The Springs at Beaverton

OAR 411-054-0055 (3) Systems: Treatment Administration (3) TREATMENT ADMINISTRATION. (a) An accurate treatment record for each resident must be kept of all treatments ordered by a legally recognized practitioner and administered by the facility to that resident. (b) The treatment record must include: (A) Current month, day and year. (B) Type of treatment (e.g., dressing change, ointment application), treatment instructions and if applicable, significant side effects or when to call the prescriber or nurse. (C) Date and time administered. (D) Resident allergies and sensitivities, applicable to treatments. (E) Instructions for p.r.n. treatments, including resident specific parameters. (F) Initials of person administering the treatments. (G) Any deviation from instructions or refusal of treatment must be documented.

Based on observation, interview, and record review, it was determined the facility failed to ensure an accurate treatment record was kept of all treatments ordered by a legally recognized practitioner and administered by the facility for 1 of 1 sampled resident (#1) who had orders for PRN oxygen treatment. Findings include, but are not limited to: Resident 1 moved into the facility in 12/2024 with diagnoses including mouth cancer and was receiving hospice services. The resident’s 11/21/25 to 03/23/26 clinical record was reviewed, observations of the resident were made, and interviews with staff were conducted. The following was identified: The resident had signed prescriber orders for oxygen, which directed staff to administer give two liters per minute via nasal cannula PRN for shortness of breath and/or patient comfort. There was no documented evidence a treatment record was kept for the oxygen that included the current month, day and year, the type of treatment, the date and time administered, instructions for PRN treatments, including resident-specific parameters, and the initials of the person administering the treatments. Observations made of the resident on 03/23/26 showed s/he was using the oxygen, with the flow rate set at two liters per minute. In an interview at 10:35 am 3/23/26, Staff 8 (CG) stated the CGs usually assisted with the oxygen placement. She confirmed staff did not document when the treatment was administered. The need to ensure an accurate treatment record was kept of all treatments ordered by a legally recognized practitioner and administered to a resident by the facility was discussed with Staff 1 (Administrator/Vice President of New Business Operations), Staff 2 (Regional RN), Staff 15 (Director of New Business Operations), and Staff 5 (Resident Services Coordinator) at 12:35 pm on 03/25/26. They acknowledged the findings.

1. Treatment records will be added in the MAR for the Oxygen order and any other current or future treatment orders. Treatment orders will include resident-specific parameters, if applicable, and documentation of administering the treatment. 2. Med-Tech training will be completed to review the order entry process within the MAR for treatment orders. Team will conduct routine quality tracking where resident orders will be audited against the MAR to ensure orders are in place and proper documentation exists with parameters and for administering the treatment. 3. Quality tracking will take place weekly. Med Tech training will reoccur with new hires and updates will be provided, as needed. 4. Registered Nurse & Administrator

OAR 411-054-0055 (3) Systems: Treatment Administration (3) TREATMENT ADMINISTRATION. (a) An accurate treatment record for each resident must be kept of all treatments ordered by a legally recognized practitioner and administered by the facility to that resident. (b) The treatment record must include: (A) Current month, day and year. (B) Type of treatment (e.g., dressing change, ointment application), treatment instructions and if applicable, significant side effects or when to call the prescriber or nurse. (C) Date and time administered. (D) Resident allergies and sensitivities, applicable to treatments. (E) Instructions for p.r.n. treatments, including resident specific parameters. (F) Initials of person administering the treatments. (G) Any deviation from instructions or refusal of treatment must be documented.

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 2 of 2 newly hired staff (#s 9 and 10) completed all required pre-service orientation training prior to beginning job responsibilities. Findings include, but are not limited to: Staff training records were reviewed with Staff 15 (Director of New Business Operations) and Staff 3 (Business Office Manager) at 2:20 pm on 03/24/26. The following was identified: There was no documented evidence Staff 9 (CG), hired 02/02/26, and Staff 10 (MT), hired 01/16/26, completed pre-service orientation training in: * Resident rights and values of community-based care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Approved HCBS course; and/or * Approved LGBTQIA2S+ course. The need to ensure newly hired staff completed all required pre-service training prior to beginning job responsibilities was discussed with Staff 1 (Administrator/Vice President of New Business Operations), Staff 2 (Regional RN), Staff 15, and Staff 5 (Resident Services Coordinator) at 12:35 pm on 03/25/26. They acknowledged the findings.

1. All employees will have completed missing preservice training. A training report can be ran to help audit training records. Each staff member will be followed up with individually to clarify the outstanding training that needs to be completed. 2. Business Office Manager and Administrator will implement a tracking process to audit training records at least every two weeks for trainings that are not complete. Additionally, new staff members will not start training on the floor until all pre-service trainings are completed. 3. This will be evaluated by the Business Office Manager and Administrator with each new hire. 4. Administrator

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 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 7, 9, and 11) demonstrated satisfactory performance in assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 15 (Director of New Business Operations) and Staff 3 (Business Office Manager) at 2:20 pm on 03/24/26. The following was identified: There was no documented evidence Staff 7 (CG), hired 02/04/26, Staff 9 (CG), hired 02/02/26, and Staff 11 (MT), hired 11/01/25, demonstrated satisfactory performance in the following: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting on changes of condition; * Conditions that require assessment, treatment, observation, and reporting; and/or * Other duties, including medication and treatment administration. The need to ensure newly hired staff demonstrated satisfactory performance in assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator/Vice President of New Business Operations), Staff 2 (Regional RN), Staff 15, and Staff 5 (Resident Services Coordinator)at 12:35 pm on 03/25/26. They acknowledged the findings. Staff 15 confirmed Staff 11 would not administer medications or treatments until he demonstrated competency.

1. All employees will have completed 30-day training requirements. Each employee will be followed up with individually to ensure completion of these competencies. 2. Business Office Manager and Administrator will implement a tracking process to monitor 30-day competency dates at least twice a month and ensure all required training is complete. 3. This will be evaluated by the Business Office Manager and Administrator with each new hire. 4. Administrator

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired direct care staff (#s 7, 9, and 11) demonstrated satisfactory performance in assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 15 (Director of New Business Operations) and Staff 3 (Business Office Manager) at 2:20 pm on 03/24/26. The following was identified: There was no documented evidence Staff 7 (CG), hired 02/04/26, Staff 9 (CG), hired 02/02/26, and Staff 11 (MT), hired 11/01/25, demonstrated satisfactory performance in the following: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting on changes of condition; * Conditions that require assessment, treatment, observation, and reporting; and/or * Other duties, including medication and treatment administration. The need to ensure newly hired staff demonstrated satisfactory performance in assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator/Vice President of New Business Operations), Staff 2 (Regional RN), Staff 15, and Staff 5 (Resident Services Coordinator)at 12:35 pm on 3/25/26. They acknowledged the findings. Staff 15 confirmed Staff 11 would not administer medications or treatments until he demonstrated competency.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

OAR 411-054-0070 (3)(b)(A)(B)(C) 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: (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) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 2 of 2 newly hired staff (#s 9 and 10) whose training records were reviewed. Findings include, but are not limited to: Refer to: C370.

1. All employees will have completed missing preservice training, including department-approved LGBTQIA2S+ training. A training report can be ran to help audit training records. Each staff member will be followed up with individually to clarify the outstanding training that needs to be completed. 2. Business Office Manager and Administrator will implement a tracking process to audit training records at least every two weeks for trainings that are not complete. Additionally, new staff members will not start training on the floor until all pre-service trainings are completed. 3. This will be evaluated by the Business Office Manager and Administrator with each new hire. 4. Administrator

OAR 411-054-0070 (3)(b)(A)(B)(C) 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: (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) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 05/07/24 at 11:05 am, the facility kitchen was observed to need cleaning in the following areas: Food spills, splatters, debris, dust, grease and/or black matter was observed on the following: * Wall behind dishmachine and surrounding the Ecolab dispensing unit;   * Vents below the doors of freezers #1 and #2; * Sides of the deep fat fryer and stove/grill;   * Back of the stove/grill; * Wall behind the stove/grill/deep fat fryer; * Shelf under the steam table; * Two large food bin lids under the prep counter; and * Ceiling vent above two compartment sinks - dust accumulation. Other areas of concern included: * Two garbage cans were not covered when not in active use. * Three kitchen staff lacked hair and/or beard restraints. The areas of concern were observed and discussed with Staff 1 (Food Service Director) and discussed with Staff 2 (Director of Operations) on 05/07/24. The findings were acknowledged.

C 240:  Wall behind dish maching, vents below doors of freezers, sides of deep fat fryer and stove/grill, back of stove/grill, wall behind deep fat fryer, shelf under steam table, large food bin lids under prep counter, and ceiling vent above compartment sinks have all been cleaned following the inspection. Further, these items have been added to weekly and monthly cleaning schedules and will be audited by a walkthrough of the kitchen monthly to be conducted by ED and Dining Services Director. Garbage Cans have been covered and staff have been reminded to keep them covered. Hair and beard restraints have been purchased are now in use for kitchen staff.

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

The findings of the first re-visit to the kitchen inspection of 05/07/24, conducted on 07/16/24, 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.

3. Resident 4 was admitted to the facility in 12/2022 with diagnoses including diabetes. Observations of the resident, resident and staff interviews, review of the service plan available to staff dated 05/16/23 and TSPs (Temporary Service Plans) showed the service plan was not reflective of the resident's current care needs or did not provide clear direction to staff in the following areas: * Use of air mattress; * Ambulation status; * Outside service provider; * Use and managing of hearing aids; and * Use and managing glasses. The need to ensure Resident 4's service plan was reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23 at 12:40 pm. They reviewed the service plan and acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and were implemented by staff for 3 of 4 sampled residents (#s 2, 3, and 4). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including history of intracranial hemorrhage, osteoporosis, cardiac pacemaker and repeated falls. Observations of the resident, interviews with staff, and review of the service plan, dated 05/09/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not implemented by staff in the following areas: * Toileting needs; * Dietary needs and preferences including mechanical soft diet and use of clothing protector when eating; * Use of sling for right arm; * Ambulation ability; * Use of glasses; and * Non-medication interventions for pain. The need to ensure service plans were reflective of current care needs, provided clear direction to staff and were implemented by staff was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 11/2019 with diagnoses including hypertension and muscle weakness and was identified in the acuity interview as experiencing a recent weight loss with dysphagia (difficulty swallowing) and speech therapy services from an outside provider. Observations of the resident, resident and staff interviews, review of the most recent service plan dated 07/12/23, and TSPs (Temporary Service Plans) showed the service plan was not reflective of the resident's current care needs or was not implemented by staff in the following areas: * Outside service providers; and * Weekly weights. The need to ensure service plans were reflective and implemented was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23 at 11:40 am. They acknowledged the findings.

1- Action taken to correct rule/violation Resident 2- Service plan was updated to reflect current care needs and preferences with clear instructions how to perform required tasks.   Resident 3- Service plan was updated to reflect current care needs including weekly weights and outside providers. Resident 4- Service plan was updated to reflect current care needs, Preferences and clear instructions how to perform tasks. 2- System correction- Inservice to be held with Health Service team covering state requirements for service plans, ensuring they are person centered. 3-Completed service plans to be reviewed by HSD, and ED to make sure they are detailed, with clear instructions, preferences and preson centered. 4-Reponsible party- RCC, HSD, ED

2. Resident 4 was admitted in 12/2022 with diagnoses including diabetes. Resident 4 required a wheelchair for mobility. Resident 4's clinical record and charting notes, reviewed from 04/03/23 through 07/27/23, showed the following changes of condition: * 05/29/23: On a new anti-depressant medication; * 06/04/23: Emergency visit due to signs of depression and lethargy; * 06/13/23: Returned from a one week hospital stay; * 06/15/23: Started on a pureed diet; and * 06/19/23: Started on a new scheduled pain medication. The facility initiated short-term monitoring. However, there was no documented evidence the changes were monitored at least weekly through resolution. Additional information was requested on 08/02/23. On 08/02/23 at 11:00 am, Staff 2 (LPN) reported she reviewed the resident's record and concluded the short-term changes in condition had not been monitored weekly until resolved. The need to ensure short term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (ED), Staff 2 and Staff 5 (Chief Operating Officer) on 08/02/23 at 12:40 pm. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were monitored through resolution, with progress noted weekly, for 2 of 4 sampled residents (#s 3 and 4) reviewed with changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 11/2019 with diagnoses including hypertension and muscle weakness, and was identified in the acuity interview as having a recent weight loss with dysphagia (difficulty swallowing). Interviews with the resident and staff, a review of the service plan dated 07/12/23, and progress notes dated 07/12/23 through 07/31/23 were reviewed. Progress notes, dated 07/12/23, documented a significant weight loss of 9.27 pounds and a temporary service plan was created. The facility initiated monitoring; however there was no documented evidence of weekly progress noted through resolution. During an interview on 08/02/23, Staff 2 (LPN) and Staff 3 (RN) confirmed the change of condition had not been monitored weekly until resolution. The need to ensure changes of condition were monitored at least weekly until resolution was discussed with Staff 1 (ED), Staff 2 and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the information.

1- Immediate Action Taken- Resident 3- Change of Condition Assessment was updated. Resident 4- Change of Condition documentation was updated 2- System Correction- HSD to create a "Change of Condition" log. She and RN will both monitor the log weekly, ensuring follow-up and documentation is occuring. 3- On-going Evaluation- HSD and RN will go over Change of Condition log weekly 4- HSD, RN

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to: 1. Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: C 302: Systems: Tracking Controlled Substances C 303: Systems: Medication and Treatment Orders C 305: Systems: Resident Right to Refuse C 310: Systems: Medication Administration C 325: Systems: Self-Administration of Medications 2. Review of the MAR for 3 of 3 sampled residents (#s 1, 2 and 4) who received medication administration from facility staff indicated the facility used non time-specific ranges for medication administration. The MAR included administration times of "AM Ra", "PM Ra" and "HS Ra". The facility's medication administration policy was requested and received on 08/01/23. Review of the document revealed the facility lacked a policy for determining medication administration times not otherwise directed by the physician or other legally recognized practitioner. The document did not include information on how "AM Ra, PM Ra or HS Ra" was determined for each medication and was not resident-specific. During an interview on 08/01/23 at 11:11 am, Staff 5 (Chief Operating Officer) confirmed there was no policy for training medication aides to administer medications with time ranges. The need to ensure a safe medication system and adequate professional oversight was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Action taken- Audit of medpass conducted to re-view orders without specific times.  New order requested from MD to clarify, with resident preferences in mind. 2-System correction- Medication policy updated to give specific parameters when generic times are given unless indicated by specific MD order.  Training with medtechs around those parameters and to alert HSD of any new or current orders with unclear times or parameters. 3- Ongoing Evaluation-Quarterly 4-HSD, RN, ED

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 1 of 1 sampled resident (# 4) whose MAR and Controlled Substance Drug Disposition logs were reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 12/2022. Resident 4 had signed physician orders for hydrocodone/acetaminophen 5-325 mg, a half tablet two times daily as needed for pain. Resident 4's 07/01/23 through 07/31/23 MAR and the Controlled Substance Disposition Log were reviewed and revealed the following: * Staff documented the hydrocodone/acetaminophen 5-325 mg was administered on the Controlled Substance Disposition log on 07/22/23, 07/25/23, 07/26/23 and 07/27/23. * There was no documented evidence on the MAR that the medication was administered to Resident 4 on those days. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 08/02/23 with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer). They acknowledged the findings.

1- Action taken- Medaide training conducted - ensuring they sign narcotics out of NARC book AND out of PCC. 2 System correction- If Narcotic and its order were received to community but are not yet in PCC medtech instructed to speak with LN 3- Ongoing Evaluation-Triple check system in place to track all narcotics and medications 4- Responsible Party- CSS, RCC, HSD,

Based on observation, interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed by the resident's physician for 1 of 3 sampled residents (# 4) whose MAR/TAR was reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 12/2022 with diagnoses including diabetes and heart disease. The resident's 06/29/23 signed physician's orders and 07/01/23 through 07/31/23 MAR/TAR were reviewed and showed the following: a. A physician order indicated to check CBG two times daily and call if  CBG was greater than 350. The MAR showed eight occasions the resident's CBG was greater than 350. There was no documented evidence the facility staff notified the CBG results to the prescriber as ordered. b. A physician's order indicated to administer oxygen at the rate of 2 L/min when visibly short of breath. The order was not transcribed to the MAR to carry out as ordered. Oxygen supplies were not observed in the resident's room. c. A physician's order indicated to administer hydrocodone/acetaminophen 5/325 mg two times a day. The MAR showed the medication was administered three times a day on 07/10/23 and four times on 07/19/23, not two times a day as prescribed. The need to ensure the facility administered all medications and treatments as prescribed was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1-Immediate Action Taken- All orders received to community put through triple check system 2-System Correction- Med tech training to include the triple check system on receiving and processing orders. 3-Ongoing Evaluation- Weekly audit of parameters, ensuring notification to MD of findings outside of said parameters. 4- Responsible Party- HSD, CSS

2. Resident 4 was admitted to the facility in 12/2022 with diagnoses including diabetes. Resident 4's 07/01/23 through 07/31/23 MAR/TAR and current physician's orders were reviewed and a signed physician order stated, "Notify hospice [of] 3 consecutive doses of any refused medications." The resident's MAR/TAR revealed the following medication refusals: * Baza protect cream to the coccyx area on 19 occasions; * Docusate sodium for constipation on three occasions; and * Barrier cream treatment on 15 occasions. On 08/02/23 Staff 2 (LPN) reported there was no documented evidence the facility staff notified the physician of the resident's medication and treatment refusals. There was no evidence the facility had a system for notifying the prescriber when a resident refused to consent to orders. The need to ensure the facility notified the physician/practitioner of medication refusals as ordered was discussed with Staff 1 (ED), Staff 2 and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 1 and 4) who had medication refusals. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2023 with diagnoses including neurological disorder and Parkinson's disease. Resident 1's 07/01/23 through 07/31/23 MAR and current physician's orders were reviewed. The resident's record showed refusals of the following medications: * Finesteride daily for urinary symptoms; * Galantamine daily for dementia; * Vitamin D3 daily for supplement; * Sertraline daily for depression; * Carbidopa-Levidopa (two doses) for Parkinson's; * Divalproex daily for seizures; * Omeprazole daily for GERD; and * Acetaminophen three times daily for pain. The MAR indicated the resident refused all of the medications on 07/22/23 and some of the medications on 07/23/23. On 08/02/23, Staff 2 (LPN) confirmed there was no documented evidence the facility notified the physician each time the resident refused medications. There was no evidence the facility had an effective system for notifying prescribers when a resident refused to consent to orders. The need to ensure the facility had a system to notify the physician/prescriber of medication refusals was discussed with Staff 1 (ED), Staff 2 and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action Taken- Faxed  Dr's- getting clarification on how often they want to be notified of missed meds. 2-System correction- spreadsheet to be created- each resident and how often the MD wants to be notified.  CSS to ensure it is up to date Monthly.  Audit of all resident charts for MD request of missed med notification clarification. 3-Ongoing- CSS will run monthly refusal reports.  MD will be asked Quarterly to update their preferences and the spreadsheet will be updated.  Spreadsheet audited monthly for accuracy by CSS 4-Responsible Party- AA- creating and updating spreadsheet, CSS spreadsheet audit, RCC to quarterly fax MD for preferences, CSS to run refusal reports

3. Resident 4 was admitted to the facility in 12/2022 with diagnoses including diabetes. a. Resident 4's physician orders and 07/01/23 through 07/31/23 MARs were reviewed during the survey and showed the following: * Baqsimi nasal spray (to treat low blood sugar) for "severe hypoglycemia". There were no resident-specific parameters or instruction to unlicensed staff that indicated when to administer the nasal spray. b. The MAR had multiple blanks. The need to ensure the resident's MARs were accurate and included resident-specific parameters was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 3 of 3 sampled residents (#s 1, 2, and 4) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including history of intracranial hemorrhage and repeated falls. Resident 2's 07/01/23 through 07/30/23 MAR was reviewed and the following was identified: A. The following PRN medications lacked clear parameters for administration: * PRN lorazepam 0.5 mg and PRN haloperidol 2 mg/ml were both prescribed to treat anxiety and lacked clear parameters for the sequence of administration. B. The following PRN medications had administration parameters which were not followed: * PRN acetaminophen 160 mg/5 ml and ibuprofen 200 mg were both prescribed for pain, with acetaminophen to be administered first, and ibuprofen to be administered second. On 07/01/23 and 07/27/23, ibuprofen was administered, and acetaminophen was not administered. C. The MAR lacked the initials of the Medication Aide who administered the following: * Sodium Fluoride 1.1% on 07/04/23 and 07/08/23; * Tramadol HCL 50 mg on 07/06/23 and 07/08/23; * Acetaminophen 160 mg/5 ml on 07/08/23; and * Lidocaine 4% on 07/08/23. The need to ensure MARs included clear parameters for multiple PRN medications that were prescribed to treat the same condition, parameters were followed as indicated, and MARs included all required components was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings. 2. Resident 1 moved into the facility in 06/2023 with diagnoses including neurological disorder. Resident 1's physician orders and 07/01/23 through 07/31/23 MARs were reviewed and showed the following: * Senna 8.6 mg tab, Take 1 - 2 tabs by mouth twice daily as needed for constipation. There were no resident-specific parameters or instructions to staff regarding when to give one tablet or when to give two tablets for constipation. The need to ensure the resident's MARs were accurate and included resident-specific parameters was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Action Taken- PRN medication orders were audited, adding clear parameters where missing. 2-System Correction- Medaide training- triple check process of new orders needs to include looking for clear parameters.  LN will add specific parameters where missing. 3- Ongoing Evaluation- monthly Audit of PRN's- RCC or CSS will pull PRN report monthly- audit for clear parameters 4-HSD, RCC, CSS

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications for 1 of 2 sampled residents (#4) who chose to self-administer their medications. Findings include, but are not limited to: Resident 4 moved to the facility in 12/2022 with diagnoses including history of urinary tract infection and diabetes. Resident 4's clinical record and charting notes, reviewed from 04/03/23 through 07/27/23, showed the following: * 05/01/23 - The resident was on alert charting for antibiotic use for urinary tract infection; and * 05/04/23 - Staff documented "... self administered abx [antibiotic]". On 08/02/23 at 11:40 am, Staff 2 (LPN) confirmed the antibiotic was not administered by facility staff. There was no documented evidence the facility evaluated Resident 4's ability to safely self-administer the antibiotic. The failure to evaluate the resident's ability to self-administer medications was discussed with Staff 1 (ED), Staff 2, and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Action Taken- RN to conduct self med assessment for resident  4 2- System Correction- Medtech training to include notifying LN if family brings in a short term med and plans to administer it themselves. 3-Ongoing Evaluation- quarterly, during service plan updates, RCC to see if additional OTC or short term meds are being taken by resident, not in the system and will alert LN if found. 4- Responsible Party-RCC, HSD, RN

3. Resident 2 was admitted to the facility in 08/2022 and had a significant change of condition on 05/10/23. The resident's ABST was last updated on 03/30/23 which indicated it had not been updated quarterly or following the significant change of condition. The need to ensure the facility's ABST was updated following a significant change of condition and no less than quarterly was reviewed with Staff 1 (ED), Staff 2 (LPN), and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to review the Acuity-Based Staffing Tool (ABST) following a significant change of condition and no less than quarterly. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 11/2019 and had a significant change of condition on 07/12/23. The resident's ABST was last updated on 03/30/23 which indicated it had not been updated quarterly or following the significant change of condition. 2. The ABST for multiple sampled and unsampled residents had not been reviewed or updated quarterly. The need to ensure the facility's ABST was updated following a significant change of condition and no less than quarterly was reviewed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action Taken- service plans reviewed and ABST updated 2-System Correction- ED and CSS will meet monthly to review ABST to accuracies.  Health Service Department will notify ED of significant changes that effect ABST. 3-Ongoing Evaluation- Monthly audits and updates 4-Responsible party-ED, CSS

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 8, 9 and 12) demonstrated satisfactory performance in any assigned duty within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 08/01/23 and revealed the following: There was no documented evidence Staff 8 (MA), Staff 9 (CG) or Staff 12 (MA), hired 06/12/23, 02/20/23 and 04/11/23, respectively, demonstrated satisfactory performance in one of more of the following required areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions which require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. The need for direct care staff to demonstrate satisfactory performance in assigned job duties within 30 days of hire was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action Taken- Audit of staff trainings completed, 30 day competencies updated 2- System Correction- CSS and HSD to ensure competencies are completed for direct care staff within 30 days of hire date. Normal signs of aging and food safety added to 30 day Competency checklist. 3- Ongoing Evaluation- AA to assist ED in auditing and tracking new hires and their documentation nd training.  Audit done withing a week of onboarding a new staff and monthly. 4-Responsible Party-AA, CSS, ED

Based on interview and record review, it was determined the facility failed to ensure long-term employees completed 12 hours of annual in-service training related to the provision of care in a CBC setting for 4 of 4 long-term staff (#s 6, 10, 13 and 15). Findings include, but are not limited to: Staff training records were reviewed on 08/01/23 and revealed the following: Staff 6 (MA), Staff 10 (MA), Staff 13 (CG) and Staff 15 (Activities), hired 08/05/2021, 12/27/2019, 03/26/2014 and 04/16/2021, respectively, failed to have documented evidence of completing 12 hours of annual in-service training related to the provision of care in a CBC setting. The need to ensure long-term staff completed the required number of annual training hours was discussed with Staff 1 (ED), Staff 2 (LPN) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action Taken- Staff audit done, those with missing hours willl be assigned additional hours of training to be in compliance 2- System Correction- all staff will be scheduled time, outside of shift, to complete hourly training. 3-Ongoing Evaluation-monthly audits of trainings to be completed by AA.  ED will contact staff and remove them from schedule if they are more than one month behind on trainings. 4- Responsible Party- AA, ED

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and document all required components on fire drill records. Findings include, but are not limited to: Fire and life safety records from 02/2023 through 07/2023 were reviewed. The fire drill records did not consistently include documentation of the following required components: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. On 08/01/23 an interview with Staff 1 (ED) revealed the facility was not relocating or evacuating residents as part of the fire drill process. On 08/02/23 the need to ensure the facility conducted and documented fire drills according to the Oregon Fire Code (OFC) was discussed with Staff 1, Staff 2 (LPN), and Staff 5 (Chief Operating Officer). They acknowledged the findings.

1-Immediate Action Taken- Maintenance Director to receive additional training on conducting a fire drill.   2-System Correction- Prior to drill, ED will go over fire drill plan with Maintenance Director.  After Drill, ED will participate in a debriefing of drill, making sure all parts of form are filled in. 3-Ongoing Evaluation- Drills to be conducted every other month. 4-Responsible party- ED, Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure exterior surfaces were maintained in good repair. Findings include, but are not limited to: Observations of facility pathways, the inside and outside courtyards and seating areas on 07/31/23 identified the following: * Multiple drop-offs of 2-4 inches were noted along pathway edges around the perimeter of the inside and outside courtyards. The need to ensure pathways around the facility were in good repair with no potential tripping hazards was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 4 (Maintenance Director) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action taken- Landscaper called to add additional dirt or barkdust where the drop is greater than 2 inches 2-System Correction- Quarterly inspection of pathways to ensure no dangerous drop off pavement done by Maintenance Director and Landscapers 3-Ongoing Evaluation- Quarterly walk throughs. 4-Responsible Party- Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: Observations on 07/31/23 and 08/02/23 showed two exit doors to the parking lot and four exit doors to the inner courtyard did not have an operational alarm or other acceptable system to alert staff when residents exited the building. The need to ensure exit doors were equipped with a functional alarming device or other acceptable system was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 4 (Maintenance Director) and Staff 5 (Chief Operating Officer) on 08/02/23. They acknowledged the findings.

1- Immediate Action Taken- exit doors fitted with alarm system, 2- System Correction- Quarterly checks that all door alarms work 3- Ongoing Evaluation- Quarterly 4- Responsible party- Maintenance Director

The findings of the relicensure survey, conducted 07/31/23 through 08/02/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 08/02/23, conducted 11/13/23 through 11/14/23, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: a. On 01/11/23 at 10:30 am, the facility kitchen was observed and the following areas were in need of cleaning and repair: * Entrance of the kitchen door frame had gouges and scrapes; * The ice maker, stove, a free-standing freezer and grill had spills, drips and grease build-up on the front and sides of the equipment and on the wall behind them; * Stove knobs had spills and grease buildup; * Shelves, to store clean stainless-steel bowls, below prep areas had dried food, spills and splatter; * Walls throughout the kitchen had multiple spills, smears, splatters or brown matters; * Floors beneath equipment (ice maker, stove, grill), and prep areas had dried food,  debris, grease build-up and dust; * Floors throughout the kitchen had thick black matter build-up and dust in corners and around edges of floor; * Ceiling ventilation vents, near F2 (Freezer two), had a layer of dust; * Ceiling vents near the entry of the kitchen had peeling off paint; * The exhaust fan grates inside the walk-in refrigerator units had dust build-up; * The dish machine, electrical box, walls, floor and pipes under the dish machine and sink had an accumulation of white matters and debris; * Sink in janitor area had grease build-up; and * Missing bottom panel from the F1 (Freezer one). b. A bucket of sanitizer was tested with a facility test strip and the solution did not reach the required sanitizing level. During the tour on 01/11/23 at 11:23 am, Staff 2 (Food Service Director) reported he used the wrong test strip, and he did not have the correct test strips to check the sanitizing solution. c. A box of potatoes were stored on the floor. The above areas were shared and discussed with Staff 1 (ED) and Staff 2 on 01/11/23. They acknowledged the findings.

C240 a. *Entrance of Kitchen door frame- 1.Corrective Action Taken: Maintenance scheduled to replace door frame with more durable non-wood frame 2 System Improvement: Weekly leadership meetings will include repair issues.  Monthly building walk-throughs by maintenace looking for gouges and scrapes. 3. Ongoing Action: Monthly kitchen inspections 4. Person/Persons Responsible: Food Service Director (FSD) and Maintenance Director C240 a. *Icemaker, stove, free-standing freezer and grill had drips and grease buildup *stove knobs had spills and grease *Shelves had dried food and splatter *walls spills and splatter 1.Corrective Action Taken: Thorough kitchen cleaning done immediately 2 System Improvement:  Weekly, monthly and quarterly cleaning schedule created and implemented 3. Ongoing Action: FSD to ensure cleaning schedule is followed 4. Person/Persons Responsible: FSD C240 a. *Floors dried food, grease build up- 1.Corrective Action Taken: Immediate thorough mopping done, Multiple estimates requisitioned to professionally clean the floor.  Cleaning to be completed on or before 3/01/23 2 System Improvement.  Monthly walk through the kitchen to look for issues including the cleanliness of the floor. 3. Ongoing Action: Professional floor cleaning to be scheduled as needed to maintain floors 4. Person/Persons Responsible: FSD, Maintenance Director C240 a. *Ceiling vents had layer of dust and peeling paint, walk in refridgerator exhaust fan has dust build up 1.Corrective Action Taken: Maintenance cleaned vents and repaired peeling paint 1/24/23 2 System Improvement: Vent cleaning added to the regualar maintanance schedule on TELS 3. Ongoing Action: Kitchen/Refridgerator Vents will be cleaned quarterly 4. Person/Persons Responsible: Maintenance Director C240 a. *Lime buildup on dish machine, electrical box, walls, floor and sink 1.Corrective Action Taken: Lime Chemicals purchased to assist with the cleaning 2 System Improvement:Lime descaling part of monthly cleaning schedule. 3. Ongoing Action:Lime Descaling added to monthly cleaning schedule 4. Person/Persons Responsible:FSD, Maintenance  Director C240 a. *Missing bottom Panel from Freezer 1- 1. Corrective Action Taken: Panel replaced immediately 1/11/2023 2: System Correction: Staff inserviced to not remove covers until job is ready to start and replace them when they walk away from the job. 3: Ongoing Action: Monthly building inspections will include looking for equipment missing pieces. 4: Person/Persons Responsible: FSD, Maintenance Director C240 b. *Sanitizer did not meet required sanitation levels. 1.Corrective Action Taken: Ordered correct testing strips according to the chemical supplier. 2. System Correction: Checking for correct testing supplies will be added to the monthly kitchen walk through. 3. Ongoing Action: Monthly kitchen walk through will check for correct chemicals and testing supplies. 4: Person/Persons Responsible: FSD C240 c. * Box of potatoes stored on the floor 1. Corrective Action Taken: Potatoes moved from the floor. 2.  System Correction: Kitchen staff inserviced on proper food storage requirements. 3. Oncoing Correction:  Monthly inservices with kitchen staff, discussing regulations and policies, and inspecting kitchen together. 4: Person Responsible: FSD

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: The facility's kitchen was toured on 05/17/23 at 10:35 am. a) Observations revealed an accumulation of grease, splatter, food debris, dirt and/or dust on or underneath the following: * Flooring under cold prep area; * Walls behind cold prep area, including electrical outlets; * Shelving below cold prep area; * Flooring under freezer one, griddle and stove; * Walls and pipes behind freezer one, griddle and stove; * Freezer one; * Deep fryer; * Griddle; * Stove; * Garbage can near stove; * Walls at threshold of kitchen and dry storage area; * Shelving beneath stand-up mixer; * Walls beneath sink near stand-up mixer; * Ovens; * Ice machine, including pipes; * Door and door frame near ice machine; * Freezer two; * Walls surrounding warewasher; and * Warewasher, including pipes and digital reader. b) The door frame near the ice machine had gouges and scrapes which rendered it an uncleanable surface. The kitchen was toured and the areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) and Staff 2 (Food Service Director) on 05/17/23 at 1:10 pm. They acknowledged the findings.

C240 a. Accumulation of grease, splatter, food debris and or dust 1. COrrrective action taken: deep cleaning work party scheduled on or before June 26th. Professional floor cleaning rescheduled to get few missed spots. 2. System Improvement: ED will ensure this is complete. 3. Ongoing plan of action: Weekly and monthly cleaning schedules to be turned into ED, who will ensure they are being completed on time, 4. Person/Persons respnsible: ED, FSD, and Maintenance Director b. back door frame had gouges and scrapes 1. Corrective Action Taken: Mantenance Director to replace door frame. 2. System improvement- Monthly inspections to be scheduled 3. Ongoing Action: Maintenance Director and FSD will inspect kitchen monthly looking for damaged surfaces and report findings to ED. 4. Person/Persons responsible: ED, FSD and Maintenance Director C 455 not in full compliance after first survey see c240

Based on observation and interview, it was determined the facility failed to ensure the kitchen inspection survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

Refer to C240

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

The findings of the first revisit to the kitchen inspection of 01/11/23, conducted 05/17/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second re-visit to the kitchen inspection of 01/11/23, conducted 07/06/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.