchen area was observed to need cleaning in the following areas: *Interior and exterior of grill, stove, convection oven; *Interior of drawer under toaster; *Interior and exterior of microwave; *Industrial mixer; *Industrial can opener and housing; *Open stainless steel shelving by prep areas and under steam table; *Interior doors of sandwich refrigerator; *Handle of walking cooler; *Floors in corners, edges and under/between equipment; and *Walls with food/debris splatter throughout kitchen. The following areas were found to need repair: *Multiple sprinkler heads had gaps in the ceiling; *Hole just above floor tile by prep table; and *Cutting boards on steam table and sandwich prep area were heavily scored/stained or chipped and were not a smooth cleanable surface. *The large industrial mixer was observed not covered when not in use. The industrial slicer was also not covered when not in use. Staff 2 (Director of Dietary Services) confirmed there were not covers for those items. *There were three cases of food items observed stored on the Walk-in cooler floor. Staff 2 verified that stock was not delivered that day. The facility received stock a full two days prior. Staff 2 acknowledged stock should not be stored on the floor. *Multiple dishwashing racks were observed stored on the floor. The Surveyor reviewed the new cleaning list with required sign off of tasks as part of plan of correction. Staff 1 (Executive Director) and 2 acknowledged there were multiple areas that were not signed off as required to indicate the daily and weekly cleaning tasks were completed. Staff 1 and 2 toured kitchen and acknowledged the above areas of concern.

Facility has created cleaning task list that includes daily, weekly and monthly cleaning tasks to address kitchen cleanliness in all areas. Staff will be required to initial and date each task as it is completed. Task list will address as needed cleaning tasks with a separate area for staff to sign and date the task completed as needed between scheduled cleanings. Task list will be completed daily and turned into the Dining Services Manager and the Executive Director. Weekly task lists will be discussed at weekly meetings between the Dining Services Manager and the Executive Director, as well as planning of monthly cleaning parties to address deep cleaning needs that cannot be address during hours the kitchen is in use. Task list will address the following items at a minimum: * Air vents - cleaned weekly *Floors & floor drains - cleaned twice daily *Walls will be cleaned after every food service and as needed to ensure that any food that builds up is cleaned off in a timely manner. Staff will wipre down walls every day at the end of servide for the day * Food storage bin lids - to be stored in proper storage area at all times throughout the course of the day * Grill & oven - all areas including front and sides to be cleaned daily. Grill will be covered on side nearest deep fat fryer with foil that will be replaced daily. Oven will be cleaned weekly to prevent buld up of carbon residue and food debris. This will be noted weeklyon checklist. * Doors on sandwich refrigerator, walk-in cooler and all reach-in's - cleaned daily & as needed during service throughout the day * Bread drawer under toaster - will be cleaned out after each meal service is completed. * Garbage cans - all garbage cans will be covered by lids when in the kitchen *Industrial mixer and slicer will have covers in place at all times when not in use. Staff will replace cover as needed to ensure it is clean and will date the over at the time it is placed on machine. *Industrial can opener and housing will be replaced and cleaned when finihed with every use to prevent future acid erosion and etching. *Cutting boards on steam table have been removed and stainless steel surface to be wiped down between meal prepartation and food service and as needed for sanitation. Staff will clean and sanitize surface at the end of service for the day. *Cutting board on sandwich prep counter to be replaced and cleaned daily to prevent staining. Weekly deep cleaning of cutting board to prevent stain build up which will be noted on cleaning checklist. *Sprinkler heads will have proper fitting escutcheons to ensure that no open areas are visible around sprinkler heads. *Hole above floor tile by prep table to be repaired. *Dishwashing racks to be stored on shelves off the floor or on rolling cart when not in use. *All stock from deliveries will be sorted and put away at the time it arrives to ensure that food storage regulations are met at all times. Dining services manager will check walk-in cooler 3 times per day to ensure that all food is properly stored on shelving and off the floor and noted on check list.

Based on observation, interviews and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 06/06/23 at 11:15 am the main kitchen area was observed to need cleaning in the following areas: *Interior and exterior of stove, convection oven; *Knobs and handles of equipment; *Interior of drawer under toaster; *Interior and exterior of microwave; *Dust build up on walk-in cooler ceiling; *Dust build up on vents and ceiling between tray line and ware washing area; *Industrial mixer; *Open stainless steel shelving by prep areas and where dishes were stored; *Interior doors of sandwich refrigerator; *Commercial grade toaster with dust/dirt debris build up on air vents; *Handle of walk-in cooler; *Walk-in cooler/freezer floor with food debris; *Floors in corners, edges and under/between equipment; and *Walls with food/debris splatter throughout kitchen. The following areas were found to need repair: *White cutting boards used for food prep were found heavily scored/stained or chipped and were not a smooth cleanable surface. *There was a case of food items observed stored on the walk-in cooler floor.  There were multiple cases of food items observed stored on the walk-in freezer floor. Staff 2 acknowledged stock should not be stored on the floor. *Multiple staff were observed preparing or serving food items without hair and/or facial hair restrained as required. Staff 3 (Assistant Administrator) toured kitchen with surveyors and acknowledged the above areas of concern. At approximately 12:00 pm, Staff 2 (Dietary Services Manager) and surveyors reviewed areas of needed attention. Staff 2 acknowledged identified issues. At 12:15 pm the sanitation concerns were reviewed with Staff 1 (Executive Director) He acknowledged the areas of non-compliance.

1) The kitchen has been deep cleaned (including walls, walk-in, equipment, appliances, vents, racks and floors) and all food has been appropriately stored. Hair and beard barriers have been provided to all staff who are preparing food. All cutting boards that are damaged are being replaced. 2/3/4) All employees who are involved with the preperation of food will be required to wear a hair/beard barrier. An in-service will be completed for all kitchen staff by 6/20/2023 on proper cleaning procedures. Additionally, the administrator or designee will review the kitchen daily to ensure it is properly cleaned and maintained including floors, walls, kitchen equipment, food storage areas and containers. All food will be properly stored when the food is delivered. An in-servie will be completed for all kitchen staff to address proper food storage by 6/20/23. The dry storage, walk-in freezer and refigerator will be walked by the adiministrator or designee each day to ensure all food is properly stored. All cutting boards that are damaged or are worn will be replaced and maintained appropriately. All cutting boards will be inspected monthly to ensure they are in good condition

Based on interview, observation and review of documentation, 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 240.

Facility will implement and maintain above described plan to maintain food sanitation and safety in compliance with OAR's. All staff will participate actively in the sanitation and safety culture of the kitchen and community.

Based on interview, observation and review of documentation, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 240.

1) The kitchen has been deep cleaned (including walls, walk-in, equipment, appliances, vents, racks and floors) and all food has been appropriately stored. Hair and beard barriers have been provided to all staff who are preparing food. All cutting boards that are damaged are being replaced. 2/3/4) All employees who are involved with the preperation of food will be required to wear a hair/beard barrier. An in-service will be completed for all kitchen staff by 6/20/2023 on proper cleaning procedures. Additionally, the administrator or designee will review the kitchen daily to ensure it is properly cleaned and maintained including floors, walls, kitchen equipment, food storage areas and containers. All food will be properly stored when the food is delivered. An in-servie will be completed for all kitchen staff to address proper food storage by 6/20/23. The dry storage, walk-in freezer and refigerator will be walked by the adiministrator or designee each day to ensure all food is properly stored. All cutting boards that are damaged or are worn will be replaced and maintained appropriately. All cutting boards will be inspected monthly to ensure they are in good condition.

The findings of the kitchen inspection conducted 01/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 1/11/23, conducted 3/22/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 01/11/23, conducted 06/06/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the third revisit to the kitchen inspection of 1/11/23, conducted 7/19/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review it was confirmed the facility failed to implement and compete service plans before a resident moves in or quarterly evaluations. Findings include: During separate interviews on 01/05/2023, Staff #1-3 (S1, S2, and S3) stated that the facility is behind on service plans and admits there are a handful out of date. S2 stated that they have been working on updating them and made that their priority. A review of the facility ' s service plan binder indicates at least 8 service plans to be out of date. The dates the service plans should have been completed are 12/6/2022, 12/21/2022, 12/12/2022, 10/19/2022, 1/2/2023, 10/2/2022, and 2 are new residents that did not receive updated service plans after they moved in 30 days later. On 01/05/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: S2 had made updating service plans their priority. S2 has been and continues to update service plans to make them all in compliance with resident ' s current needs.

Based on interview, observation, and record review it was confirmed the facility failed to establish, maintain, and comply with infection prevention and control protocols. Findings include: During an interview on 01/05/2023, Staff #1 (S1) stated that this is the resident ' s home, and we suggest guests wear masks but do not require them too. S1 also stated observing guests enter the facility without a mask on and that S1 did not ask them to wear a mask while in the facility. During an unannounced site visit on 01/05/2023, Compliance Specialist (CS) observed no required signs posted for infection control or mask requirements on the entrance or throughout the building. A review of the Oregon Health Care Association covid updated guidelines for facility ' s dated 11/23/2022 states that masks requirements remain. Consistent masking by health care providers in health care settings, as well as masking by visitors. Also stating, Visitors: No screening requirements for visitors entering facility, but facility should provide guidance (e.g., posted signs at entrances, reception area and/or visitor sign-in area). Infection prevention, such as providing instructional signage in the facility on hand hygiene, use of a mask, or other applicable facility practices). Visitors who do not adhere to the core principles of infection prevention may be asked to leave. On 01/05/2023, these findings were reviewed with S1. Plan of Correction: Starting on 01/05/2023. S1 will be finding the proper sign posting for the entrance of the facility and will remind visitors to put masks on when entering the facility.

Based on interview and record review it was confirmed that the facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. Findings include: During an onsite interview on 01/05/2023, Staff #1 (S1) stated that they were administering insulin and other medications in October and November 2022. S1 stated that they were administering insulin before their delegation from the Registered Nurse. A review of S1 Initial staff skills assessment for RN delegation dated 11/11/2022 and the complaint dated 11/3/2022 shows that S1 was administering insulin before the delegation was provided. S1 did not provide other training or delegations for medication administration. The delegation for insulin is not for specific residents but a general one for the building. On 01/05/2023, these findings were reviewed and acknowledged by S1. Plan of Correction: S1 is no longer working as a med tech. There is now a delegation for S1 to administer insulin.

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 01/05/2023.  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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day