Dallas Retirement Village Assisted Living

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

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations made in the facility kitchen and campus main food storage areas on 01/14/26, from 09:30 am through 2:00 pm, identified the following: 1. Campus Main Food Storage Area a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, white/grey billowy organic matter, and/or grease was visible on, underneath, or between the following: * Reach-in milk cooler interior door frame; * Reach-in milk cooler exterior door; * Walk-in cooler main flooring; * Walk-in cooler flooring under stationary racks; * Walk-in cooler stationary racks; * Walk-in cooler fan cages; and * Walk-in freezer floor under racks. b. Multiple items were observed stored in walk-in cooler and walk-in freezer that were uncovered/unprotected from potential contamination. Walk-in cooler fans and racks were observed with large amounts of white/grey billowy mold-like organic matter. c. Multiple packages of sliced deli meat were observed in walk-in cooler with date of 12/19 with the word “Frozen” next to the date. There were no other markings on the package to indicate when the item was pulled from the freezer or a use-by date to ensure it was within the appropriate safe use date. 2. ALF facility Main Kitchen/Food Prep and Service Area a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Floor drains under equipment; * Floor drain in the middle of the floor; * Large honeycomb ceiling vent adjacent to service line; and * Juice machine area underneath by dispensing nozzles. b. The following areas were found in need of repair: * Area around center floor drain not smooth/easily cleanable. c. Multiple dishwashing racks observed stored on the floor. d. Package of raw pre-cut onions and package of pre-cut carrots were observed stored in reach-in cooler without open dates. e. Facility process for date marking was using day of prep as day zero and all items observed dated had 8 days out from day of prep instead of 7 days as required. The above items were reviewed with Staff 2 (Dining Services Manager) and Staff 1 (Executive Director) at 1:30 pm. They acknowledged the identified areas in need of correction.

All identified kitchen areas, including coolers, freezers, racks, drains, vents, and equipment surfaces were deep cleaned and sanitized on or before January 30,2026. The Executive Chef or designee re-educated all culinary and service staff on required daily and weekly cleaning procedures on or before January 30,2026. The Executive Chef or designee will make daily, weekday observations of the kitchen for cleaning and sanitizing procedure completion. The Executive Chef or designee will conduct weekly audits of kitchen cleaning and sanitizing procedures for 12 weeks or until substantial compliance is achieved. All uncovered or unprotected items were immediately discarded. The Executive Chef or designee re-educated all culinary and service staff to proper storage and covering of foods on or before January 30,2026 The Executive Chef or designee will make daily, weekday observations of items stored in the walk-in cooler and freezer for proper covering. The Executiv Chef or designee will conduct weekly audits of items stored in the walk-in cooler and freezer for proper covering for 12 weeks or until substantial compliance is achieved. All items without open and/or prepared dates were immediately discarded. The Executive Chef or designee re-educated all culinary and service staff to labeiling and dating of foods on or before January 30,2026. The Executive Chef or designee will make daily, weekday observations of items for proper labeling and dating. The Executive Chef or designee will conduct weekly audits of items for proper labeling and dating for 12 weeks or until substantial compliance is achieved. All items labeled with day of prep as day zero and day of discard as day 8 were corrected to show day of prep as day 1 and day of discard as day 7. The Executive Chef or designee re-educated all culinary and service staff to labeling and dating of foods on or before January 30,2026. The Executive Chef or designee will make daily, weekday observations of items stored in the walk-in cooler and freezer for proper covering. The Exective Chef or designee will conduct weekly audits of items for proper labeling and dating for 12 weeks or until substantial compliance is achieved. All dishwasher racks were immediately removed from the floor and properly stored on shelving. The Executive Chef or designee re-educated all culinary and service staff to proper storage of dishwasher racks on or before January 30,2026. The Executive Chef or designee will make daily, weekday observations of dishwasher rack storage. The Executive Chef or designee will conduct weekly audits of dishwasher rack storage for 12 weeks or until substantial compliance is achieved.

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 411-054-0036 (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 resident care needs and provided clear instruction to staff for 2 of 4 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 08/2025 with diagnoses including hypertension. Resident 2’s clinical records were reviewed, interviews with staff and the resident were conducted, and observations were made. The 11/20/25 service plan was not reflective of the resident care needs and lacked clear direction to staff in the following areas: * Transfers; * Mobility; * Dressing; * Bathing; and * Toileting. During lunch on 01/07/26, Resident 2 was observed needing hands on assistance from staff to push his/her wheelchair to and from the dining room. On 01/08/26 at approximately 3:30pm, the need to ensure resident service plans were reflective of resident care needs and provided clear direction to staff was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings. 2. Resident 1 moved into the facility in 06/2022 and was subsequently diagnosed with conditions including generalized anxiety disorder and auditory hallucinations. The resident's record, including the most recent service plan, dated 12/04/25, progress notes, dated 10/07/25 through 01/05/26, and temporary service plans were reviewed, observations were made, and interviews with staff were conducted. The following was identified: The service plan was not reflective of the resident's status and/or did not provide clear direction regarding the delivery of services in the following areas: * Specific and clear directions to staff regarding the resident’s paranoid delusions and hallucinations (e.g. what they relate to and what staff need to do when the resident exhibits them); * Use of PRN psychotropics and effective non-pharmacological interventions; and * Pain status and non-pharmacological interventions for pain. On 01/09/26 at 12:30 pm, the need to ensure the service plan was reflective of the resident’s current status and provided clear directions for staff was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings.

All resident records were reviewed for accuracy or completeness on or before January 27, 2026. Resident records identified as having outdated or missing information were updated on or before January 27, 2026. The Administrator or designee re-educated staff to ensure all required elements are included in resident records. Resident records will be audited weekly for completion. The Administrator or designee will conduct weekly audits of resident records for completion for 12 weeks or until substantial compliance is achieved.

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.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 1 and 2) whose MARs and Controlled Substance Drug Disposition logs were reviewed. Findings include but are not limited to: 1. Resident 1 moved into the facility in 06/2022 and had diagnoses which included unspecified abdominal pain and unspecified osteoarthritis, and s/he had recently been admitted to hospice services. The resident’s 12/01/25 through 01/05/26 MARs, Controlled Substance Disposition Log, and current physician orders were reviewed, and the following was identified: Resident 1 had an order for oxycodone HCL (narcotic analgesic) 5 mg, one tablet every four hours PRN for breakthrough pain or shortness of breath. Resident 1's Controlled Substance Disposition Log identified five occasions when staff signed on the drug disposition log that the oxycodone was given. However, the MAR lacked documentation that the resident received the medication. Inconsistencies between the MARs and Controlled Substance Disposition log were reviewed with Staff 2 (RN) and Staff 3 (LPN) on 01/06/26 at 11:00 am and 01/09/26 9:00 am. They acknowledged the findings. 2. Resident 2 moved into the facility in 08/2025 with diagnoses including hypertension. The resident's 12/01/25 through 01/05/26 MARs, Controlled Substance Disposition Log, and current physician orders were reviewed and identified the following: Resident 2 had signed physician orders for oxycodone, 2.5 mg by mouth every 6 hours as needed for pain. There were four occasions where the medication has been documented as administered on the Controlled Substance Disposition Log but were not signed out on the MAR. In an interview on 01/06/26 at approximately 2:18pm, Staff 3 (LPN) reported she did not audit the Controlled Substance Disposition Log and MAR to ensure they were reflective of one another and instead audited the Controlled Substance Disposition Log and medication bubble packs to ensure they were reflective of one another. On 01/08/26 at approximately 3:30pm, the inconsistencies between the MARs and Controlled Substance Disposition Log were reviewed Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3, Staff 4 (Infection Control Specialist), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings.

Director of Health Services or designee completed an audit of narcotic book to MAR on or before January 16, 2026. Director of Health Services or designee re-educated staff to facility policy for narcotic administration. Narcotic administration will be audited at least weekly for proper documentation. Director of Health Services or designee will conduct at least weekly audits of resident records for completion for 12 weeks or until substantial compliance is achieved.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 2 of 2 sampled residents (#s 2 and 3) who had documented medication refusals. Findings include, but are not limited to: Resident 3 moved into the facility 08/2022 with diagnoses including stroke, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. Resident 3's record including the 12/01/25 – 01/05/26 MARs was reviewed during the survey and identified the resident had multiple medication refusals between 12/01/25 and 01/05/26. The medications refused included: *Aspirin (for stroke); *Clopidogrel (for stroke); *Escitalopram oxalate (for major depressive disorder); *Metoprolol (for hypertension); *Pantoprazole (for gastroesophageal reflux disease); *Buspirone (for anxiety disorder); *Macrobid (for UTI); *Tylenol (for pain); *Latanoprost (for glaucoma); *Trelegy Ellipta (for chronic obstructive pulmonary disease); *Brimonidine (for glaucoma); and *Nystatin Powder (for yeast rash). There was no documented evidence the facility notified the physician when the resident refused consent to the physician’s orders. During an interview conducted on 01/08/26 at approximately 2:00 pm, Staff 1 (MCC Administrator) confirmed the facility did not have a system in place to notify the physician when a resident refused medications. On 01/09/26 at 12:30 pm, the need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), and Staff 5 (RCC). They acknowledged the findings. 2. Resident 2 moved into the facility in 08/2025 with diagnoses including hypertension. The resident’s 12/01/25 through 01/05/26 MARs, physician orders, and 10/07/25 through 01/05/26 progress notes were reviewed. The resident refused consent to orders for the following medication: *Systane Ophthalmic Solution 0.4-0.3% (for dry, irritated, burning eyes) on four occasions. There was no documented evidence the prescriber was notified after each refusal for the medication. On 01/08/26 at approximately 3:30pm, the need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings.

Director of Health Services or designee completed an audit of medication refusal on the MAR on or before January 16, 2026 Director of Health Services or designee added medication refusal instructions to the MAR for all residents. Director of Health Services or designee will audit resident MARs quarterly, at change of condition and as needed to ensure medication refusals are documented timely. Director of Health Services or designee will conduct at least weekly audits or resident records for completion for 12 weeks or until substantial compliance is achieved.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity Based Staffing Tool (ABST) accurately captured care time staff were providing to each resident as outlined in each individual service plan for 2 of 4 sampled residents (#s 1 and 2) whose ABST was reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 08/2025 with diagnoses including hypertension. Interviews with staff, observations of the resident, and review of the resident’s service plan indicated Resident 4's ABST minutes did not accurately capture the care time staff provided in the following areas: *Personal hygiene such as shaving and mouth care; *Time responding to call lights; *Time spent providing non-drug intervention for pain; *Time ambulation, escorting to/from meals/activities; *Transfers in/out of bed/chair; *Bathing; *Bowel/bladder management; and *Dressing/undressing. On 01/08/26 at approximately 3:30pm, the need to accurately capture care time on the resident's ABST was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings. 2. Resident 1 moved into the facility in 06/2022 and had diagnoses which included unspecified abdominal pain and unspecified osteoarthritis, and s/he had recently been admitted to hospice services. Interviews with staff during the survey and review of the resident’s current service plan dated 12/04/25 and the 12/01/25 through 01/05/26 MARs indicated Resident 1’s ABST minutes did not accurately capture the care time staff provided in the following areas: * Time is spent providing non-drug interventions for pain management; * Time is spent providing treatments? (e.g. skin care, wound care, antibiotic treatment); and * Time is spent ensuring non-drug interventions for behaviors. Multiple staff interviews during the survey indicated the resident routinely received topical treatments to his/her hands for arthritis and was frequently provided with ice packs to the knee for pain management. In addition, due to the resident’s mental health needs, staff reported they were required to regularly intervene and de-escalate situations to support the resident’s safety and well-being. The need to accurately capture care time on the resident's ABST was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), Staff 5 (RCC) on 01/09/26 at 12:30 pm. They acknowledged the findings.

All resident's ABST were reviewed for accuracy on or before January 20, 2026. The Administrator or designee re-educated staff on ensuring ABST accuracy. ABST will be audited by RCCs for accuracy. Administrator or designee will conduct weekly audits of up to 5 residents ABST for accuracy for 12 weeks or until substantial compliance is achieved

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

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 ensure the facility’s acuity-based staffing tool (ABST) was updated following a significant change of condition for 1 of 4 sampled residents (#2), and multiple unsampled residents whose ABST evaluations were reviewed. Findings include but are not limited to: 1. Resident 2 moved into the facility in 08/2025 with diagnoses including hypertension. The resident service plan was last reviewed and updated on 11/20/25. Clinical records were reviewed, and interviews with staff and Resident 2 were conducted, and it was determined Resident 2 experienced a significant change of condition on 12/19/25. Resident 2’s ABST was last updated on 08/23/25, and the facility failed to update the resident ABST quarterly and following a significant change of condition as required. 2. 12 unsampled resident ABST evaluations had not been updated within the last 90 days. On 01/08/26 at approximately 3:30pm, the need to ensure the facility ABST was updated when a resident experienced a significant change of condition and no less than quarterly was discussed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), Staff 5 (RCC), and Staff 6 (RCC). They acknowledged the findings.

All resident's ABST were reviewed for accuracy on or before January 20, 2026. The Administrator or designee re-educated staff on ensuring ABST accuracy. Residents with a CoC ABST will be audited weekly for accuracy. Administrator or designee will conduct weekly audits of COC ABST for accuracy for 12 weeks or until substantial compliance is achieved

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.

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

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics and pre-service dementia training was completed prior to beginning job duties for 2 of 4 newly hired staff (#s 11 and 13) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 01/07/26 through 01/09/26. The following was identified: There was no documented evidence Staff 11 (CG), hired 10/22/25, had completed the following required pre-service orientation training prior to beginning job responsibilities: * Infectious disease prevention; and * Pre-service dementia training. b. There was no documented evidence Staff 13 (CG), hired 09/02/25, had completed the required pre-service dementia training prior to beginning job responsibilities. The need to ensure staff completed all required pre-service orientation and training prior to beginning their job responsibilities, and for direct care staff to complete required pre-service dementia training prior to providing care to residents was reviewed on 01/09/26 at 10:15 am with Staff 1 (MCC Administrator) and Staff 7 (Staff Coordinator). They acknowledged the findings

All employees identified in survey have completed required trainings on or before January 20, 2026. The Administrator re-educated the Staffing Coordinator to required pre-service training and documentation on or before January 20, 2026. New hire training documentation will be audited for completion of required elements weekly. The Administrator or designee will conduct weekly audits of new hire training records for completion fo r12 weeks or until substantial compliance is achieved.

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

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 ensure fire drills were conducted according to the Oregon Fire Code (OFC) and had documentation of all required components. Findings include, but are not limited to: Fire and life safety records dated 07/2025 through 11/2025 were reviewed with Staff 8 (Maintenance Director) at 2:00 pm on 01/07/26. The facility fire drills lacked documentation of the following required components: * Escape route used; and * Evidence alternate routes were used during the fire drills. The need to ensure fire drills were conducted in accordance with the OFC and that documentation included all required components was reviewed with Staff 1 (MCC Administrator), Staff 2 (RN), Staff 3 (LPN), Staff 4 (Infection Control Specialist), and Staff 5 (RCC) on 01/09/25 at 12:30 pm. All staff acknowledged the findings.

Facility fire drill documentation form has been updated to include all required elements. The Administrator or designee re-educated all staff on fire drill requirements on or before January 27, 2026. The facility will practice fire drills and/or provide an in-service monthly. The Administrator or designee will conduct monthly audits of fire drill training records for all required elements for 12 weeks or until substantial compliance is achieved.

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 observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations made in the kitchen on 10/24/23 from 10:15 am through 1:30 pm identified the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: *Handwashing sink; *Water/ice machine; *Floor throughout the kitchen; *Floors in-between and under equipment; *Large can opener; *Inside conventional oven; *Prep space next to stove; *Shelves and door seals of reach-in refrigerator and freezer; and *Fire sprinkler, vents, and light fixtures above the tray line. b. The following areas were found in need of repair: * Black serving trays had visible staining. * Floor with splitting seam * Service carts with visible damage (not smooth and cleanable) c. The staff supervising servers reported the rinse temperature for the dish machine did not need to be 180 degrees Fahrenheit, and she had been told 172 degrees Fahrenheit was acceptable. Dish washer rinse log was reviewed and multiple entries were noted less than the required 180 degrees. Surveyor educated staff on the temperature needed to sanitize dishes in the rinse cycle of the dish machine. d. Kitchen staff was observed to handle RTE (ready to eat) food items with potentially contaminated gloves during meal serve out. e. Kitchen staff did not check the temperature of a hot dog cooked to order on the grill before plating and serving to resident. Large container of pea/cheese/mayo salad was not kept on ice bath during serve out to ensure temperature remained at 41 or below. Findings were reviewed with Staff 2 (Dining Services Manager) on 10/24/23 at 1:00 pm. He acknowledged the findings. The need to ensure all areas of the kitchen were maintained in a sanitary manner and all equipment was in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Dining Services Manager) on 10/24/23 at 1:00 pm. They acknowledged the findings.

a1. Handwashing sink, floors in-between and under equipment in service area, shelves & door seals in refrigerator in service area have all been cleaned.   All items have been added to the weekly cleaning list which is completed by serving staff and audited by Dining Services Supervisor monthly.  Report given to Administrator or designee monthly. a2. Large can opener damaged parts have been replaced.  Inside conventional oven, prep space next to stove and shelves and doors in refridgerator and freezer have been cleaned. Routine checks and cleaning has been added to the Cook's weekly cleaning list. This will be audited by Dining Manager and report given to Administrator or Designee monthly. A concern regarding the grill top above the conventional oven has been discovered and we are working to repair or replace appliance. a3. Water/ice machine, floors through out the kitchen, fire sprikler, vents and light fixtures above the tray line have been cleaned.  Facility Operations Director has developed reoccuring work orders for each item listed above to be completed by Facility Ops employees routinely.   Dining Servies Director will audit kitchen quarterly and report to Administrator. b1.Black trays have been replaced. b2. The split in the floor has been repaired and floor condition has been added to Dining Services Director's quarterly audit. b3. Service carts with damage have either been repaired or replaced.  Checking the condition of the carts has been added to Dining Services Supervisor's monthly audit sheet. c1. Staff have been re-educated on the required temperature of the dishwasher at the monthly staff meeting.  A laminated sign will be posted near the dishwasher and a note has been added to the temp log sheet.  The Dining Services Supervisor has added a review of the temp log sheet to their monthly audit and will provide ongoing education as needed.   c2. Eco lab was out to service the dishwasher and made some adjustments to ensure temp reaches 180 degrees.  Upon testing, temp consistenly reached 180 degrees. d1. All kitchen staff have completed additional food safety training. Dining Manager has added observation of hand hygeine and handling of ready to eat food to their monthly audit.  Report given monthly to Administrator or Designee. e1. All kitchen staff have completed additional food safety training - which included the need to temp food before serving and keeping chilled items on ice. Dining Manager has added observation of temping food and proper storage of chilled food to monthly audit.  Report given monthly to Administrator or Designee.

The findings of the kitchen inspection, conducted 10/24/23, 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 10/24/23, conducted 01/29/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review, conducted during a site visit on 08/15/23, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 11). Findings include, but are not limited to: A review of Resident 11's July 2023 MAR and an incident investigation dated 07/23/23 revealed the following: *Resident 11 had an order for Clonazepam .5 mg take one tablet by mouth two times a day. *On 07/23/23 Resident 11 did not receive his/her morning dose of Clonazepam medication. During an interview with Resident 11 on 08/15/23 s/he stated remembering not getting the medication a few weeks previously, and had notexperienced any side effects or negative outcomes. The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 08/15/23. The facility failed to carry out medication orders as prescribed. Verbal plan of Correction: The Administrator to confirm that follow up training was completed with MT. LPN began printing reports that showed any holes in the MARs for MT's to review and correct, which was reviewed at clinical meeting on Thursdays. LPN to move medication errors to top of dashboard, review daily, and complete review weekly with the Administrator.

Based on observation, interview and record review, conducted during a site visit on 08/15/23, it was confirmed the facility failed to fully implement an ABST for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to: A review of the facility's ABST for 08/15/23 revealed the following: *The facility required 66.41 hours of direct care or 8.85 shifts; and *Resident 1 and Resident 2's care needs were not completely entered into the ABST. The facility's posted staffing plan revealed the following: stated: Day shift: 3 MA, 5 Universal workers, not increased to reflect ABST direct care needs. Eight direct care staff were observed working on day shift on 08/15/23. During an interview on 08/15/23, Staff 1 (Administrator) stated the facility staffed nine care staff during the day. She further stated, they are not always able to do that and confirmed there were only eight care staff working that morning. The facility failed to fully implement an ABST. The findings were reviewed with and acknowledged by Staff 1 on 08/15/23. Verbal plan of correction: The Administrator will update the posted staffing plan by end of day on 08/15/23. She will audit ABST by end of week, and will implement a rule that the new move-in checklist must be used and ABST must be completed prior to the resident moving into the facility.  The Administrator to meet with the RCC weekly and audit the facility's checklist for compliance.

The findings of the on-site investigation, conducted 08/15/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. 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, interview and record review, Compliance Specialist (CS) was unable to confirm that the facility failed visually observe the resident take the medication. Findings include but not limited to: During an unannounced site visit on 03/16/2023, CS completed several walk throughs of the facility and did not see any medications on the floor outside of resident rooms or left in resident rooms. CS observed Staff #4 (S4) pass medications to two residents and S4 observed both residents take their medications. During interview, S4 stated that they are required to observe all residents take their medications and that they have never seen a staff member leave medications at a resident's door. A review of the facility's Medication& Treatment Pass/Administration Policy and Procedure dated 10/22 stated "observe the resident taking the medication/treatment." These findings were reviewed with Staff #6-Staff #7 (S6-S7) on 03/16/2023.

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 03/16/2023.  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 determined the facility failed to ensure injuries of unknown cause were promptly investigated to rule out abuse, and reported to the local Seniors and People with Disabilities Office (SPD) for 2 of 2 sampled residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 08/2022, with diagnoses including cerebral infarction and hemiplegia/hemiparalysis affecting the dominant side. Interviews with staff and review of Resident 3's clinical records, including incident reports, progress notes dated 08/02/22 - 10/25/22, service plans, temporary service plans, evaluations, and hospital discharge records, revealed the following: * On 08/14/22, an incident report noted staff found Resident 3 on the floor near the foot of his/her bed. The resident stated s/he fell trying to move his/her wheelchair and reported hitting his/her head. The resident was sent to the hospital and was diagnosed with a "closed head injury." The facility's investigation lacked information as to whether or not staff had been following the service plan. There was no documented evidence abuse or suspected abuse had been ruled out, there was no documented evidence of an Administrator's review, and that the facility reported the incident to the local SPD office. * On 08/22/22, a progress note indicated staff discovered a bruise on Resident's 3 right shoulder. There was no documented evidence the Administrator reviewed the incident. * On 10/14/22, an incident report noted Resident 3 "stated [s/he] fell twice" and staff noted a bruise on the right side of Resident 3's face. A progress note dated 10/15/22 noted the resident stated s/he fell twice and did not notify staff immediately. The resident stated s/he fell trying to walk from the bed to his/her electric scooter and hit his/her face on the scooter, and the second fall occurred when s/he was trying to walk to his/her scooter and fell on his/her tailbone. The facility's investigation lacked information as to whether or not staff had been following the service plan. There was no documented evidence abuse or suspected abuse had been ruled out, there was no documented evidence of an Administrator's review, and that the facility reported the incident to the local SPD office. There was no documented evidence of an Administrator's review of the investigation until 10/21/22 The need to ensure incidents of abuse, suspected abuse, and injuries of unknown cause were promptly investigated and reviewed by the Administrator and incidents were immediately reported to the local Senior and People with Disabilities Office (SPD) if abuse or suspected abuse could not be ruled out was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 10/25/22 and 10/26/22. They acknowledged the findings and reported the required incidents to the local SPD office per the survey team's request; confirmation was provided. 2. Resident 2 was admitted to the facility in 06/2021 with diagnoses including rheumatoid arthritis and congestive heart failure. The resident's service plan, dated 10/07/22, observations of the resident, and interviews with care staff  indicated the resident required assistance to transfer and ambulate using a walker for short distances. Review of incident investigations and progress notes from 07/24/21 through 10/24/22 showed the following: A incident report dated 08/05/22 indicated the resident had paged for assistance at 3:00 am and was found on the floor in the bathroom with bleeding from both sides of his/her head, a skin tear on the left hand, and bleeding from the neck. The resident reported using the bathroom, but did not remember anything after that statement. The incident report indicated the resident was not wearing slippers or non-skid socks and the room was dark. Resident 2 was transported to the emergency room, admitted for an infection, and returned to the facility on 08/08/22. The facility failed to complete an investigation of the unwitnessed fall with injuries to rule out abuse and neglect and did not report the incident to the local SPD. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and to report to the local SPD when indicated was discussed with Staff 1 (Administrator), Staff 5 (RN Consultant), and Staff 8 (LPN) on 10/25/22. The staff acknowledged the findings. At the request of the surveyor, the facility reported the incident to the local SPD on 10/25/22 and provided the Surveyor a copy of the submitted report.

1. Dallas Retirement Village (DRV) has hired Elerwise Nurse consulting to provide root cause analysis training to all management staff, which is scheduled for November 29, 2022.  Elderwise is also going to provide Fall Prevention and Abuse Reporting training to all ALF staff, which is scheduled for November 29, 2022. 2. The RCCs will have thorough training provided by Elderwise and support of the administator.  They will take lead on Incident Investigations and review need for abuse reporting with administrator. Prompt list created for IR investigation by HSAs. 3. Abuse reporting will be audited and reviewed at monthly QAPI meeting.   4. The Administrator will be responsible for ensuring the corrections are monitored.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and that food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: A survey of the first-floor kitchen was completed by Nursing Facility surveyors on 07/01/22. The second-floor kitchen was toured on 10/24/22 and showed the following: * Brown build-up on floor at the baseboard juncture throughout kitchen; * Dust build-up on kitchen fans, including fan above clean dishes exiting ware washer; * Black debris on full length of windowsill; * Gouges on walls in multiple areas exposing drywall, creating an uncleanable surface; * Paper signs throughout kitchen, creating an uncleanable surface; and * Garbage cans throughout kitchen did not have lids. These findings were reviewed with Staff 9 (Kitchen Manager) and Staff 10 (Dining and Food Services Director) on 10/25/22 and with Staff 1 (Administrator) on 10/26/22. They acknowledged the findings.

All areas in the kitchen and pantry observed to be unclean during survey process have been cleaned.  Garbage cans with lids have been ordered and papers have been taken down and replaced with papers in plastic wipeable sleeves.   Aprons have been purchased and staff have been retrained on proper hand hygeine. Daily cleaning assignments/tasks have been delegated to staff.  Weekly deep clean days with additional heavy duty cleaning tasks have been implemented.      Windowsills, fans, floor/baseboard juncture, and walls are all on cleaning schedule and have been delegated to staff. Director of Dining servies or an appointed staff will walk kitchen daily to assure ongoing compliance and cleaning will remain intact. Weekly audit of all items listed above will be performed by the Director of Dining servies or designee.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements, were updated with changes as needed within 30 days of move-in for 1 of 4 sampled residents (#3) whose evaluations were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 08/2022, with diagnoses including cerebral infarction, hemiplegia/hemiparalysis affecting the dominant side, anxiety disorder, and major depressive disorder Resident 3's move-in evaluation did not include the following information: * Non-pharmacological interventions for reported pain and did not include information related to the resident's mental health diagnoses of major depressive disorder and anxiety disorder, including past treatments and non-pharmacological interventions; and * The resident was a fall risk and required frequent safety checks and staff escorts with mobility in his/her electric scooter. There was no documented evidence Resident 3's evaluation was updated when the resident experienced multiple unwitnessed falls within 30 days of move-in. The need to ensure move-in evaluations addressed all required elements, were updated as needed within 30 days of move-in was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 10/26/22. They acknowledged the findings.

Resident 3's evaluation has been updated to include all missing fields as identified in survey. Person's responsible for Evaluations have been retrained on required componants of the evaluations.   A sample of evaluations will be audited monthly to ensure they are completed timely, include all required components and are reflective of resident current care needs. A monthly evaluation report to be generated to determine due dates and ensure compliance.   The RCCs and Administrator are responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were updated following quarterly evaluations and provided clear direction to staff regarding the delivery of services for 1 of 4 sampled residents (#4) whose service plan was reviewed. Findings include, but are not limited to: Resident 4's service plan was reviewed during the survey. The following deficiencies were identified: * The resident's most current service plan was dated 04/11/22. In an interview on 10/25/22, Staff 3 (Resident Care Coordinator) confirmed Resident 4's service plan had not been updated quarterly as required. * The resident's service plan lacked clear direction to staff regarding catheter care, including when, how, and how often assistance was to be provided. The need to ensure service plans were updated following quarterly evaluations and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 5 (RN Consultant), and Staff 8 (LPN) on 10/26/22. They acknowledged the findings.

Resident 4's Service Plan has been updated to include missing fields as identified in survey.   Person's responsible for Service Plans have been retrained on the required componants of the service plan and Service Plan schedule - initial, 30 days, with significant change of condition and quarterly.   A sample of Service Plans will be audited monthly to ensure they are completed timely, include all required components and are reflective of resident current care needs. A monthly evaluation report to be generated to determine due dates and ensure compliance.     The RCCs and Administrator are responsible to see that the corrections are completed and monitored.

2. Resident 2 was admitted to the facility in 06/2021 with diagnoses including rheumatoid arthritis and congestive heart failure. Observations of Resident 2 during the survey revealed s/he had very fragile, translucent-appearing skin and wore protective arm sleeves. The resident was observed to have a bandage on his/her upper right arm. Resident 2's record revealed the following: An assessment, written by Staff 2 (RN) on 09/21/22 after a hospital return indicated the resident had "several small bruises throughout." There was no further information about the bruising documented, including the location of the bruising or monitoring progress weekly through resolution. Staff 8 (LPN) was interviewed on 10/25/22 at 11:35 am. She reported she had been monitoring the bruises, although had not completed any documentation. The need to ensure changes of condition, including skin injuries, were evaluated and monitored at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 5 (RN Consultant), and Staff 8 on 10/25/22.  They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes in residents' conditions were evaluated to determine resident-specific interventions and conditions were monitored, including the effectiveness of interventions, at least weekly through condition resolution for 2 of 4 sampled residents (#s 2 and 3) who experienced short-term changes of condition. Resident 3 experienced multiple unwitnessed falls, two of which resulted in injury. 1, Resident 3 was admitted to the facility in 08/2022, with diagnoses including cerebral infarction, hemiplegia/hemiparalysis affecting dominant side, diabetes, and anxiety. Observations, interviews, and review of Resident 3's clinical records, including incident reports, progress notes dated 08/02/22 - 10/25/22, service plans, temporary service plans, task records, evaluations, and hospital discharge records, revealed the following: Resident 3's move-in evaluation, Level of Care evaluation, and service plan noted the resident was alert and oriented and able to make his/her needs known  and required staff assistance with transfers, dressing, bathing, and toileting. Resident 3 was noted to be a fall risk related to right-sided weakness and required frequent safety checks, staff escorts with mobility in his/her wheelchair, and encouragement to use the call light for assistance. Review of Resident 3's clinical records revealed the resident experienced eight unwitnessed falls between 08/02/22 and 10/25/22: a. On 08/04/22, staff found Resident 3 on the floor in his/her room. The resident stated s/he fell when trying to get a shirt from the closet. No injury was noted. There was no documented evidence the facility developed fall interventions, or evaluated the interventions in place for effectiveness. b. On 08/12/22, staff found Resident 3 the on floor next to the entryway door. The resident stated s/he got up from the electric scooter to try to plug it in. There was no documented evidence the facility developed fall interventions or monitored the service plan interventions for effectiveness. c. On 08/14/22, staff found Resident 3 on the floor near the end of his/her bed. The resident stated s/he was eating lunch at the end of the bed and attempted to transfer self to move the wheelchair. The resident reported hitting his/her head and was sent to the hospital via emergency medical services (EMS), then diagnosed with a "closed head injury." * A temporary service plan related to falls was developed 08/15/22 and instructed staff to encourage Resident 3 to eat in the dining room and staff to place meal trays on the table in his/her room and assist him/her to the table. A progress note dated 08/15/22 indicated the facility contacted Resident 3's family to request lowering the resident's bed. *There was no documented evidence the facility monitored the effectiveness of previous interventions for staff to assist with transfers and encourage the resident to use the call light prior to the fall on 08/14/22 . d. On 08/22/22, staff found Resident 3 on the floor in his/her room after the resident tried to transfer from the couch to the electric scooter.  No injury was noted. A temporary service plan was developed but did not include new fall prevention interventions, and there was no documented evidence previous interventions were monitored for effectiveness.     e. On 09/04/22, staff found Resident 3 on the floor after s/he slipped out of bed. A temporary service plan was developed and instructed staff to ensure adequate lighting in the resident's room and ensure the light near the bathroom sink was on. There was no through investigation of the previous service-planned interventions for effectiveness, and the resident continued to fall. f. On 10/03/22, a home health staff member reported the resident had reported s/he fell on 09/30/22. No injury was noted when the facility evaluated the resident. The staff task record was updated with instructions for staff to provide safety checks four times per shift. g. On 10/14/2022, an incident reported noted Resident 3 "stated [s/he] fell twice" and staff noted a bruise on the right side of Resident 3's face. A progress note dated 10/15/22 noted the resident stated s/he fell twice and did not notify staff immediately. The resident stated s/he fell trying to walk from the bed to electric scooter and hit his/her face on the scooter and the second fall s/he was trying to walk to the electric scooter and fell on his/her tailbone. The facility called EMS who recommended further evaluation at the hospital, but the resident declined transport. There was no documented evidence the facility monitored the effectiveness of previous interventions for safety checks four times per shift, and the task record, dated 10/03/22 through 10/23/22, showed multiple days with inconsistent documentation. During an interview on 10/26/22, Staff 17 (CG) stated Resident 3 was supposed to have stand-by assistance from staff for most ADLs, but s/he never used the call light for assistance and staff checked on her multiple times a day. During an interview on 10/25/22, Resident 3 stated s/he was able to transfer self and get around walking in his/her room but "needed to be more careful, so [s/he] didn't fall". Resident 3 stated "the one time I fell, staff came right away when I pressed the call button for help." The facility failed to develop new fall prevention interventions and monitor previous interventions for effectiveness when Resident 3 experienced unwitnessed falls on 08/04/22 and 08/12/22. The resident experienced a third unwitnessed fall on 08/14/22, which resulted in a closed head injury. The resident continued to experience multiple unwitnessed falls, new fall interventions were not consistently developed and/or monitored for effectiveness, and on 10/14/22 the resident reported falls and sustained a bruise to his/her face and reported pain on his/her tail bone. The need to ensure short-term changes of condition were evaluated to determine resident-specific interventions and conditions were monitored, including the effectiveness of interventions, at least weekly through condition resolution was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 10/25/22. They acknowledged the findings.

Resident identified in survey as having insufficient monitoring has had record review to ensure all change of conditions are addressed and that service plan relfects current needs.   Staff responsible for change of condition monitoring will be retrained on required elements of change of condition monitoring. Clicinal meeting to be held at least weekly to ensure change of conditions are being addressed and monitored and that staff is made aware of short and long term care need changes. Monthly audit of sample of residents with change of condition will be reviews to ensure monitoring is in place and staff are made aware. AL Administrator and Director of Health Services are responsibe to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#3) who received insulin injections by unlicensed staff. Findings include, but are not limited to: Delegation records for Resident 3, reviewed on 10/25/22, indicated the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 11 (MT), Staff 20 (MT), and Staff 21 (MT) to include: * Nursing assessment and condition of the client to determine if the client's condition was stable and predictable; * The rationale for deciding the task of nursing care could be safely delegated to unlicensed persons; * Frequency the client should be reassessed, including rationale; and * Re-evaluation of the condition of the resident and skill of the delegated staff within 60 days of initial delegation. The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (Administrator), Staff 5 (RN Consultant), and Staff 8 (LPN) on 10/25/22. They acknowledged the findings.

LPNs are the only staff who are currently administering insulin. We are working to find an Agency RN and receiving support from Elderwise nurse consulting as we work to hire an RN. Will provide training to incoming RN on proper delegation protocol. The Administrator and Director of Health Services will review Delegation records weekly.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for all medications and treatments the facility was responsible to administer, for 1 of 4 sampled residents (# 3) whose MARs and orders were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 08/2022, with a diagnosis of diabetes. Interviews with staff and review of Resident 3's physician orders and 10/01/22 through 10/24/22 MAR/TAR revealed the following orders were not carried out as prescribed: * An order for insulin detmir solution (for type 2 diabetes), inject 9 units at bedtime, was not administered on 10/01/22, 10/05/22, and 10/08/22; and * An order to check CBG two times per day was not carried out on 10/01/22, 10/05/22, and 10/08/22. The need ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 8 (LPN) on 10/26/22. They acknowledged the findings.

Retrained staff on the importance of completing documentation in the MAR/TAR and administering medications as ordered. LN or designee will routinely audit MAR/TAR to flag and address missing documentation. Report of Audits given at monthly QAPI. Director of Health Services, LPN and Administrator will be responsible to see the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters were included on the MAR and staff documented which non-pharmacological interventions were attempted without success prior to administering a PRN psychotropic medication for 1 of 1 sampled resident (#6) who was prescribed and used PRN psychotropic medication. Findings include, but are not limited to: Resident 6 was admitted to the facility in 07/2022 with diagnoses including anxiety disorder. The resident's physician orders and 10/01/22 through 10/24/22 MAR and progress notes were reviewed. The following was identified: * The resident had a physician order for lorazepam (a psychotropic medication) as needed for anxiety, which had been administered 18 times between 10/01/22 and 10/24/22. There were no resident-specific parameters on the MAR indicating how the resident expressed anxiety. * Staff documented administration of PRN lorazepam in the resident's progress notes, but did not indicate what interventions had been attempted without success prior to administration of the PRN psychotropic. The need to have resident-specific parameters for PRN psychotropic medications on the MAR, as well as the need for staff to document which non-drug interventions were attempted without success prior to administration of a PRN psychotropic, was discussed with Staff 1 (Administrator), Staff 5 (RN Consultant), and Staff 8 (LPN) on 10/26/22. They acknowledged the findings.

Medication records have been audited to ensure non-pharmalogical interventions are present on MAR to attempt prior to administering pyschotropic medications. Staff responsible for medications have been educated on the requirements to document non-pharmalogical interventions prior to administering any psychotropic medication. Community LN will perform routine audits of psychotropic medication use to ensure compliance with interventions and documenation. Administrator and/or designee will audit MAR monthly for compliance.

Based on interview and record review, it was determined the facility failed to complete an Acuity-Based Staffing Tool (ABST) assessment for each resident and update the ABST information when there was a significant change of condition for 2 of 4 sampled residents (#s 2 and 4). Findings include, but are not limited to: On 10/25/22, the Facilities ABST assessment was reviewed with Staff 1 (Administrator). She confirmed the ABST tool  determined the facilities staffing plan. The ABST staffing hours recommended were reviewed and found equal to the number of staff listed on the staffing plan. Further review of the ABST tool and usage identified the following: a. The ABST tool showed 42 residents had information entered into the system, however the facility census was 45. Staff 1 and 4 (RCC) acknowledged the tool was incomplete, with three residents residing in the facility not entered into the ABST. Staff 4 completed entering of the ABST assessment information for the three missing residents prior to end of day on 10/25/22. b. The ABST information was reviewed during survey for four sampled residents. Resident 2 and 4's ABST information was determined to have entries which were inaccurate. Staff 4 acknowledged the inaccuracies and reported the tool had not been updated after the residents had a significant change of condition.  Staff 4 updated the information for both residents on 10/25/22. Staff 1 ran the report after all the ABST information was complete and updated. She  changed the staffing plan and schedule to increase staffing to include an additional care staff to both day and evening shifts as was indicated on the report. During the survey, there were no concerns of the facility having inadequate staff. The need to complete ABST information for all residents in the facility and update the information in the tool after significant changes of condition was reviewed with Staff 1 and Staff 4.

The ABST has been audited to ensure all residents are included and the tool is reflective of their care needs. Staff responsible for updating the ABST have been retrained and tools have been implemented for ongoing compliance. The RCCs will perform routine audits to ensure compliance.  Reporting findings at monthly QAPI meeting. RCCs and Administrator will be responsible to see that corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 13, 14, 15, and 16) completed all required pre-service orientation and dementia training prior to beginning their job responsibilities and providing care for residents and 2 of 2 long-term staff (#s 7 and 22) completed infectious disease prevention training prior to 07/01/22. Findings include, but are not limited to: Staff training records were reviewed on 10/25/22 and revealed the following: 1. There was no documented evidence Staff 13 (MT), Staff 14 (MT), Staff 15 (CG), or Staff 16 (CG), hired 08/02/22, 08/30/22, 08/30/22, and 09/19/22, respectively, completed one or more of the following required pre-service orientation elements prior to performing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Infectious Disease Prevention; * Fire safety and emergency procedures; and * Written job description. 2. There was no documented evidence Staff 13, Staff 14, Staff 15, or Staff 16 completed the one or more of the following dementia training topics prior to providing care to residents: * Techniques for understanding, communicating, and responding to behaviors and reducing the use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and the use of the person-centered approach. 3. There was no documented evidence Staff 7 (Marketing), hired 05/03/22, or Staff 22 (Director of Environmental Services), hired 08/26/02, completed infectious disease prevention training prior to 07/01/22. The need to ensure training is completed by newly hired and long-term staff within the required time frame was discussed with Staff 1 (Administrator) on 10/26/22. She acknowledged the findings.

All employees identified in survey have completed required trainings and documentation verifying training is in place. The Staffing Coordinator has been retrained on required pre-service training and documentation needed for new employees.   Auditing tools are implemented for ongoing monitoring of pre-service training for new employees. Training records will be audited monthly by the Staffing Coordinator and reported to Administrator. The Staffing Coordinator and Administrator are responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired staff (#s 15, and 16) demonstrated competency in all assigned job duties within 30 days of hire, including first aid and abdominal thrust. Findings include, but are not limited to: Staff training records were reviewed on 10/25/22 and the following was identified: 1. There was no documented evidence Staff 15 (CG), hired 08/30/22, or Staff 16 (CG), hired 09/19/22, demonstrated competency in the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Identification, documentation, and reporting of changes of condition; * Conditions which require assessment, treatment, observation, and reporting; * General food safety, serving, and sanitation; and * First Aid/abdominal thrust. The need to ensure newly hired employees demonstrated competency in all assigned job duties, and completed first aid and abdominal thrust training, within 30 days of hire was discussed with Staff 1 (Administrator) on 10/26/22. She acknowledged the findings.

All employees identified in survey have completed required compentancy trainings and documentation verifying training is in place. Auditing tools are in place and Staffing Coordinator has been retrained on required compentancy training and documentation needed for new employees. The Staffing Coordinator will audit training documents prior to each new employee working independently and give monthly report to administrator. The Staffing Coordinator and Administrator are responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure and document 4 of 4 long-term staff (#s 11, 12, 17, and 18) completed 12 hours of annual in-service training, including at least 6 hours related to dementia care. Findings include, but are not limited to: Staff training records were reviewed on 10/25/22 and revealed the following: There was no documented evidence Staff 11 (MT), Staff 12 (CG), Staff 17 (CG), or Staff 18 (CG), hired 06/21/19, 12/23/19, 03/11/05, and 07/01/03, respectively, completed at least 12 hours of training related to the provision of care in CBC, with  a minimum of six hours of training on dementia care topics. The to ensure long-term staff completed the required number of hours of annual in-service training and document the training was discussed with Staff 1 (Administrator) on 10/26/22. She acknowledged the findings.

All Employee files have been audited for compliance with annual on-going training.  All staff identified as dificient in training have since been assigned training and will be monitored until completion. Training will be assigned monthly along with our on-going inservices. The Staffing Coordinator, Administrator and/or designee will audit for compliance monthly.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternate months and to document all required elements of fire drills required by the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 10/25/22, and the following was identified: * There was no documented evidence staff were instructed on fire and life safety on alternate months from fire drills; and * Fire drill records did not include evidence drills were being conducted on all shifts or alternate escape routes were used during drills. The need to provide fire and life safety instruction to staff and document all required elements of fire drills as required by the OFC was discussed with Staff 1 (Administrator) and Staff 5 (Operations Director) on 10/26/22. They acknowledged the findings.

Person's responsible for Fire Life safety training and drills has been retrained on fire life safety training and documenatation.  Missing componants in documentation have been added to training materials. The Facility Ops director has updated the training schedule and training requirements. Fire Life Safety training records will be reviewed monthly. The Facility Operations Director and Adiminstrator will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed on 10/25/22. There was no documented evidence of a written record, including content and residents attending, of annual instruction to residents on 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. The need to ensure residents were provided instruction as required by the Oregon Fire Code was discussed with Staff 1 (Administrator) on 10/26/22.

Person's responsible for Fire Life safety Resident instruction have been retrained on fire life safety training requirements and documenatation.  Materials for resident instruction have been created. The RCCs have audit tool in place to ensure ongoing intruction to residents each quarter. The RCCs and Adiminstrator will be responsible to see that the corrections are completed and monitored.

The findings of the re-licensure survey, conducted 10/24/22 through 10/26/22, 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the revisit to the re-licensure survey of 10/26/22, conducted 03/21/23 through 03/22/23 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.