The Aspens

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

Observations of the main facility kitchen on 06/10/25, from 10:08 am through 1:00 pm, revealed the following:

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

* Wall and flooring behind warewasher;
* Knobs of the stove and interior of both ovens; and
* Vents above freezer and service line.

b. The following were in need of repair:

* The floor had multiple black dings and chips throughout the kitchen;
* The caulking in the warewashing area had black matter debris buildup;
* The can opener was dull with metal shavings observed and the housing unit was unable to be removed to clean; and
* Multiple cutting boards were heavily worn and scratched.

c. Pans and cooking utensils were stored uncovered hanging above service line. Multiple observations revealed staff returned several utensils and pans back up on the rack slightly wet while food was present and uncovered on the service line, leading to possible contamination.

d. The blender and food processor were stored without a cover when not in use.

d. Kitchen staff did not check the temperature of the food before plating and serving to residents. The yams were temped at 112 degrees Fahrenheit. Staff 8 (Lead Cook) stirred the yams and the temperature increased to 180 degrees Fahrenheit and the yams were replated.

f. Multiple observations were made of the probe thermometer not being properly cleaned in between temping different foods.

g. A kitchen staff was observed dipping pork chops in batter and breadcrumbs and placing them on a baking pan with gloved hands. With the same gloved hands he went to the food prep sink, ran his gloved hands under the water, no hand soap was used or present, and then dried his gloved hands on a towel next to the sink. Additional observations were made of staff rinsing their hands in the prep sink with no soap and drying their hands off with the same towel.

h. Staff 8 was not able to correctly demonstrate adequate knowledge of signs and symptoms of foodborne illnesses.

The kitchen was toured and the above findings, including areas needing to be cleaned and repaired, proper storage of cooking items, and proper hand hygiene between dirty and clean tasks were reviewed with Staff 1 (Director) and Staff 8 on 06/10/25 at 2:07 pm They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to complete quarterly evaluations for 2 of 3 sampled residents (#s 1 and 3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in September 2020 with diagnoses including Alzheimer’s disease.

Resident 3's most recent quarterly evaluation was updated 2/17/25.

On 06/12/25, Staff 1 (Director) reported the evaluation dated 2/17/25 was all she had related to a quarterly evaluation for Resident 3.

On 06/12/25, the need to ensure a quarterly evaluation was completed timely was discussed with Staff 1, Staff 2 (Assistant Director), Staff 3 (Co-Owner, Hearth and Truss), and Staff 14 (Regional Nurse). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2021 with multiple sclerosis, anxiety and bipolar disorder.

A review of the resident's clinical record revealed the resident's most recent quarterly evaluation was completed on 02/14/25. A smoking evaluation was requested on 06/10/25 and the most updated quarterly smoking evaluation had been completed on 04/17/24. No further documentation was provided.

The need to ensure residents were evaluated quarterly was discussed with Staff 1 (Director), Staff 2 (Assistant Director), Staff 3 (Co-Owner, Hearth and Truss) and Staff 14 (Regional Nurse) on 06/12/25 at 4:10 pm. They acknowledged the findings.

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific instructions or interventions were determined and communicated with staff, and the condition was monitored through resolution for 3 of 4 residents (#s 1, and 2) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in October 2024 with diagnoses including heart failure, and was identified in the acuity interview as having a history of falls, weight changes and hospital visits.

Observations of the resident were made, interviews with staff were conducted, review of the resident's 04/23/25 evaluation and service plan, 03/09/25 through 06/09/25 temporary service plans (TSPs), progress notes, and incident reports were completed. The following was revealed:

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted at least weekly through resolution:

* 04/14/25 – Return from hospital;
* 04/14/25 – Discontinuation of four medications;
* 04/18/25 – Medication changes for furosemide and Nitro-time;
* 05/01/25 – Non-injury fall; and
* 05/12/25 – Non-injury fall.

The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Director), Staff 2 (Assistant Director), Staff 3 (Co-Owner, Hearth and Truss), and Staff 14 (Regional Nurse) on 06/12/25. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2021 with multiple sclerosis, anxiety and bipolar disorder.

Observations of the resident were made, interviews with resident and staff were conducted, review of the resident's 02/14/25 evaluation and 04/29/25 service plan, 03/10/25 through 06/09/25 progress notes, temporary service plans (TSPs), and incident reports were completed. The following was identified:

The following short-term changes of condition lacked documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined actions or interventions to staff, and/or documented weekly progress until the condition resolved:

* 03/17/25 – Medication changes;
* 03/18/25 – A progress note indicated Resident 1 “told med tech resident in [apartment #] beat [him/her] up…punched [him/her], spit on [him/her] and slammed [his/her] foot in the door…”;
* 03/27/25 – During a medication pass Resident 1 was not answering his/her door and required a sternum rub to wake up;
* 04/01/25 – A progress note reported “…resident was having difficulty speaking and holding [his/her] med cup”;
* 04/03/25 – Emergency room visit for a urinary tract infection (UTI) with antibiotics;
* 04/04/25 – New medication;
* 04/22/25 - UTI and new medications;
* 05/09/25 – A progress note indicated Resident 1 “could not wake up this morning…even with shaking and doing chest rubs…when [Resident 1] did wake up [his/her] eyes were wide open…hands were shaking and [s/he] kept dropping [his/her] cigarette.”;
* 05/12/25 – Return from hospital for pneumonia and two antibiotics; and
* 05/29/25 – A progress note indicated Resident 1 reported to staff an unwanted physical encounter with another resident.

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1, Staff 2 (Assistant Director), Staff 3 (Co-Owner, Hearth and Truss), and Staff 14 (Regional Nurse) on 06/12/25 at 4:10 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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure service providers leave written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care if necessary for 1 of 2 sampled residents (#1) who received outside services. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2021 with multiple sclerosis, anxiety and bipolar disorder.

During the acuity interview on 06/09/25, Resident 1 was identified as having monthly visits from a behavior specialist.

Resident 1's progress notes, dated 03/10/25 through 06/09/25, were reviewed, as well as all outside provider communications. The following was identified:

The facility did not receive or document outside provider notes and recommendations from January 2025 through May 2025.

In an interview on 06/12/25 at 11:45 am, Staff 1 (Director) acknowledged a new behavioral specialist had been visiting monthly and had not been leaving written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care.

The need to coordinate care with outside providers and ensure service providers left written information in the facility that addressed on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 1, Staff 2 (Assistant Director), Staff 3 (Co-Owner, Hearth and Truss) and Staff 14 (Regional Nurse) on 06/12/25 at 4:10 pm. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc

(2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 4 sampled residents (#5) whose orders were reviewed. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 10/2016 with diagnoses including malignant neoplasm of the brain.

Resident 5's clinical records were reviewed and revealed a 05/15/25 physician order for a pureed diet. The service plan, dated 05/01/25, noted the resident was on a “pureed preference” diet and “regular” thin liquids.

Meal observations made on 06/10/25 and 06/11/25 revealed the resident was served foods that were not a pureed texture. In an interview at 12:12 pm, Staff 2 (Assistant Director) observed the meal served to Resident 5 and acknowledged the chicken casserole and vegetables were not pureed.

On 06/12/25 Staff 2 provided additional training and materials to kitchen staff to ensure Resident 5 would receive a pureed diet. Observations during subsequent meals on 06/12/25 confirmed Resident 5 received a pureed diet.

The need to follow all physician orders as prescribed was discussed with Staff 1 (Director), Staff 2, Staff 3 and Staff 14 (Regional Nurse) on 06/12/25 at 4:10 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at move-in and at least quarterly to ensure their ability to safely self-administer medications for 1 of 1 sampled resident (#1) who self-administered medications. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2021 with multiple sclerosis, anxiety and bipolar disorder.

During the acuity interview on 06/09/25, Resident 1 was identified as self-administering migraine medication. However, review of Resident 1's MAR on 06/10/25 revealed s/he was also self-administering nicotine lozenges for nicotine cravings up until 06/05/25, and during the interview on 06/11/25 with the resident, s/he confirmed s/he was also administering olopatadine eye drops for dry eyes and allergies. S/he also clarified s/he had been taking the nicotine lozenges but had recently stopped taking them.

In an interview on 06/12/25, Staff 2 (Assistant Director) confirmed Resident 1 self-administered eye drops and ”up until recently” the nicotine lozenges.

Review of Resident 1's medical records revealed there was no documented evaluation of Resident 1's ability to safely self-administer the nicotine lozenges. Additionally, the most recent quarterly evaluation to self-administer the migraine medication and eye drops were on 04/04/24 and 09/21/24, respectively.

The need to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter to assure the residents' ability to safely self-administer was reviewed with Staff 1 (Director), Staff 2, Staff 3 (Co-Owner, Hearth and Truss) and Staff 14 (Regional Nurse) on 06/12/25 at 4:10 pm. They acknowledged the findings. No further information was provided.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds

(5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

A review of the facility’s ABST, the posted staffing plan, the staffing schedule for 06/01/25 through 06/07/25 and the current resident roster identified the following:

* The facility’s posted staffing plan showed they scheduled five CGs and one MT for day and swing shifts and two CGs and one MT for night shift every day of the week.

* Based on the staffing schedules provided, the facility did not staff to their posted staffing plan approximately 19% of the time between 06/01/25 and 06/07/25.

On 06/11/25 the need to have enough qualified direct care staff on each shift was discussed with Staff 1 (Director). She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 4, 9 and 10) completed all required pre-service orientation and pre-service dementia training prior to beginning their job responsibilities and providing care for residents. Findings include, but are not limited to:

Staff training records were reviewed on 06/11/25 at 2:45 pm with Staff 2 (Assistant Director), and the following was identified:

a. There was no documented evidence Staff 4 (CG/MT), Staff 9 (CG/MT) and Staff 10 (CG), hired 01/20/25, 01/09/25, and 02/10/25, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities:

* Abuse reporting requirements;
* Fire safety and emergency procedures; and
* Infectious disease prevention training.

b. There was no documented evidence Staff 9 and Staff 10 had completed one or more of the following pre-service dementia care training topics prior to beginning their job responsibilities:

* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;
* Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics;
* Strategies for addressing social needs and engaging them in meaningful activities; and
* Specific aspects of dementia care including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.

The need for staff to complete all required pre-service orientation training and for direct care staff to complete required pre-service dementia training was discussed with Staff 1 (Director), Staff 2, Staff 3 (Co-Owner, Hearth and Truss) and Staff 14 (Regional Nurse) on 06/12/25 at 4:10 pm. They acknowledged the findings. No further information was provided.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service

(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding:

(a) A review of their written position description with their job responsibilities.

(b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings.
(A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities.
(B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of
this rule.

(c) Abuse and reporting requirements.
(d) Fire safety and emergency procedures.

(e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease.

(A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:
(i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease.
(ii) Policy addressing respiratory hygiene and coughing etiquette.
(iii) Standard precautions.
(iv) Hand hygiene.
(v) Use of personal protective equipment.
(vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection.
(vii) Isolating and cohorting of residents during a disease outbreak.
(viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks
under ORS 433.004 and safeguards for employees who report disease outbreaks.

(B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.
(i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.
(ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.

(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below:
(A) Effective March 31, 2024, all staff must have completed the required training.
(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities.
(g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate.

(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.
(a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.
(A) Documentation of dementia training:
(i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training.
Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.
(ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.
(B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training.
(C) A certificate of completion must be made available to the Department upon request.
(D) Pre-service dementia care training must include the following subject areas:
(i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.
(ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.
(iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.
(iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:
(I) Identify and address pain.
(II) Provide food and fluids.
(III) Prevent wandering and elopement.
(IV) Use a person-centered approach.

(b) ORIENTATION TO RESIDENT. Pre-service orientation to resident:
(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan.
(B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term direct care staff (#s 5, 6 and 7) and 2 of 3 long-term non-direct care staff (#s 2 and 8) completed infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 06/11/25 at 2:45 pm with Staff 2 (Assistant Director) and the following was identified:

a. There was no documented evidence Staff 2 (Assistant Director), Staff 5 (CG), Staff 6 (CG/MT), Staff 7 (CG), and Staff 8 (Cook), hired 03/16/12, 02/10/20, 01/25/22, 08/26/16, and 08/17/23, respectively, completed annual training on infectious disease outbreak and control.

The need to ensure and document that long-term direct care staff and non-direct care staff completed annual infectious disease training was discussed with Staff 1 (Director), Staff 2, Staff 3 (Co-Owner, Hearth and Truss) and Staff 14 (Regional Nurse) on 06/12/25 at 4:10 pm. They acknowledged the findings. No further information was provided.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff

(6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF.

(a) Annual infectious disease training requires the following:
(A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training.
(B) Annual in-service training must be documented in the employee record.

(b) Biennial LGBTQIA2S+ training requires the following:
(A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff.
(i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite.
(ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility.

(B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either:
(i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or
(ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility.

(C) ORS 441.116 requires all LGBTQIA2S+ trainings address:
(i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus.
(ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status.
(iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status.
(iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns.
(v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination.
(vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training.
(vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state.

(D) The proposal for training submitted by a facility, entity, or individual shall include:
(i) The regulatory criteria described in paragraph (C) of this section as part of the proposal.
(ii) The following elements must be included in the proposal:
(I) A statement of the qualifications and training experience of the facility, individual or entity providing the training;
(II) The proposed methodology for providing the training either online or in person.
(III) An outline of the training.
(IV) Copies of the materials to be used in the training.
(iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision.

(c) Annual Home and Community-Based Services (HCBS) training requires the following:
(A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations.
(B) Annual in-service training must be documented in the employee record.
(C) These annual trainings will be required as of April 1, 2025.

(7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF.
(a) All direct care staff must complete and document 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, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire.
(b) Requirements for annual in-service dementia training:
(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.
(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.
(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.
(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.
(E) The facility shall determine the competency of direct care staff in dementia care in the following ways:
(i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19).
(ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff.
(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency.

(8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code (OFC), and fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to:

Six months of facility fire drill and fire and life safety records from 12/2024 to 05/2025 were reviewed with Staff 1 (Director) on 06/12/25.

a. Staff 1 confirmed there was one fire drill completed during the six-month time frame reviewed; and

b. Staff 1 confirmed there was one occurrence where staff were trained in fire and life safety procedures during the six-month time frame reviewed.

The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed with Staff 1 on 06/12/25. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 05/15/23, 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 05/15/23, conducted 07/20/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the kitchen, food storage, prep, and service on 05/15/23 revealed:Spills, splatters, and debris were noted:* Behind and on the interior of the range;* Interior and exterior of cabinets and drawers throughout the kitchen;* The open shelving below the tray line; * The knife rack;* The can opener blade and casing;* Interior of all reach in refrigerators and freezers;* Floor throughout the kitchen and dry storage area; * The dishwashing area flooring, walls, and equipment; and* Interior of the microwave.* Staff 2 (Assistant Director/Cook) explained the facility used bleach and water for the sanitizer bucket and it was not monitored to ensure the correct solution. The auto dispense Quaternary solution was available, but not hooked up to the sink.* The chlorine solution used for sanitizing dishes was not monitored to ensure correct ratios.* Multiple prepared food items in the refrigerator were not dated or labeled.* Multiple packaged food items were not dated when opened.* Unpasteurized eggs were stored above other foods.* There were expired food items in the refrigerator.* Boxes were stored beneath the shelving in the dry storage not allowing for six inches for clearance or cleaning.* There was no evidence of the monitoring of food temperatures on the steam table.The areas in need of cleaning and food storage guidelines were reviewed with Staff 1 (Director) and Staff 2 on 05/15/23. They acknowledged the findings.

The findings of the re-licensure survey, conducted 03/28/22 through 03/29/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 03/29/22, conducted on 06/30/22, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home, and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training, was completed prior to providing services to residents for 3 of 3 newly hired staff (#s 11, 12 and 13) whose training records were reviewed. Findings include, but are not limited to:Staff training records were requested on 03/29/22.Staff 11 (MT), hired 01/24/22, Staff 12 (CG) hire 12/25/21, and Staff 13 (CG) hired 01/25/22, lacked documented evidence of having completed all of the required pre-service dementia training.The need for staff to complete required pre-service dementia training, before working with residents, was reviewed with Staff 1 (RCC/Administrator Designee) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired caregiving staff (# 11) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 03/29/22.There was no documented evidence Staff 11 (MA), hired 01/24/22 had demonstrated competence in medication administration. Staff 4 (LPN) immediately completed and documented medication pass training, including demonstration of competence. The need to ensure staff had documentation of demonstrated competence in all job duties within 30 days was reviewed with Staff 1 (RCC/Administrator Designee), Staff 2 (Regional Director of Operations) and Staff 4 (LPN). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. Findings include, but are not limited to:The exterior of the facility was toured on 03/28/22. The following issue was identified as needing repaired:Exterior sidewalks around the facility had multiple areas where the concrete was uneven, creating a trip hazard.On 03/28/22, the building's exterior was toured with Staff 1 (RCC/Administrator Designee) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to:The facility was toured on 03/28/22 at 11:30 am. The following issues were identified:* Dings, gouges, dents and scratches on multiple doors and door frames;* Broken tile molding in numerous areas in the dining room; and* Scratched, gouged, and dented handrails throughout the facility.The areas needing repair were reviewed with Staff 1 (RCC/Administrator Designee) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents exited the facility. Findings include, but are not limited to:The Assisted Living had a main entrance, three additional doors by which residents could exit the building, and three doors which exited to an enclosed courtyard.The facility was toured on 03/28/22. There was no system in place which alerted staff when a resident exited the facility.The need to have a system which alerted staff when residents exited the building was discussed with Staff 1 (RCC/Administrator Designee) and Staff 2 (Regional Director of Operations). They acknowledged there were no door alarms or other systems in place to alert staff when residents exited.