Azalea Gardens Senior Living

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

Based on observation and interview, it was determined the facility failed to ensure residents’ right to be treated with dignity and respect for 1 of 1 sampled resident (#1) whose care was observed. Findings include, but are not limited to: Resident 1 was admitted to the assisted living facility in 02/2026 with diagnoses including multiple sclerosis. 1. During the survey, on 04/21/26, the following was observed: Staff 9 (MT) and Staff 16 (CG) were observed on 04/21/26 between 12:18 pm and 12:37 pm providing incontinence care to Resident 1. The resident was lying in bed and both staff removed wedges, soiled brief, and linens from the resident. The resident’s lower body was completely undressed. The room had a large window with the blinds open, allowing visibility from a public area, and several cars were observed passing by during the observation. At one point during care, at 12:28 pm, the resident was completely unclothed while the window blinds were open. The facility failed to provide privacy and dignity during personal care. 2. During the survey, on 04/22/26, the following was observed: Staff 14 (CG) and Staff 18 (CG) were observed on 04/22/26, between 3:21 pm and 3:43 pm, to provide a bed bath for Resident 1. The resident was lying in bed and Staff 14 folded the blanket to expose Resident 1’s legs. At the start of the bed bath, the resident’s room door and window blinds were open, allowing visibility from outside. After cleaning Resident 1’s legs and feet, both staff assisted with repositioning, turning the resident from side to side. Staff 18 removed the soiled brief and linens, and the resident’s lower body was fully undressed. Staff 14 continued providing perineal care while the room door and window blinds remained open. The facility failed to provide privacy and dignity during personal care. On 04/23/26 at approximately 11:30 am, the above observation was shared with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC). They acknowledged the facility failed to treat the resident with dignity and respect during the care.

1.Residents care plans will be immediately reviewed and updated to specifically address privacy and dignity measures during all personal care, including incontinence care, bed baths, dressing, and repositioning. All direct care, nursing, and medication staff will be re-trained on OAR 411-054-0027 requirements, emphasizing: Closing blinds and curtains, closing resident room doors, maintaining resident coverage throughout care, protecting resident dignity during all personal care tasks Immediate facility-wide observations will be conducted to ensure all residents receiving personal care are provided privacy protections. Residents currently receiving extensive personal care services will have care approaches reviewed to ensure compliance with privacy standards. 2.A mandatory privacy protocol checklist will be implemented requiring staff to verify: Window blinds are closed, doors are shut, privacy curtains are in place when applicable, residents remain covered except during the specific area of care being provided Privacy and dignity standards will be added to: New hire orientation, Annual staff training, and routine competency evaluations Supervisors will conduct routine environmental rounds to verify privacy compliance during care delivery. Shift-to-shift communication will include reminders regarding resident dignity and privacy expectations. Progressive disciplinary procedures will be enforced for non-compliance with resident rights policies. 3. Weekly privacy audits will be conducted for the first 4 weeks. Bi-weekly audits will be conducted for the following 8 weeks. Monthly audits will continue thereafter for ongoing compliance. Immediate corrective action will be taken for any additional concerns identified. 4. Administrator, Resident Care Coordinator, Shift Supervisors, Designee assigned by facility leadership These individuals will be responsible for: Staff education completion, audit oversight, monitoring compliance, implementing corrective action when necessary, ensuring sustained adherence to resident rights regulations.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ needs and preferences and provided clear direction to staff for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the assisted living facility in 04/2021 with diagnoses including congestive heart failure. The resident’s 01/21/26 to 04/21/26 clinical record was reviewed, interviews with the resident and staff were conducted, and observations were made. The service plan, dated 02/06/26, was not reflective of the resident’s current care needs in the following areas: * Conflicting information regarding use of compression socks; * Conflicting information regarding bathing status; and * The resident’s refusal to allow the facility to administer supplements and aspirin as ordered by the prescriber. On 04/22/26 at 1:30 pm, Staff 16 (CG) stated Resident 3 did not wear compression socks though the service plan instructed staff to assist with donning and doffing of socks. Resident 3 was also assisted with showers, not bed baths, as was specified in the service plan. This was confirmed by Staff 1 (Administrator) on 04/23/26 at 3:55 pm. The need to ensure residents’ service plans were reflective of their needs and provided clear direction to staff was reviewed with Staff 1, Staff 3 (Regional RN), Staff 4 (RCC), and Staff 7 (LPN) on 04/23/26 at 3:55 pm. They acknowledged the findings. 2. Resident 1 was admitted to the assisted living facility in 02/2026 with diagnoses including multiple sclerosis. Observations of the resident, interviews with staff and the resident, and a review of the 03/17/26 service plan were completed during the survey. The service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Instructions regarding the use of wedges to support body positioning and posture; * Instructions regarding elevating the legs and heels; * Instructions for the use of side rails and safety precautions; * Conflicting information regarding transfer status; * Conflicting information regarding showering or bathing status; * Bathing preferences, including time of day for bathing; and * Instructions for the use of an air mattress. During the survey, it was observed the resident used wedges, pillows and rolled blankets to support the body positioning and legs, as well as an air mattress and side rails. However, the service plan did not include any instructions regarding the use of this equipment. Additionally, the service plan stated the resident received showers using a shower bench; however, observation and staff interview confirmed the resident required and preferred bed baths. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC) on 04/23/26 at 11:20 am. They acknowledged the findings. No further information was provided. 3. Resident 2 was admitted to the MCC in 04/2025 with diagnoses including dementia and Parkinson’s disease. Clinical record review for Resident 2 identified the service plan available to staff, dated 04/09/26, including temporary service plans, did not provide clear direction to staff regarding: * Use of soft back brace when out of bed, related to a lumbar compression fracture; * Use of high back reclining wheelchair; * Use of side rails and associated safety precautions; and * Toileting and commode use with two-person assistance. During an observation of personal care on 04/22/26 at 2:10 pm, two care staff transferred Resident 2 to a commode in the resident’s room. Staff confirmed Resident 2 required two-person assistance for all transfers. On 04/23/26 at 4:20 pm, the need to ensure service plans were reflective and provided clear directions to staff was discussed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC). They acknowledged the findings.

The facility will immediately initiate corrective action to address deficiencies identified in resident service plans that were not reflective of current care needs, specifically regarding conflicting documentation for compression stocking use, bathing status, and medication refusal. The licensee will conduct a comprehensive review of all resident service plans. Each identified discrepancy will be corrected to ensure accuracy and alignment with the resident’s current assessed needs and provider orders. Updated service plans will clearly reflect: Appropriate use and orders for compression stockings, current bathing and toileting assistance level and schedule, resident rights and documented refusal of medication administration when applicable, use of Assistive Devices. Revised service plans will be reviewed with interdisciplinary staff and updated immediately upon identification of any change in condition or care needs. The licensee will ensure all service plans meet the requirements of OAR 411-054-0036(2), including accuracy, current resident needs, and consistency with care provided. A standardized service plan review process will be implemented during: Admission, thirty, sixty and ninety-day reviews, and any significant change in resident condition A two-step verification process will be established where the primary care coordinator completes updates and a secondary licensed staff member audits for accuracy and consistency. All caregivers will be required to read, acknowledge, and sign each resident’s service plan upon hire, during updates, and whenever revisions occur to ensure understanding and compliance. 3.Service plans will be reviewed: Upon admission, thirty, sixty, and ninety days, as weel as Immediately following any significant change in condition. A monthly internal audit of a random sample of service plans will be conducted to ensure ongoing compliance and accuracy. Any identified issues will be corrected immediately upon discovery. 4.The Administrator will have overall responsibility for ensuring implementation, compliance, and ongoing monitoring of all corrective actions. The Administrator or designee (Care Coordinator will: Conduct the comprehensive service plan review Ensure updates are completed accurately and timely Maintain documentation of caregiver review and signatures The Administrator will oversee ongoing compliance audits and ensure corrective actions remain effective and sustained over time.

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

Based on observation, interview, and record review, it was determined the facility failed to consistently determine and document what action or intervention was needed for short-term changes of condition, communicate the action or interview to staff on each shift, monitor the resident consistent with the resident’s evaluated needs, and document weekly progress until the condition was resolved for 3 of 3 sampled residents (#s 1, 2, and 3) reviewed with changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the assisted living facility in 02/2026 with diagnoses including multiple sclerosis and neurogenic bowel dysfunction. The resident’s clinical record from 02/13/26 through 04/21/26 was reviewed, observations of the resident were made, and interviews with the resident and facility staff were conducted. The facility failed to determine specific actions or interventions needed for the resident, communicate the determined actions or interventions to staff, or document weekly progress until the conditions were resolved for the following short-term changes of condition: * 02/13/26 - Excoriated area across buttocks; * 03/05/26 – Missed scheduled baclofen 10 mg for muscle relaxant; * 03/18/26 – Changed senna from PRN to scheduled to help constipation; * 03/20/26, 03/21/26, 03/22/26, 03/27/26, 03/28/26, and 03/29/26 - a medication, Eliquis, to prevent thrombosis and embolism, was not administered; * 04/02/26 – Changed multiple medications, including triamcinolone cream to reduce inflammation, for 10 days, discontinuation of nystatin cream to treat yeast skin infection and Tylenol 325 mg for pain, starting nystatin powder, and continuation of Tylenol 500 mg; * 04/04/26 – Missed scheduled fluconazole 150 mg to treat and prevent various fungal and yeast infection; and * 04/08/26 and 04/09/26 – Emergency department visits. The need to ensure the facility determined and documented what action or intervention was needed for short-term changes of condition, communicated the action or intervention to staff on each shift, monitored the resident consistent with the resident’s evaluated needs and documented weekly progress until the condition was resolved was reviewed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC) on 04/23/26 at 11:20 am. They acknowledged the findings. No further information was provided. 2. Resident 2 was admitted to the MCC in 04/2025 with diagnoses including dementia and Parkinson’s disease. Review of the resident’s clinical record, including observation notes dated 01/23/26 through 04/21/26, identified the following: Resident 2 was hospitalized from 01/30/26 through 02/03/26 and returned to the facility on 02/03/26 with a lumbar compression fracture and ambulatory dysfunction. There was no documented evidence the facility determined and documented what action or intervention was needed related to the resident’s lumbar compression fracture and ambulatory dysfunction, communicated the action or intervention to staff on each shift, or monitored the resident consistent with the resident’s evaluated needs. An observation note dated 02/04/26 at 10:00 am documented Resident 2 was sent back to the emergency room due to “decrease in level of consciousness” and being “unable to take meds, eat or drink.” An observation note dated 02/04/26 at 4:15 pm indicated Resident 2 was being transported back to the facility and would be on hospice. There was no documented evidence the facility determined and documented what action or intervention was needed related to Resident 2’s change in condition, communicated the action or intervention to direct care staff on each shift, or monitored the resident consistent with the resident’s evaluated needs. On 04/23/26 at 4:20 pm, the need to ensure the facility determined and documented what action or intervention was needed for resident changes in condition, communicated the action or intervention to staff on each shift, and monitored residents consistent with their evaluated needs was discussed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC). They acknowledged the findings. 3. Resident 3 was admitted to the assisted living facility in 04/2021 with diagnoses including congestive heart failure. Review of the resident’s 01/21/26 to 04/21/26 clinical record revealed the following: a. On 02/22/26, a MT documented, “the resident is constipated” and had requested assistance from a CG to digitally remove bowel. In a progress note on 03/11/26, the resident again reported constipation, and requested CG assistance in removing the obstruction. On 03/17/26, the resident was sent to the ER due to constipation. There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident when s/he first reported constipation on 02/22/26, communicated those actions to staff, and monitored and documented on the progress of the condition at least weekly until the condition resolved. On 04/23/26 at 9:40 am, Staff 3 (Regional RN) confirmed staff did not document bowel movements between 02/22/26 and 03/17/26 or monitor the resident for constipation. b. On 04/01/26, Staff 7 (LPN) documented “open sore noted to top of left ear… consistent with medical device-related pressure injury from mask ear loop.” There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, communicated those actions to staff, and monitored and documented on the progress of the injury at least weekly until the injury was resolved. Observations of the resident on 04/21/26 at 2:40 pm revealed a non-adhesive bandage on her left ear, which was secured by the ear loop of a disposable mask, which Resident 3 stated, “I wear at all times.” The need to ensure the facility consistently determined and documented what actions or interventions were needed for residents with short-term changes in condition, communicated actions or interventions to staff on each shift, and documented weekly progress until the conditions were resolved was reviewed with Staff 1 (Administrator), Staff 3, Staff 4 (RCC), and Staff 7 on 04/23/26 at 3:55 pm. They acknowledged the findings.

1. The facility immediately conducted a comprehensive review of all resident records identified during survey findings related to changes of condition, including excoriation to buttocks, constipation, medication omissions, medication changes, emergency room visits, hospitalization returns, pressure injuries, ambulatory dysfunction, altered level of consciousness, and hospice related conditions. Resident service plans, temporary service plans, observation notes, and monitoring documentation were reviewed and updated to ensure interventions and monitoring needs were clearly identified, documented, and communicated to staff. Specific interventions were developed and implemented for each identified condition, including monitoring instructions, documentation requirements, physician notification requirements, medication follow-up, skin monitoring, bowel monitoring, fall risk precautions, mobility assistance, and hospice related care needs. Staff were educated regarding OAR 411-054-0040 requirements for identifying changes of condition, documenting interventions, communicating care instructions to direct care staff each shift, and documenting progress notes at least weekly until the condition is resolved. Any residents currently experiencing unresolved changes of condition were immediately reviewed to ensure proper interventions and monitoring are in place. 2. The Administrator or designee holds daily stand up meetings with department directors to discuss needs, goals, and oversight of operations. Daily stand up meetings include review of the electronic health records "dashboard" ensure review of changes of condition, incident reports and other clinical components. Administrator or designee also attends daily shift change reports with care staff to commicate and provide direction to staff on care needs. The Administrator reports at least weekly to the executive COO and VP of Health Services key quality indicators such as staffing, incident reports, care concerns and other quality improvement metrix. This information is reviewed at least weekly during a Quality Assurance (QA) meeting with the executive team to ensure compliance. 3. The Administrator or Designee is to oversee these processes daily. 4. The Administrator is to ensure that the above is occuring with oversight of the COO and VP of Health Services.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

Based on interview and record review, it was determined the facility failed to ensure an RN assessed a resident with a significant change of condition and documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (#2) who experienced a significant change of condition. Findings include, but are not limited to: Resident 2 was admitted to the MCC in 04/2025 with diagnoses including dementia and Parkinson’s disease. Review of Resident 2’s clinical record, including observation notes dated 01/23/26 through 04/21/26, identified the following: Resident 2 returned to the facility on 02/03/26 with a lumbar compression fracture and ambulatory dysfunction. Staff documented on 02/04/26 that Resident 2 was sent back to the emergency room due to “decrease in level of consciousness” and being “unable to take meds, eat or drink.” Observation notes dated 02/04/26 at 4:15 pm indicated Resident 2 was being transported back to the facility and would be on hospice. Resident 2 was admitted to hospice on 02/06/26. Review of observation notes identified the initial RN significant change of condition assessment was not completed until 02/16/26, 13 days after Resident 2 returned to the facility with a lumbar compression fracture and ambulatory dysfunction. The note addressed Resident 2’s hospice-related decline but did not include an RN assessment of the lumbar compression fracture or related needs, including pain, mobility, transfers, brace use, or interventions. During an interview on 04/23/26 at 4:00 pm, Staff 3 (Regional RN) acknowledged the initial RN significant change of condition note was not completed until 02/16/26 and was not completed timely after Resident 2 returned to the facility on 02/03/26 with a lumbar compression fracture and ambulatory dysfunction. On 04/23/26 at 4:20 pm, the need to ensure an RN assessed residents with a significant change of condition and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 3, and Staff 4 (RCC). They acknowledged the findings.

1.The facility acknowledges that documentation did not demonstrate that a timely RN s1.The facility acknowledges that documentation did not demonstrate that a timely RN significant change of condition assessment was completed following Resident’s return to the facility with a lumbar compression fracture, ambulatory dysfunction, subsequent emergency room visit, decline in condition, and hospice admission. An RN has reviewed the resident’s records, hospitalization documentation, hospice records, observation notes, and related care needs to ensure all identified needs and interventions were addressed. The resident’s service plan and clinical documentation were reviewed and updated to reflect assessed needs related to pain management, mobility, transfers, brace use, fall risk, positioning, hospice services, and staff intervention requirements. Licensed nursing staff and management were educated regarding requirements for timely RN assessment and documentation of significant changes of condition in accordance with OAR 411-054-0045. 2.The facility has implemented a process requiring immediate notification to the RN and Resident Care Coordinator when a resident experiences a significant change of condition, including but not limited to hospitalization, emergency room return, fracture, decline in mobility, altered level of consciousness, inability to eat or drink, hospice admission, or other major health status changes. The RN will complete and document a significant change assessment within required timeframes, including findings, resident status, identified risks, interventions, staff instructions, and follow-up recommendations. A clinical review checklist has been implemented to ensure assessments include all applicable areas such as pain, mobility, transfers, skin condition, equipment or brace use, nutrition, hydration, cognition, and safety interventions. Service plans will be updated promptly following assessment findings, and staff will be instructed regarding all new interventions. 3.The Resident Care Coordinator and/or designee will audit significant change of condition documentation, RN assessments, and related service plan updates weekly for a period of 90 days to ensure compliance with OAR requirements. Audits will include review of hospital returns, hospice admissions, emergency room visits, and documented resident declines to verify timely RN assessment completion and implementation of interventions. Any identified concerns will be addressed immediately through additional staff training and corrective action. 4.The Executive Director, Resident Care Coordinator, and Registered Nurse will be responsible for ensuring corrective actions are completed, monitoring ongoing compliance, conducting audits, and providing additional education or intervention as needed. ignificant change of condition assessment was completed following Resident’s return to the facility with a lumbar compression fracture, ambulatory dysfunction, subsequent emergency room visit, decline in condition, and hospice admission. An RN has reviewed the resident’s records, hospitalization documentation, hospice records, observation notes, and related care needs to ensure all identified needs and interventions were addressed. The resident’s service plan and clinical documentation were reviewed and updated to reflect assessed needs related to pain management, mobility, transfers, brace use, fall risk, positioning, hospice services, and staff intervention requirements. Licensed nursing staff and management were educated regarding requirements for timely RN assessment and documentation of significant changes of condition in accordance with OAR 411-054-0045. 2.The facility has implemented a process requiring immediate notification to the RN and Resident Care Coordinator when a resident experiences a significant change of condition, including but not limited to hospitalization, emergency room return, fracture, decline in mobility, altered level of consciousness, inability to eat or drink, hospice admission, or other major health status changes. The RN will complete and document a significant change assessment within required timeframes, including findings, resident status, identified risks, interventions, staff instructions, and follow-up recommendations. A clinical review checklist has been implemented to ensure assessments include all applicable areas such as pain, mobility, transfers, skin condition, equipment or brace use, nutrition, hydration, cognition, and safety interventions. Service plans will be updated promptly following assessment findings, and staff will be instructed regarding all new interventions. 3.The Resident Care Coordinator and/or designee will audit significant change of condition documentation, RN assessments, and related service plan updates weekly for a period of 90 days to ensure compliance with OAR requirements. Audits will include review of hospital returns, hospice admissions, emergency room visits, and documented resident declines to verify timely RN assessment completion and implementation of interventions. Any identified concerns will be addressed immediately through additional staff training and corrective action. 4.The Executive Director, Resident Care Coordinator, and Registered Nurse will be responsible for ensuring corrective actions are completed, monitoring ongoing compliance, conducting audits, and providing additional education or intervention as needed.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

Based on interview and record review, it was determined the facility failed to ensure information and interventions provided by outside providers on-site were communicated to staff and service plans adjusted if necessary for 2 of 2 sampled residents (#s 1 and 2) who received outside services. Findings include, but are not limited to: 1. Resident 1 was admitted to the assisted living facility in 02/2026 with diagnoses including multiple sclerosis and was identified during the acuity interview on 04/21/26 as receiving home health services. Review of “Outside Services Documentation Forms" from 02/25/26 through 04/17/26 included the following recommendations, made by the provider: * 02/25/26 – “Turn more frequently, Elevate heels…” and “proper foley [catheter] care each shift”; * 02/27/26 – “position on side to air out”; * 03/03/26 – “Exercise to include, Recline bed 1 x [time] every hour, float heels, roll under knees and blankets off toes” to prevent contraction; * 03/17/26 – “frequent pressure relief with increased knee flexion”; and * 04/17/36 – “Please use only miconazole powder mixed [with] zinc protective cream to sacrum Rash then sprinkle more powder over – twice daily …no Nystatin please!” There was no documented evidence the facility communicated these recommendations to direct care staff or that the service plan was adjusted to ensure continuity of care. The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC) on 04/23/26 at 11:20 am. They acknowledged the findings. 2. Resident 2 was admitted to the MCC in 04/2025 with diagnoses including dementia and Parkinson’s disease. During the acuity interview on 04/21/26, Resident 2 was identified as receiving hospice services. On 04/22/26 at 3:00 pm, outside service provider documentation was requested. Staff 1 (Administrator) provided outside provider coordination forms and indicated they had not been reviewed. The forms were dated 02/10/26 through 04/10/26 and had either not been reviewed or maintained in the resident’s clinical record. There was no documented evidence the facility communicated the outside provider interventions to staff. On 04/23/26 at 4:20 pm, the need to coordinate on-site health services with outside service providers and ensure written information from hospice was reviewed and maintained in the resident’s record was discussed with Staff 1, Staff 3 (Regional RN), and Staff 4 (RCC). They acknowledged the findings.

1. Resident records, service plans, alert charting, and physician/provider recommendations were reviewed to ensure all current outside provider instructions were accurately transcribed into the resident service plan and communicated to caregiving staff. The identified resident’s service plan was updated to include all applicable interventions and treatment recommendations including repositioning schedules, heel elevation, Foley catheter care, pressure relief interventions, exercise recommendations, and wound care instructions. Care staff were immediately re-educated regarding implementation of provider recommendations and documentation expectations related to continuity of care. A system was implemented requiring all outside provider recommendations to be reviewed by the Resident Care Coordinator or designee within 24 hours of receipt, with documentation showing: Review of the recommendation; Communication to caregiving staff; Necessary updates to the service plan or temporary service plan; Verification that interventions were initiated. 2. The facility has revised its process for handling outside health service recommendations to ensure continuity of care is maintained at all times. Moving forward: All outside provider recommendations, therapy notes, wound care instructions, and discharge paperwork will be routed to the Resident Care Coordinator, nurse, or designee for review upon receipt. A standardized documentation process will be utilized to confirm recommendations are reviewed, acknowledged, communicated to staff, and implemented. All Outside Provider notes will be entered int the EHR. Service plans and temporary service plans will be updated promptly to reflect changes in care needs and provider instructions. Direct care staff will review and sign updated care instructions to verify understanding of interventions required during each shift. Management will conduct periodic audits of outside service documentation to ensure recommendations are reflected in resident care plans and charting. Staff education will be completed regarding OAR 411-054-0045(2), continuity of care requirements, documentation expectations, and communication procedures for outside health service recommendations. 3.The Resident Care Coordinator, nurse, or designee will audit outside provider recommendations and corresponding service plan updates weekly for 60 days to ensure compliance with facility procedures and Oregon Administrative Rule requirements. After the initial monitoring period, audits will continue monthly as part of the facility’s quality assurance program. Any identified concerns will result in immediate corrective action and additional staff training as needed. 4.The Executive Director, Resident Care Coordinator, and licensed nursing staff or designee will be responsible for ensuring corrections are completed, monitored, and maintained. Facility management will oversee staff education, auditing processes, service plan updates, and verification that outside provider recommendations are consistently communicated and implemented to ensure continuity of resident care in accordance with OAR 411-054-0045(2).

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to incontinence and personal care for 1 of 2 sampled residents (# 1) whose care was observed and for multiple unsampled residents during meal service in the MCC. Findings include but are not limited to: Observations were made during the survey to determine adherence to universal precautions for infection control. 1. Resident 1 was admitted to the assisted living facility in 02/2026 with diagnoses including multiple sclerosis. a. During the survey on 04/21/26, the following was observed: Staff 9 (MT) and Staff 16 (CG) were observed on 04/21/26 between 12:18 pm and 12:37 pm to provide incontinence care to Resident 1. The resident was lying in bed and both staff removed wedges, soiled brief and linens from the resident with gloved hands. Both staff provided incontinent care, applied clean incontinence products and powder treatment, and performed dressing changes using the same gloves. Once all the care was finished, Staff 16 removed the right-hand glove and emptied urine from the collection bag. Staff 16 then removed the left-hand glove and refilled the resident’s water bottle immediately after glove removal, without performing hand hygiene. b. During the survey on 04/22/26, the following was observed: Staff 14 (CG) and Staff 18 (CG) were observed on 04/22/26 between 3:21 pm and 3:43 pm to provide a bed bath for Resident 1. Staff 14 bathed the resident in bed using gloved hands and wet towels. Staff 18 removed a soiled brief and linens from the resident with gloved hands and placed soiled items on the floor. Then Staff 14 retrieved clean towels, linens, and a sheet, which were in direct contact with the floor, and used them during the care. Staff 14 touched her hair, clean linens, and soiled brief with the same gloves. Both staff used the same gloves while performing multiple tasks, including cleaning the resident, removing the soiled brief, applying a new brief and incontinent product and handling clean linens. The need to ensure infection prevention and control practices were followed during personal care was discussed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC) on 04/23/26 at 11:20 am. They acknowledged the findings. 2. Observations during meal service in the MCC on 04/21/26 and 04/22/26 showed direct care staff who provided ADL care to residents were also responsible for setting up the dining room for meal service, delivering meals, and providing feeding assistance to residents. Staff were observed performing meal service duties without wearing aprons or other protective covering over potentially contaminated clothing. On 04/23/25 at 5:30 pm, the need to ensure infection prevention and control practices were maintained by having staff wear aprons or other protective covering over their clothing during meal service was discussed with Staff 1 (Administrator), Staff 3 (Regional RN), Staff 4 (RCC), and Staff 7 (LPN). They acknowledged the findings.

1.The Administrator immediately reviewed the identified infection control concerns with all direct care, medication, and dietary staff. The facility implemented immediate corrective measures requiring staff to: Perform hand hygiene before and after resident care tasks and immediately following glove removal; Change gloves between contaminated and clean tasks; Avoid placing clean linens or supplies on contaminated surfaces; Prevent clean items from coming into contact with the floor or other contaminated areas; wear protective coverings, including aprons, during dining service or meal assistance; Follow proper infection control procedures during dressing changes, incontinence care, bathing assistance, and food service. The Administrator also conducted an immediate review of infection control supply availability to ensure adequate access to gloves, hand hygiene products, aprons, gowns, and disinfecting supplies throughout the community. 2.The Administraor will revise and reinforce the community infection prevention and control program to ensure consistent compliance with OAR 411-054-0050(1-5). Mandatory infection control training will be completed by all staff and incorporated into orientation for all newly hired employees. Training topics will include: Universal precautions; Proper handwashing and sanitizer use; Appropriate glove use and glove changes; Cross contamination prevention; Safe handling of clean and soiled linens; Infection prevention during dressing changes and personal care; Meal service sanitation practices; Appropriate use of personal protective equipment (PPE). The facility will also implement routine infection control observations during all shifts to ensure staff consistently follow required procedures. Management staff will provide immediate coaching and corrective action if concerns are identified. Dining service procedures will be reviewed to ensure staff providing direct resident care appropriately change PPE and perform hand hygiene prior to handling food service duties. 3.The Administrator or designee will conduct weekly infection control audits for a minimum of 90 days. Audits will include observation of direct resident care, dressing changes, bathing assistance, hand hygiene practices, linen handling, PPE use, and meal service procedures. Findings from the audits will be reviewed with staff during routine meetings and additional training will be provided as needed. After the initial 90-day monitoring period, infection control practices will continue to be reviewed routinely through ongoing quality assurance and management oversight. 4.The Administrator, Resident Care Coordinator, and Registered Nurse will be responsible for ensuring corrections are completed, staff training is conducted, infection control audits are performed, and ongoing compliance with infection prevention and control requirements is maintained.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system.

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to: During the relicensure survey, conducted 04/21/26 through 04/23/26, professional oversight of the facility's medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C303: Systems: Treatment Orders; * C305: Systems: Resident Right to Refuse; and * C330: Systems: Psychotropic Medication. The need to ensure a safe medication and treatment system was discussed with Staff 1 (Administrator), Staff 3 (Regional RN), Staff 4 (RCC), and Staff 7 (LPN) on 04/23/26 at 3:55 pm. They acknowledged the findings.

1. A comprehensive review of medication administration practices, treatment orders, psychotropic medication documentation, and resident right-to-refuse procedures will be completed. The facility nurse and administrator will review all current resident records to ensure: Treatment orders are current, accurately transcribed, and properly implemented; Documentation reflects resident rights to refuse medications and treatments; Psychotropic medication monitoring and documentation meet regulatory requirements; Medication and treatment systems are consistent with physician orders and resident service plans. Any discrepancies identified during the audit will be corrected immediately. Staff members responsible for medication administration received re-education regarding physician orders, refusal documentation, psychotropic medication monitoring requirements, and medication system procedures in accordance with OAR 411-054-0055. 2. The facility has implemented oversight procedures to strengthen medication and treatment administration systems. These corrective measures include: Monthly RN or designee review of medication administration records, treatment records, and physician orders; Enhanced review process for psychotropic medications, including non-pharmaceutical interventions and monitoring documentation and behaviors when applicable; Re-education for all medication technicians, caregivers, and nursing staff regarding resident rights, treatment orders, refusals, and psychotropic medication requirements; Implementation of routine chart audits to ensure physician orders are accurately reflected in resident records and service plans; Improved communication systems between healthcare providers, nursing staff, and direct care staff regarding new or changed orders. Newly hired staff responsible for medication administration will receive training and competency validation prior to independently administering medications or treatments. 3.The facility administrator, RN, or designee will conduct weekly audits of medication administration systems, treatment orders, refusal documentation, and psychotropic medication monitoring for a period of 90 days. After 90 days, audits will continue monthly or more frequently as needed to ensure ongoing compliance. Audit findings will be reviewed during management meetings and corrective action will be implemented immediately if concerns are identified. 4.The Executive Director/Administrator, Resident Care Coordinator, and Registered Nurse will be responsible for ensuring all corrections are completed, monitored, and maintained. These individuals will oversee staff training, auditing processes, compliance monitoring, and ongoing quality assurance related to medication and treatment administration systems.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 2) who were administered medications and treatments. Findings include, but are not limited to: 1. Resident 1 was admitted to the assisted living facility in 02/2026 with diagnoses including multiple sclerosis and neurogenic bowel dysfunction. The clinical record dated 02/11/26 through 04/22/26 was reviewed and noted the following: a. A physician order indicated alert charting for no bowel movement related to neurogenic bowel every shift; however, the bowel charting notes revealed the order was not carried out as prescribed. b. The resident had a physician's order to administer Eliquis 2.5 mg two times a day for venous thrombosis and embolism. The progress notes showed Eliquis was not administered due to the medication not being available on 03/20/26, 03/21/26, 03/22/26, 03/27/26, 03/28/26, and 03/29/26. c. The resident had a physician's order to administer baclofen 10 mg two times a day related to progressive multiple sclerosis. The progress notes showed baclofen was not administered due to the medication not being available on 03/05/26. d. The resident had a physician's order to apply nystatin powder two times a day to prevent yeast infection. The MARs showed nystatin powder was not applied due to the medication not being available on 04/01/26, 04/13/26, and 04/14/26. e. The resident had a physician's order to administer fluconazole 150 mg every 72 hours for 2 doses to treat fungal and yeast infections. The MARs showed the medication was not administered due to the medication not being available on 04/01/26 and 04/04/26. f. The resident had a physician's order to administer Mylanta 30 milliliter (ml) orally every four hours PRN for complaint of upset stomach or heartburn; however, the MAR directed staff to administer the medication 10 ml by mouth four times daily as needed. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 3 (Regional RN), Staff 4 (RCC), and Staff 7 (LPN) on 04/23/26 at 5:10 pm. They acknowledged the findings. 2. Resident 2 was admitted to the MCC in 04/2025 with diagnoses including dementia and Parkinson’s disease. Review of Resident 2’s clinical record, including the 04/01/26 through 04/21/26 MAR and signed physician orders dated 03/24/26, identified the following: * The 03/24/26 signed physician orders directed staff to administer carbidopa-levodopa for Parkinson’s disease, 10-100 mg tablet, 0.5 tablet by mouth three times a day. The 04/01/26 through 04/21/26 MAR showed Resident 2 did not receive 21 doses as ordered. The scheduled medication notations section of the MAR indicated the medication was ordered and awaiting delivery; and * The 03/24/2026 signed physician orders directed staff to administer duloxetine for depression, 30 mg, one capsule by mouth every day. The MAR showed Resident 2 was not administered duloxetine for 10 days between 04/01/26 and 04/21/26. The scheduled medication notations section of the MAR indicated the medication was ordered and awaiting delivery. On 04/22/26 at 1:45 pm, Staff 9 (MT) stated the facility was receiving limited amounts of the medications and the MT did not know why. On 04/22/26 at 2:00 pm, Resident 2 not receiving medications as ordered was discussed with Staff 1 (Administrator) and Staff 3 (Regional RN). Staff 1 and Staff 3 indicated they were not aware Resident 2 had not been receiving the medications as ordered. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1, Staff 3, and Staff 4 (RCC) on 04/23/26 at 4:20 pm. They acknowledged the findings.

1.The facility will conduct a compre1.A review of current residents with physician orders requiring provider notification for medication or treatment refusals was completed to ensure all required notifications were current and properly documented. Staff members responsible for medication administration and documentation received re-education regarding resident rights to refuse, physician notification requirements, and proper documentation procedures when refusals occur. 2.The facility will revise and reinforce medication refusal procedures to ensure physician or practitioner notification occurs as ordered whenever a resident refuses medications or treatments. Medication administration staff will be educated on reviewing physician orders for specific refusal notification instructions prior to medication pass. The facility will implement an audit process to verify refusals are documented appropriately and that required provider notifications are completed timely. The Resident Care Coordinator and/or designee will review alert charting, progress notes, and medication refusal documentation routinely to ensure compliance with OAR 411-054-0055(1)(j-k). 3.Medication and treatment refusal documentation, including provider notification requirements, will be audited weekly for four weeks, then monthly thereafter for continued compliance. Additional monitoring will occur during routine clinical record reviews and medication administration observations. 4.The Executive Director, Resident Care Coordinator, and Licensed Nurse/RN will be responsible for ensuring corrective actions are completed, staff education is conducted, audits are performed, and ongoing compliance with physician notification requirements related to resident refusals is maintained. hensive review of all physician medication and treatm1.The facility will conduct a comprehensive review of all physician medication and treatment orders to ensure orders were accurately transcribed, available, and administered as prescribed. The identified concerns involving unavailable medications, incomplete treatment administration, inaccurate MAR transcription, and failure to carry out physician orders will be reviewed by the Administrator, Resident Care Coordinator, and RN. Corrective actions taken included: Verification of all current physician orders against the Medication Administration Records (MARs) Immediate correction of inaccurate MAR instructions, including clarification of Mylanta dosing instructions; Review of all missed medications and treatments to determine resident impact and physician notification requirements; Contact with pharmacies to address medication delivery concerns and refill processes; Re-education of medication technicians: timely medication reordering procedures, proper transcription of physician orders, required documentation for unavailable medications, notification requirements to the RN, provider, and pharmacy when medications are unavailable, and ensuring treatments and medications are administered exactly as prescribed. 2.The facility has implemented enhanced medication management and treatment oversight systems to ensure physician orders are carried out as prescribed. System changes include: Establishment of a routine medication cart audit process to monitor medication supply levels and treatment availability; Standardized physician order transcription review by the RN, RCC, or designee to ensure MARs accurately reflect current orders; Creation of a follow-up procedure requiring staff to escalate unavailable medications immediately to the pharmacy, RN, and administration; Enhanced monitoring of high-risk medications, including anticoagulants and psychotropic medications; Monthly audits of physician orders, MARs, and progress notes to verify accuracy and compliance; Staff retraining regarding treatment order implementation, documentation standards, and medication administration requirements under Oregon Administrative Rules. The facility will also review pharmacy communication practices to ensure medications are delivered timely and refill requests are processed prior to depletion. 3.Weekly audits of medication administration records, treatment records, physician orders, and medication availability will be conducted for 90 days by the Administrator, Resident Care Coordinator, or RN. Audit reviews will include: missed medications, unavailable medications, transcription accuracy, treatment completion, and timely provider/pharmacy notification. After the initial 90-day period, audits will continue monthly or more frequently if concerns are identified. Audit findings and corrective actions will be reviewed during quality assurance and management meetings to ensure continued compliance. 4.The Executive Director/Administrator, Resident Care Coordinator, Registered Nurse, and designated medication management staff will be responsible for ensuring corrections are completed, monitored, and maintained. These individuals will oversee: medication and treatment audits, staff training and competency validation, physician order verification, pharmacy communication, and ongoing compliance with OAR 411-054-0055 requirements regarding medication and treatment systems. ent orders to ensure orders were accurately transcribed, available, and administered as prescribed. The identified concerns involving unavailable medications, incomplete treatment administration, inaccurate MAR transcription, and failure to carry out physician orders will be reviewed by the Administrator, Resident Care Coordinator, and RN. Corrective actions taken included: Verification of all current physician orders against the Medication Administration Records (MARs) Immediate correction of inaccurate MAR instructions, including clarification of Mylanta dosing instructions; Review of all missed medications and treatments to determine resident impact and physician notification requirements; Contact with pharmacies to address medication delivery concerns and refill processes; Re-education of medication technicians: timely medication reordering procedures, proper transcription of physician orders, required documentation for unavailable medications, notification requirements to the RN, provider, and pharmacy when medications are unavailable, and ensuring treatments and medications are administered exactly as prescribed. 2.The facility has implemented enhanced medication management and treatment oversight systems to ensure physician orders are carried out as prescribed. System changes include: Establishment of a routine medication cart audit process to monitor medication supply levels and treatment availability; Standardized physician order transcription review by the RN, RCC, or designee to ensure MARs accurately reflect current orders; Creation of a follow-up procedure requiring staff to escalate unavailable medications immediately to the pharmacy, RN, and administration; Enhanced monitoring of high-risk medications, including anticoagulants and psychotropic medications; Monthly audits of physician orders, MARs, and progress notes to verify accuracy and compliance; Staff retraining regarding treatment order implementation, documentation standards, and medication administration requirements under Oregon Administrative Rules. The facility will also review pharmacy communication practices to ensure medications are delivered timely and refill requests are processed prior to depletion. 3.Weekly audits of medication administration records, treatment records, physician orders, and medication availability will be conducted for 90 days by the Administrator, Resident Care Coordinator, or RN. Audit reviews will include: missed medications, unavailable medications, transcription accuracy, treatment completion, and timely provider/pharmacy notification. After the initial 90-day period, audits will continue monthly or more frequently if concerns are identified. Audit findings and corrective actions will be reviewed during quality assurance and management meetings to ensure continued compliance. 4.The Executive Director/Administrator, Resident Care Coordinator, Registered Nurse, and designated medication management staff will be responsible for ensuring corrections are completed, monitored, and maintained. These individuals will oversee: medication and treatment audits, staff training and competency validation, physician order verification, pharmacy communication, and ongoing compliance with OAR 411-054-0055 requirements regarding medication and treatment systems.

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 or other practitioner if a resident refused consent to an order for 2 of 3 sampled residents (#s 1 and 2) who had documented refusals. Findings include, but are not limited to: 1. Resident 1 was admitted to the assisted living facility in 02/2026 with diagnoses including multiple sclerosis. Clinical records dated 02/06/26 through 04/21/26 were reviewed and noted the following: * Signed MD orders, dated 02/06/26, indicated to “notify PCP [if] resident refuses medication or treatment” daily; * Staff documented Resident 1 refused Eliquis, for venous thrombosis and embolism, on 03/20/26 and Senna for bowel movement on 04/10/26 and 04/11/26; and * There was no documented evidence the facility notified the physician/practitioner when the resident refused consent to the orders. In an interview on 04/23/26 at 8:19 am, Staff 1 (Administrator) stated staff’s reporting of resident refusals had “not been done correctly.” On 04/23/26 at 8:19 am, the need to ensure residents' physician or other prescriber was notified of all refusals was discussed with Staff 1, and the staff acknowledged the findings. 2. Resident 2 was admitted to the MCC in 04/2025 with diagnoses including dementia and Parkinson’s disease. Review of Resident 2’s 02/2026 and 03/2026 MARs identified multiple medication refusals. The clinical record did not include documentation the physician was notified when Resident 2 refused consent to medication orders. On 04/23/26 at 4:20 pm, the need to notify the physician when a resident refused consent to an order was discussed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC). They acknowledged the findings.

1.A review of current residents with physician orders requiring provider notification for medication or treatment refusals was completed to ensure all required notifications were current and properly documented. Staff members responsible for medication administration and documentation received re-education regarding resident rights to refuse, physician notification requirements, and proper documentation procedures when refusals occur. 2.The facility will revise and reinforce medication refusal procedures to ensure physician or practitioner notification occurs as ordered whenever a resident refuses medications or treatments. Medication administration staff will be educated on reviewing physician orders for specific refusal notification instructions prior to medication pass. The facility will implement an audit process to verify refusals are documented appropriately and that required provider notifications are completed timely. The Resident Care Coordinator and/or designee will review alert charting, progress notes, and medication refusal documentation routinely to ensure compliance with OAR 411-054-0055(1)(j-k). 3.Medication and treatment refusal documentation, including provider notification requirements, will be audited weekly for four weeks, then monthly thereafter for continued compliance. Additional monitoring will occur during routine clinical record reviews and medication administration observations. 4.The Executive Director, Resident Care Coordinator, and Licensed Nurse/RN will be responsible for ensuring corrective actions are completed, staff education is conducted, audits are performed, and ongoing compliance with physician notification requirements related to resident refusals is maintained.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and documentation that non-pharmacological interventions were tried with ineffective results prior to administering them for 2 of 2 sampled residents (#s 2 and 4) who had orders for PRN psychotropic medications. Findings include, but are not limited to: 1. Resident 4 was admitted to the MCC in 10/2025 with diagnoses including cognitive impairment. Review of the resident’s 04/01/26 through 04/23/26 MAR and current physician orders identified the following: Resident 4 had orders for the following PRN medications for anxiety: * Lorazepam 0.5 mg, administer half a tablet every 2 hours; and * Haloperidol 2 mg/mL solution, administer 1 mg sublingually every 3 hours for anxiety or restlessness not controlled with lorazepam. The resident was administered the PRN lorazepam five times and the haloperidol ten times between 04/01/26 and 04/23/26. There was no documented evidence staff attempted non-pharmacological interventions with ineffective results prior to administering the medication. On 04/23/26 at 1:30 pm, Staff 8 (MT) confirmed direct care staff were not instructed to document attempted non-pharmaceutical interventions prior to administering a PRN psychotropic medication to Resident 4. The need to ensure documentation that non-pharmacological interventions were tried with ineffective results prior to administering a PRN psychotropic medication was reviewed with Staff 1 (Administrator), Staff 3 (Regional RN), Staff 4 (RCC), and Staff 7 (LPN) on 04/23/26 at 3:55 pm. They acknowledged the findings. 2. Resident 2 was admitted to the MCC in 04/2025 with diagnoses including dementia and Parkinson’s disease. Review of the resident’s 04/01/26 through 04/21/26 MAR and signed physician orders dated 03/24/26 identified the following: Resident 4 had an order for PRN lorazepam, administer 0.5 mg tablet every four hours as needed for anxiety. The resident was administered the PRN lorazepam three times between 04/02/26 and 04/11/26. There was no documentation that non-pharmacological interventions were attempted prior to administration and no documentation that those interventions were ineffective. The need to ensure PRN psychotropic medications were administered only after documented non-pharmacological interventions were tried with ineffective results was discussed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC). They acknowledged the findings.

1. Resident-specific parameters will be obtained or clarified with the prescribing practitioner for all PRN psychotropic medication orders that lack sufficient direction regarding behaviors, symptoms, dosage thresholds, or circumstances for use. The MARs, physician orders, and progress notes for Residents will be reviewed to ensure documentation reflects the reason for administration, behaviors observed, interventions attempted, and resident response to the medication. Staff members responsible for medication administration received immediate re-education regarding requirements for PRN psychotropic medication administration, including documentation of resident-specific symptoms, non-pharmacological interventions attempted prior to administration, and documentation that those interventions were ineffective before medication was given. 2.Nursing adds non-pharmacolocal resident specific interventions any time a new medication is ordered. Med Techs trained to notify nursing any time they see a PRN psychotropic. In addition with the 3rd check of all orders the RN will review. This will be reviewed quarterly with the service conference and referral to nursing if resident has a PRN psychotropic medication. 3. With all new orders and quarterly 4. RCC and RN with oversight of Administrator.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was assessed by an RN, PT, or OT prior to use, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident’s service plan for 2 of 2 sampled residents (#1 and 2) who used side rails. Findings include, but are not limited to: 1. Resident 2 was admitted to the MCC in 04/2025 with diagnoses including dementia and Parkinson’s disease. Resident 2 was observed on 04/21/26 using a hospital bed with bilateral half side rails in the up position. Clinical record review from 01/21/26 through 04/21/26 showed no documented assessment by an RN, PT, or OT for Resident 2’s bilateral half side rails. The service plan did not include use of the side rails, and there was no documentation that direct care staff were instructed on the correct use of or precautions related to the side rails. On 04/23/26 at 4:20 pm, The need to ensure a device with restraining qualities was assessed, care planned, and staff were instructed on the correct use and precautions was discussed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC). They acknowledged the findings. 2. Resident 1 was admitted to the assisted living facility in 02/2026 with diagnoses including multiple sclerosis and was observed 04/21/26 and 04/22/26 to use bilateral half-length side rails on the hospital bed. Review of the resident's 02/06/26 through 04/21/26 clinical record showed there was no assessment for the use of the side rails. In an interview on 04/22/26 at 11:40 am, Staff 3 (Regional RN) confirmed that there was no assessment of the use of side rails. Review of the resident’s service plan, dated 03/17/26, showed it did not include any instruction or precautions related to the use of the device. Staff interview noted the resident had been using the side rails for bed mobility. The need to ensure any device with potential restraining qualities was assessed and staff were provided clear instruction on the use of and precautions for the device was discussed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC) on 04/23/26 at 11:20 am. They acknowledged the findings.

1.The facility will immediately conduct a comprehensive review of all residents utilizing supportive devices with restraining qualities, including side rails. Residents will receive assessments completed by a Registered Nurse to determine the appropriateness, safety, and continued need for the bilateral half side rails and other supportive devices. Service plans will be updated to accurately reflect the use of the supportive devices, including specific instructions, safety precautions, monitoring requirements, and the purpose of use. Documentation will also be completed verifying that all direct care staff received instruction regarding the proper use of side rails, associated risks, required safety precautions, and resident-specific interventions related to the devices. 2.The facility will revise its supportive device procedures to ensure no supportive device with restraining qualities is implemented without a documented assessment completed by an RN prior to use. A standardized process will be implemented requiring verification that: An assessment has been completed prior to use; The device is accurately reflected within the resident’s service plan; Staff training and competency regarding the device and precautions are documented; and Ongoing monitoring is completed and documented as required. The Resident Care Coordinator or designee will complete an audit of all current residents utilizing supportive devices to ensure continued compliance with OAR 411-054-0060. 3.Audits of residents utilizing supportive devices will be conducted weekly for four weeks, then monthly thereafter for continued compliance. Audits will include review of required assessments, service plan documentation, and staff training records to ensure supportive devices are used safely and in accordance with facility policy and Oregon Administrative Rules. 4.The Administrator, Resident Care Coordinator, and Registered Nurse will be responsible for ensuring corrective actions are completed, monitoring ongoing compliance, conducting audits, and ensuring all supportive device documentation, assessments, and staff training requirements remain current and compliant with OAR 411-054-0060.

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 4 newly hired sampled direct care staff (#s 11, 13, and 17) completed first aid and abdominal thrust training within 30 days of hire. Findings include but are not limited to: Training records were reviewed with Staff 2 (Business Office Manager) on 04/22/26 and showed the following: * Training records for Staff 11 (MT) hired 12/05/25, Staff 13 (CG), hired 03/20/26, and Staff 17 (CG), hired 02/23/26, lacked documented evidence first aid and abdominal thrust training were completed within 30 days of hire. The need to ensure staff completed first aid and abdominal thrust training within 30 days of hire was reviewed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC) on 04/22/26 at 10:05 am. They acknowledged the findings.

1.The facility immediately reviewed the training records for all newly hired direct care staff. Staff identified as not having documented completion of First Aid and abdominal thrust training within 30 days of hire were scheduled for the required training. Personnel files will be updated to include all supporting documentation and certificates of completion. The facility will also review current staffing records to ensure all active direct care staff meet required training timelines in accordance with OAR 411-054-0070. 2.The facility has implemented an onboarding and training tracking system to ensure all required trainings are completed within the required timeframes. A standardized orientation checklist and training compliance log will be maintained for each newly hired employee. The Administrator, Business Office Manager, and Resident Care Coordinator will review employee training requirements at hire, during orientation, and prior to the 30-day deadline to ensure compliance. Training records will be maintained in employee files and monitored routinely to verify completion all training, including First Aid and abdominal thrust training within regulatory timelines. 3. Training records and onboarding documentation for all newly hired direct care staff will be reviewed weekly for 90 days and monthly thereafter to ensure continued compliance with training requirements and completion timelines. 4.The Administrator, Business Office Manager, and Resident Care Coordinator will be responsible for ensuring required trainings are completed within 30 days of hire, documentation is maintained appropriately, and ongoing monitoring is conducted to ensure continued compliance with OAR 411-054-0070.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

Based on observation and interview, it was determined the facility failed to ensure resident-use pathways and accesses to the MCC interior courtyard were smooth, accessible, and maintained in good repair. Findings include, but are not limited to: On 04/21/26 at 9:25 am, observations of the MCC interior courtyard identified drop-offs exceeding 2.5 inches along the pavement edges outside the hallway doors used by residents to access the courtyard. The drop-offs created uneven walking surfaces in the resident-use access areas and pathway within the courtyard. On 04/23/26 at 2:00 pm, Staff 1 (Administrator) was shown the drop-offs in the MCC interior courtyard. The need to maintain resident-use pathways and courtyard access areas in good repair was discussed with Staff 1. She acknowledged the findings.

1. The identified drop-offs exceeding 2.5 inches along the pavement edges in the memory care interior courtyard were immediately assessed by facility management. Interim safety measures were implemented to reduce resident access to the affected areas until repairs could be completed. The facility arranged for repair and leveling of the uneven walking surfaces to ensure resident pathways and courtyard access areas are smooth, accessible, and maintained in good repair. Staff were informed of the identified hazard and instructed to closely monitor resident use of the courtyard until corrective actions were finalized. 2.The facility will implement a routine environmental safety inspection process for all resident-use exterior areas, including courtyards, walkways, and access pathways. Maintenance staff and administration will complete scheduled inspections to identify trip hazards, uneven pavement, or other environmental concerns requiring repair. Any identified hazards will be documented and corrected promptly. The facility will also review preventive maintenance procedures to ensure exterior walking surfaces remain safe and compliant with OAR requirements. 3.Exterior resident-use pathways and courtyard areas will be inspected weekly by maintenance staff and additionally during routine environmental safety rounds conducted by administration. Findings and any corrective actions taken will be documented and reviewed monthly to ensure ongoing compliance and resident safety. 4.The Administrator, Maintenance Director, and Resident Care Coordinator will be responsible for ensuring corrective actions are completed, inspections are conducted as scheduled, identified hazards are repaired promptly, and ongoing compliance with exterior safety requirements is maintained.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: On 04/21/26 at 10:30 am, the interiors of the assisted living facility and MCC were toured. Observations identified the following: * Multiple areas of dark staining were observed on the carpet throughout the MCC hallways and in Resident Room 118; * In the MCC dining room/community room, Window blinds were damaged and missing slats and large gouges were observed on the walls; and * Baseboards along the perimeter of the assisted living dining room had areas of missing finish, exposed wood, and chipped edges. On 04/23/26 at 2:00 pm, the need to keep interior materials and surfaces clean and in good repair was discussed with Staff 1 (Administrator). She acknowledged the findings.

1.Damaged and stained carpeting throughout the memory care hallways, memory care dining room, community room, and resident room 118 will be assessed for replacement or professional deep cleaning. Damaged window blinds with missing slats in the memory care dining room and community room will be replaced. Gouged walls and damaged baseboards in the assisted living dining room will be repaired, patched, repainted, and refinished. 2.The facility will implement an ongoing environmental maintenance and inspection program to ensure all interior materials and surfaces remain in good repair. Routine building inspections will be conducted to identify damaged flooring, walls, baseboards, furniture, blinds, and other interior surfaces requiring maintenance or replacement. A maintenance tracking log will be maintained to document identified concerns, corrective actions taken, and completion dates. Staff will be instructed to promptly report maintenance concerns to the Administrator or Maintenance Director for timely follow-up and repair. 3.Environmental rounds will be completed weekly by the Maintenance Director or designee to monitor the condition of carpets, walls, baseboards, furniture, blinds, and other interior surfaces throughout the assisted living and memory care areas. Findings will be reviewed monthly by the Administrator to ensure repairs and maintenance needs are addressed timely and ongoing compliance is maintained. 4.The Administrator, Maintenance Director, and designees will be responsible for ensuring corrective actions are completed, environmental inspections are conducted routinely, maintenance concerns are addressed promptly, and ongoing compliance with OAR 411-054-0300 (4)(d-i) is maintained.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit.

Based on observation and interview, it was determined the facility failed to provide exit door alarms or other acceptable systems for security purposes and to alert staff when residents exited the facility. Findings include, but are not limited to: On 04/21/26 at 10:20 am, the main front exit doors, exit doors leading to the outdoor courtyard in assisted living, and exit doors leading to the secured courtyards in the MCC were observed. The exit doors did not have alarms or other acceptable systems to alert staff when residents exited the facility. On 04/23/26 at 2:05 pm, the exit doors were shown to Staff 1 (Administrator). The need to provide exit door alarms or other acceptable systems for security purposes and to alert staff when residents exited the facility was discussed. Staff 1 acknowledged the findings.

1.The facility immediately initiated corrective action to address the lack of exit door alarms or other acceptable alert systems on resident exit doors. A review of all exit points in both the assisted living and memory care areas was completed, including the main front entrance, assisted living courtyard doors, and memory care secured courtyard exit doors. Temporary monitoring measures were implemented until appropriate alarm systems could be installed and/or activated. The facility will coordinate with its maintenance provider and alarm vendor to ensure all resident exit doors will be equipped with functioning alarm systems or other approved security alert mechanisms that notify staff when residents exit the building or secured areas. Staff were re-educated regarding resident monitoring and immediate response expectations related to exit door safety and security. 2.The facility will implement an ongoing preventative maintenance and environmental safety program to ensure all required exit door alarm systems remain operational at all times. Routine inspections of all exit alarms and security systems will be incorporated into the facility’s maintenance schedule. Any malfunctioning or non-operational alarm systems identified during inspections will be immediately addressed and repaired. Staff will receive education regarding monitoring of exit systems, reporting procedures for malfunctioning alarms, and resident safety expectations related to secured exits and courtyards. The Administrator and Maintenance Director will ensure compliance with OAR 411-054-0300 (11-13) through ongoing oversight of the facility environment and security systems. 3.Exit door alarm systems and security alert functions will be checked daily by designated staff to verify proper operation. In addition, the Maintenance Director or designee will complete and document routine environmental safety inspections monthly to ensure continued compliance. Findings from inspections will be reviewed by the Administrator, and any identified concerns will be corrected promptly. 4.The Administrator, Maintenance Director, and designee will be responsible for ensuring corrective actions are completed, monitoring ongoing compliance, maintaining documentation of alarm system checks and repairs, and ensuring staff follow established procedures related to resident exit safety and security systems.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Based on observation and interview, it was determined the facility failed to create an environment in which residents were treated with dignity and respect and received services in a manner that protected privacy. Findings include, but are not limited to: Refer to C200.

Refer to C0200

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting.

Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the right to freedom from restraints. Findings include, but are not limited to: Refer to C 340.

Refer to C0340

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit. Findings include, but are not limited to: On 04/21/26 at 12:30 pm, observations of shared bathrooms between roommate units in Resident Rooms 112 and 118 identified the bathroom doors did not lock. Residents sharing the bathrooms could not lock the doors for privacy when using the bathroom. On 04/23/26 at 2:00 pm, the need to ensure each individual had privacy in his or her own unit, including privacy when using shared bathrooms between roommate units, was discussed with Staff 1 (Administrator). She acknowledged the findings.

1.Appropriate locking hardware will be installed on the bathroom doors to ensure residents are able to secure the bathroom for privacy while in use. Staff were educated regarding resident privacy rights and the importance of maintaining privacy within shared living environments. Residents affected by the deficiency were interviewed to ensure privacy concerns were addressed and resolved. 2. The facility will complete a comprehensive audit of all resident bathrooms and shared living areas to ensure privacy features, including functional locking mechanisms, are present and operational in accordance with OAR requirements. A maintenance and environmental safety checklist will be updated to include verification of privacy locks during routine inspections. Staff will receive ongoing education regarding resident dignity, privacy rights, and environmental compliance expectations. 3.The Administrator, Maintenance Director, or designee will conduct monthly environmental rounds for a period of no less than three months to verify that bathroom locks and other privacy-related features remain functional and compliant. Findings will be reviewed and corrective action taken immediately if concerns are identified. 4.The Administrator, Maintenance Director, and Resident Care Coordinator will be responsible for ensuring the corrective actions are completed, monitoring ongoing compliance, and maintaining documentation of inspections, repairs, and staff education.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C200, C231, C372, C610, C613, and C655.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C200, C372, C610, C613, and C655.

Refer to C200, C372, C610, C613, and C655

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired staff (#s 6, 13, 15, and 17) completed all required pre-service orientation training, 3 of 3 sampled newly hired staff (#s 13, 15, and 17) completed pre-service dementia training, and 4 of 4 sampled newly hired direct care staff (#s 11, 13, 15, and 17) completed competency training within 30 days of hire. Findings include, but are not limited to: The facility’s training records were reviewed on 04/22/26 with Staff 2 (Business Office Manager). The following was identified: 1. Staff 6 (Dietary Director) was hired 02/11/26, Staff 13 (CG) was hired 03/20/26, Staff 15 (CG) was hired 12/22/25, and Staff 17 (CG) was hired 02/23/26. There was no documented evidence the staff had completed pre-service orientation and the pre-service training in one or more of the following required topics prior to beginning their job responsibilities: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Infectious Disease Prevention; * Approved HCBS course; and * Approved LGBTQIA2S+ course. 2. There was no documented evidence Staff 13, 15, and 17 had completed the pre-service dementia training in one or more of the following required topics prior to beginning their job responsibilities: * Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging the person with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and use of a person-centered approach; * Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require ongoing assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * Use of supportive devices with restraining qualities in memory care communities. 3. There was no documented evidence Staff 11 (MT), hired 12/05/25, Staff 13, Staff 15, and Staff 17 had demonstrated competency in one or more of the following required topics within 30 days of hire: * 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 that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. The need to ensure all required training was completed and staff demonstrated competency in the required time frames was discussed with Staff 1 (Administrator), Staff 3 (Regional RN), and Staff 4 (RCC) on 04/22/26 at 10:05 am. They acknowledged the findings.

1.The facility immediately conducted a review of all employee training records for direct care staff, medication technicians, and department heads to identify missing orientation, preservice, dementia care, and competency-based trainings. The following required trainings were completed or scheduled immediately for affected staff: Facility orientation and preservice training Resident rights and community-based care values Abuse reporting requirements Fire safety and emergency procedures Infectious disease prevention Approved HCBS course Approved LGBTQIA2S+ course Preservice dementia care training Competency demonstrations required within 30 days of hire Documentation of all completed training, competency evaluations, and staff signatures was placed in employee files. 2.The facility revised its onboarding and training process to ensure all newly hired staff complete required orientation and preservice training prior to independently performing job responsibilities. A standardized onboarding checklist was implemented for all positions to verify completion of: Required orientation topics Dementia-specific training requirements Competency demonstrations Required state-approved courses The Administrator, Resident Care Coordinator, and Business Office Manager will jointly review all new hire files prior to staff being placed on the schedule independently. The facility also implemented a training schedule to ensure staff have additional time dedicated to 30-day competency requirements to ensure timely completion. In addition, the facility will conduct monthly audits of employee files to ensure compliance with OAR 411-057-0155 training requirements. 3.Employee training records and onboarding documentation will be reviewed: At the time of hire Prior to independent assignment of job duties At 30 days post-hire for competency verification Monthly for ongoing compliance audits for a period of no less than six months Quarterly thereafter as part of the facility’s quality assurance process Any deficiencies identified during audits will be corrected immediately. 4.The Administrator, Business Office Manager, and Resident Care Coordinator will be responsible for ensuring all required staff training, orientation, dementia education, and competency evaluations are completed, documented, and monitored for compliance with OAR requirements.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C260, C270, C280, C290, C295, C300, C303, C305, C330, and C340.

Refer to C260, C270, C280, C290, C295, C300, C303, C305, C330, and C340

OAR 411-057-0160(g) Outside Area (g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e).

Based on observation and interview, it was determined the facility failed to ensure the MCC secured outdoor space met minimum space requirements and allowed residents to enter and return without staff assistance. Findings include, but are not limited to: The MCC had an unlocked interior courtyard available to residents. The courtyard was measured by the survey team and did not meet the required minimum of 600 square feet for secured outdoor space. A larger secured, fenced courtyard with a paved walkway was observed on the north side of the MCC. The exit door to the larger courtyard was locked and required staff to enter a code. Multiple staff stated the door remained locked because staff could not observe residents in the area and residents could fall. Residents were not able to enter and return from the larger courtyard without staff assistance. The need to ensure MCC residents had secured outdoor space that met minimum space requirements and allowed residents to enter and return without staff assistance was discussed with Staff 1 (Administrator) on 04/23/26 at 2:00 pm. She acknowledged the findings.

1.The facility has taken immediate action to correct the identified violation regarding access to secured outdoor space in memory care. The secured courtyard door will be unlocked to allow residents the ability to independently enter and return from the secured outdoor area without staff assistance, as required by rule. Door alert systems have will be added to notify staff when residents enter or exit the courtyard area. Staff have been instructed that when residents are utilizing the courtyard, staff are responsible for maintaining awareness of resident location and providing appropriate monitoring and supervision as needed to ensure resident safety. The facility has also reviewed the use and accessibility of all outdoor spaces within memory care to ensure compliance with required standards. 2.The facility will update memory care policies and procedures regarding resident access to secured outdoor spaces to ensure compliance with OAR requirements. Staff will receive re-education regarding resident rights to access secured outdoor areas independently and the expectation for ongoing resident monitoring while residents are utilizing the courtyard. Leadership will ensure all secured outdoor spaces remain accessible to residents unless otherwise restricted under applicable physician orders or regulatory exceptions. Environmental and safety rounds will include review of courtyard accessibility, functionality of door alerts, and observation of staff monitoring practices. 3. The Executive Director, Resident Care Coordinator, or designee will conduct weekly audits for four weeks to verify the courtyard remains accessible, the alert system is functioning properly, and staff are appropriately monitoring residents utilizing the outdoor space. Following the initial audit period, ongoing monitoring will occur monthly as part of the facility’s quality assurance program. 4. The Executive Director, Resident Care Coordinator, and Maintenance Director will be responsible for ensuring the corrections are completed, staff education is provided, the courtyard access remains compliant, and ongoing monitoring is conducted.

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

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 12/08/25 showed the following areas needed cleaning or repair. * Drips, splatters, and/or debris were observed inside cupboards, under shelves, on top of dry goods, inside drawers, on the ceiling, and on the walls throughout the kitchen and dry storage; * Multiple light covers in the kitchen had debris and dead insects inside; * Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges. Several sections of patched flooring around the center island were cracked or separating at the edges; * Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and/or missing paint; * Thick debris and sludge were located in the drain under the sink and a strong sour odor was present; * Lower-level metal shelves throughout the dry storage had debris, dust, drips, and/or spills; * Three cutting boards were significantly worn with discoloration and grooves; * Two knives in the butcher block had handles that were extremely worn, scratched and gouged; * Large amounts of debris were noted underneath the stove on an exposed shelf area. The ovens had one missing cover piece in place along the bottom and another one partially dangling as it impeded the opening and closing of the oven doors. Debris was noted in the bottom of the ovens; * Cobwebs, dust, and dead insects were noted in the windowsill, and the screen to the open window had a thick layer of dust and debris on it; * No alcohol wipes were available for cleaning of the probe thermometer; * Particle board/wood shelving in the custodian closet was warped, stained, and had chipped and peeling paint. A large piece of flooring was missing, with a chunk of loose laminate underneath buckets underneath the tankless water heater; * A large cut/split in the laminate flooring was located near the door closest to the dish area; * The microwave had splatters and spills on the interior. The interior door had a large area of missing paint and rust; * A large scrape with missing paint and drywall was noted along the wall in the attached break/storage room. Multiple drawers and cupboards had spills and/or debris next to clean dishes and utensils; and * The baseboard behind the stove was detached and hanging forward. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Facilities Services Director) on 12/08/25. The staff acknowledged the findings.

1.A comprehensive deep cleaning of the kitchen, dry storage, custodial closet, and break/storage room was initiated, including all cupboards, drawers, shelves, ceilings, walls, floors, baseboards, windowsills, light covers, drains, equipment interiors/exteriors, and areas underneath appliances. All debris, grease, sludge, dust, cobwebs, and insects to be removed and surfaces sanitized using approved cleaning agents. The sink drain thoroughly cleaned and deodorized to eliminate sludge buildup and odor. Worn and damaged food-contact items were removed from service, including: Three significantly worn cutting boards Two knives with excessively damaged handles These items are to be replaced with new, food-safe equipment. Alcohol wipes were immediately stocked and made available for proper probe thermometer sanitation. Damaged and unsafe equipment to be addressed: Loose and missing oven cover pieces to be repaired or replaced to ensure safe operation. Remove debris from the ovens and exposed shelving beneath the stove. Microwave interior cleaned and sanitized; damaged/rusted interior surfaces scheduled for repair or replacement. Structural and surface repairs were initiated or scheduled, including: Repair or replacement of cracked, separating, missing, or damaged flooring. Repair of chipped cupboards, shelves, exposed particle board, and peeling paint. Reattachment of the detached baseboard behind the stove. Repair damaged drywall and scraped walls in the break/storage room. Replacement of warped and deteriorated particle board shelving in the custodial closet. All clean dishes and utensils were removed, rewashed, and properly stored after affected storage areas were cleaned. 2.A revised environmental cleaning and sanitation schedule was implemented, clearly outlining: Daily, weekly, and monthly cleaning tasks. Assigned responsibilities by position. A preventive maintenance program was reinforced to ensure routine inspection and timely repair of: Flooring Cabinets and shelving Walls, baseboards, and ceilings Kitchen equipment and fixtures A food safety equipment replacement protocol was established to ensure cutting boards, utensils, and knives are routinely inspected and replaced before becoming excessively worn. Staff were re-educated on: Proper cleaning of food-contact and non–food-contact surfaces Appropriate storage practices to prevent contamination Proper sanitation of thermometers and small equipment A supply monitoring system was implemented to ensure essential sanitation items (e.g., alcohol wipes, cleaning supplies) are consistently available. Windows, screens, and light covers were added to routine pest-prevention and cleaning checks. 3. Daily visual inspections of the kitchen and dry storage areas will be conducted by kitchen leadership. Weekly documented sanitation audits will be completed using a standardized checklist. Monthly environmental and maintenance inspections will be conducted to assess flooring, cabinetry, shelving, walls, equipment condition, and overall cleanliness. Any identified concerns will be corrected immediately and documented. 4.Maintenance Director Responsible for completing and monitoring all repairs, structural corrections, equipment maintenance, and preventive maintenance inspections. Executive Director Responsible for overall compliance oversight, ensuring corrective actions are completed, monitoring systems are followed, and ongoing sanitation and maintenance standards are upheld. The Maintenance Director and Executive Director will ensure that all corrective actions are completed, documented, and sustained to maintain a safe, sanitary, and compliant environment. Continuous monitoring will be conducted to prevent recurrence of these deficiencies.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Refer to C240

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:   Observations of the kitchen and memory care kitchenette on 05/13/24 and 05/14/24 showed the following areas needed cleaning or repair. Main Kitchen: * Drips, splatters and/or debris were observed inside cupboards, under shelves, on top of dry goods, inside drawers, on the ceiling and on the walls throughout the kitchen and dry storage; * A broken light cover was noted near the tray line, other light covers had debris and dead insects inside and missing covers were noted to the lights in the dry storage; * Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges. Several sections of flooring around the center island were heavily discolored with a black/brown haze; * Shelving in multiple refrigerators and/or freezer units had spills, debris, white accumulation with dangling pieces, rust and chipped/peeling shelf coating; * Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board, bubbling paint; * Chipped laminate was noted on counter edges of the center island, the back splash was pulling away from the wall along the back counter, the counter near the back corner was pulling apart at the seam; * Debris and standing water were located in the drain under the sink as well as black stains along the interior walls and a strong sour odor; * The ice machine had spills and debris on the lower vent slats, broken and missing slats were noted as well; * Metal shelves throughout the kitchen had debris, drips and/or spills; * Two cutting boards were worn with numerous grooves; * Four large plastic pitchers were stained brown and had scrapes on the interior; * Debris, spills and stains in cupboard drawers and on shelves in the dining room drink station; * Scoop handles were extremely worn, scratched and gouged; * Large amounts of debris were noted underneath the stove on an exposed shelf area. The ovens did not have a cover piece in place along the bottom as it impeded the opening and closing of the oven doors; * Numerous open packages were noted in the dry storage area including cake mix, sugars, flour, biscuit mixes and breadcrumbs; * Cobwebs, dust and dead insects were noted in the windowsill, the screen to the open window had a thick layer of dust and debris on it; and * Food splatters/spills were noted on the underside of the small stand mixer. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Executive Director) and Staff 2 (Dietary Manager) on 05/14/24. The staff acknowledged the findings.

1.Additional training to be completed with Dining Services Manager and Dining staff on proper cleaning and storage protocols. Administrator and Maintenance Director will work together to repair and/or replace building defects and other areas of the kitchen in need of repair. Administrator will work with Dining Services Manager to replace worn equipment and appliances. 2. Administrator will oversee Dining Services in weekly Kitchen cleaning inspections. The Dining Services Manager will provide Administrator with an inventory of items needing to be replaced or repaired, monthly. 3. Weekly and Monthly 4. Administrator and/or Dining Services Manager

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:   Observations of the main kitchen on 09/09/24 showed the following areas needed cleaning or repair. * Drips, splatters and/or debris were observed inside cupboards, under shelves, inside drawers, and on the walls throughout the kitchen and dry storage; * A broken light cover was noted near the tray line, other light covers had debris and dead insects inside and missing covers were noted to the lights in the dry storage; * Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges. Several sections of flooring around the center island were heavily discolored with a black/brown haze and multiple seams were cracked or pulling apart; * Shelving in multiple refrigerators and/or freezer units had spills, debris, white accumulation with dangling pieces, rust and chipped/peeling shelf coating; * Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and bubbling paint; * Chipped laminate was noted on counter edges of the center island, the back splash was pulling away from the wall along the back counter, the counter near the back corner was pulling apart at the seam; * An open box of paper tray liners was stored on the floor next to the stove, multiple pieces of food and other debris were noted on the clean papers and inside the box; * The ice machine had spills and debris on the lower vent slats, broken and missing slats were noted as well; * Cobwebs, dust and dead insects were noted in the windowsill, the screen to the open window had a thick layer of dust and debris on it and multiple chips with exposed particle board noted; and * The ceiling vent near the kitchen entrance had thick accumulation of dark gray dust. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED), Staff 3 (Maintenance Director) and Staff 4 (Dietary Services Manager) on 09/09/24. The staff acknowledged the findings.

1.Continued training to be completed with Dining Services Manager and Dining staff on proper cleaning and storage protocols. The kitchen survey has been included in additional discussions and counceling on kitchen cleaning protocols. We have a new Dining Services Manager who is assisting in reaching these goals. Administrator and Maintenance Director are continuing to work together to repair and/or replace building defects and other areas of the kitchen in need of repair. Plans for overcoming financial barriers in place. Administrator has been and will continue working with Dining Services Manager to replace worn equipment and appliances. 2. Administrator will continue to oversee Dining Services in weekly Kitchen cleaning inspections. The Dining Services Manager will continue to provide Administrator with an inventory of items needing to be replaced or repaired, monthly. 3. Weekly and Monthly 4. Administrator and/or Dining Services Manager/Maintenance Director

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:   Observations of the main kitchen on 02/05/25 showed the following areas needed cleaning or repair: * Missing covers were noted on the lights in the dry storage; * Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment, and at the door edges; * Shelving in the Victory refrigerator had rust and chipped/peeling shelf coating; * Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and bubbling paint; * The ice machine had broken and missing slats to the bottom vents; * The interior walls under the sink by the range had black stains along the interior walls; and * Doors and door frames throughout the kitchen had scuffs, scrapes, and/or gouges with bare wood exposed, rendering the surfaces uncleanable. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 3 (Maintenance Director), Staff 4 (Dietary Services Manager), and Staff 5 (Business Office Manager) on 02/05/25. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Refer to C240

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C240.

Please Refer to C240

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 240.

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

Please Refer to C240

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

The findings of the kitchen inspection, conducted 05/13/24 through 05/14/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 05/14/24, conducted 09/09/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 05/14/24, conducted 02/05/25, 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. 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 third revisit to the kitchen inspection of 05/14/24, conducted on 06/17/25, 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 facility was found to be in substantial compliance.

Based on interview and record review, conducted during a site visit on 04/22/24 the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 4) was substantiated. Findings include, but are not limited to: Interviews with Staff 1 (Administrator) and Staff 2 (RCC) were conducted: " Staff 1 stated the incident occurred and a facility self-report was made. " Staff 2 stated s/he administered the incorrect medication dose and completed the associated incident report. Review of Resident 4's MAR, dated 11/01/23 through 11/30/23, and signed prescriber order, dated 12/09/23 indicated s/he was ordered "clonazepam 1 MG TAB - 0.5 tablet (0.5mg) by mouth every day at noon". Review of the incident report, dated 11/05/23, indicated during the 12p, med pass on 11/01/23 and 11/02/23 Staff 2 administered 1mg of clonazepam instead of .5 mg of clonazepam. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Findings were reviewed and acknowledged by Staff 1. VPC: Staff 1 and 2 will hold MT meetings to review proper  MAR reading and procedures and reinforce the importance of matching medications accurately to the MAR.

Based on interview and record review conducted during a site visit on 04/22/2024, it was determined that the facility failed to fully implement an Acuity Based Staffing Tool (ABST) for 1 of 3 sampled residents (#1, # 2 and #3). Findings include, but are not limited to: Interview with Staff 1 (Administrator) was conducted indicating: · The facility reported use of the State Acuity-Based Staffing Tool (ABST) to generate its staffing plan. · Current census: 36 residents · Reported staffing levels: o Day shift:  4 caregivers (CG) / 1 medication technician (MT) o Swing shift:  4 (CG) / 1 (MT) o Night (Noc) shift:  2 (CG) / 1(MT) The following records were reviewed and indicated: · Staff Roster · Resident Roster o Assisted Living: 23 residents o Memory Care: 13 residents · Facility Posted Staffing o Day Shift: 2 CG and 1 MT (MT covers both ALF and MC) o Swing Shift: 2 CG and 1 MT (MT covers both ALF and MC) o Night (Noc) Shift: 1 CG and 1 MT (MT covers both ALF and MC) o Posted staffing does not align with the facility ' s reported schedule. · Facility ABST Tool o Assisted Living: 24 Residents o Memory Care: 13 Residents o Facility ABST does not match Resident Roster. (Staff 1 noted one resident had been removed, as they no longer reside at the facility.) o Facility ABST tool does not reflect current ADL needs for Residents 1, 2 and 3.   o Facility is not staffing to the levels indicated by the ABST tool. (Swing shift is short by one caregiver.) It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool. Findings were reviewed with and acknowledged by Staff 1. Verbal Plan of Correction: Staff 1 will audit the ABST tool to ensure that all residents are accurately entered, acuity levels are properly updated, and an accurate staffing plan is generated based on resident needs.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident's needs for 1 of 1 sampled resident (# 2) who was recently admitted to the facility, and the most recent quarterly evaluation was reflective of the resident's current needs for 1 of 2 sampled residents (# 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder. Review of the move-in evaluation identified the following required elements were not documented as being addressed: * Customary routines related to sleeping and bathing; * Interests, hobbies, social, leisure activities; * Spiritual, cultural preferences and traditions; * Personality: including how the person copes with change or challenging situations; * Pharmaceutical and non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Nutritional habits, fluid preferences and weight if indicated; * Complex medication regimen; * History of dehydration or unexplained weigh loss or gain; * Elopement risk or history; * Recent losses; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature. 2. Resident 3 was admitted to the facility in 12/2021 with diagnoses including anemia, polyneuropathy, paroxysmal atrial fibrillation, combined systolic (congestive) and diastolic (congestive) heart failure, and edema. Review of the quarterly evaluation revealed the quarterly evaluation was not reflective of the resident's current needs in the following areas: * History of dehydration or unexplained weight loss or gain; * Recent losses; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature. The need to ensure the initial move-in contained all required elements and the quarterly evaluations were reflective or the resident's current needs was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

1. Additional training on the completion of initial evaluations to be done with the LPN. LPN has been instructed to ensure all boxes are checked and a narrative for each portion of the evaluation/service plan to ensure step by step instructions for staff to care for resident. 2.RN and ED will review eval prior to move in to ensure all areas have been completed. 3. Evaluations will be reviewed prior to each move in. Then every 30, 60, and 90 days. 4. Clinical Team (ED, RCC, RN, LPN)

2. Resident 1 was admitted to the MCC in 08/2022, with diagnoses including Parkinson's Disease, anxiety, and dementia. Resident 1's service plan, dated 11/26/23, was not reflective of the resident's current status or did not provide clear instructions to staff in the following areas: * use of wheel chair; * activity participation/involvement; and * challenging behaviors. Observations on 11/28/23, noted Resident 1 sitting in a wheel chair for both meals and activities. In an interview on 11/28/23, Staff 10 (Caregiver) stated Resident 1 used a wheel chair "when needed, depending on how [he/she] is doing that day". On 11/30/23 the need to ensure service plans were reflective of residents current needs and provided clear directions to staff was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services 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 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder. Interviews with the resident and staff, and review of the current service plan revealed Resident 2's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Dental status and use of assistive devices; * Dietary and nutrition management including current allergies; * Instructions on non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Instructions for whom skin impairments should be reported to; * Instructions for whom weight gain or loss, and changes in appetite should be reported to; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; and * Instructions on signs and symptoms of infection to report while monitoring incision site with sutures. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

1. Additional training on the completion of person centered service plans to be done with the LPN and RCC. LPN and RCC  has been instructed to ensure all boxes are checked and a narrative for each portion of the evaluation/service plan to include resident prefrences and needs. 2.RCC, LPN, and ED to ensure adequate details are added to each service plan as well as step by step instructions for staff to follow.   3. Evals will be reviewed prior to each move in. Then every 30, 60, and 90 days. 4. Clinical Team (ED, RCC, RN, LPN)

Based on observation, interview, and record review, it was determined the facility failed to determine and document what action or intervention was needed for the resident with a short-term change of condition, communicate actions or interventions to staff on each shift, and/or to document weekly progress until the condition resolved for 2 of 4 sampled residents (#s 2 and 3) reviewed with changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder. Clinical records, including the current service plan, observation notes from 08/27/23 through 11/27/23 were reviewed, and interviews with facility staff and the resident were conducted. The following short-term change of conditions lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved: * 09/23/23: Redness in right eye; * 10/20/23: Witnessed fall with no injury reported; * 10/29/23: "Resident has had diarrhea stool for the past 36 hours ...."; * 10/31/23: Dark urine; * 11/01/23: Emergency Room visit related to surgical removal of neurofibroma; * 11/02/23: Discontinued medications: Naproxen 500mg (for pain), Atenolol 50mg (for blood pressure), and Benazepril 10mg (for blood pressure); * 11/02/23: New medication order: Senna 8.6mg (for bowel care); * 11/03/23: New medication order: Clindamycin 300mg (antibiotic); * 11/15/23: Abdominal pain and diarrhea; * 11/16/23: Abdominal pain and diarrhea; * 11/19/23: Diarrhea; * 11/23/23: Rash under right breast and on the back; * 11/24/23: Emergency Room visit related to nausea/vomiting and skin infection; and * 11/26/23: Emergency Room visit related to back skin cellulitis, skin maceration and bleeding from neurofibroma. 2. Resident 3 was admitted to the facility in 12/2021 with diagnoses including anemia, polyneuropathy, paroxysmal atrial fibrillation, combined systolic (congestive) and diastolic (congestive) heart failure, and edema. Clinical records, including the current service plan, observation notes from 08/27/23 through 11/27/23 were reviewed, and interviews with facility staff and the resident were conducted. The following short-term change of conditions lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved: * 09/04/23: " ...leg's toes were weeping a yellow color resident stated that s/he saw blood in the shower ..."; * 09/07/23: Shortness of breath; * 09/08/23: Shortness of breath; * 09/10/23: " ...right leg is very infected ..."; * 09/23/23: "Wounds on the bottom of residents L foot are very tender and beginning to swell ..."; * 11/09/23: Discontinued medications: Aquaphor ointment (for skin care), Ferrous Sulfate 325mg (supplement), and Probiotic (for digestive health); * 11/09/23: "It appears resident is struggling with bouts of depression ...." and * 11/24/23: Unwitnessed fall with no injuries reported. The need to ensure the facility evaluated the resident's short-term changes of condition and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

1. Adequate documentation and resolution to be added to the short term changes. 2. All potential short term or significant change in conditions will be reviewed by reading the observation notes daily. Any changes or concerns will be sent to the RN and LPN to review. 3. Daily by the administrator reading all of the observation notes. This will also be added to daily/weekly checklist to ensure ISP and Alert Charting are completed as well as weekly monitoring and resultions by the nursing team. 4. Clinical Team (ED, RCC, LPN, RN)

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 2 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including mild cognitive impairment and muscle weakness. Resident 4's current physician orders, dated 11/06/23, and MARs from 11/06/23 through 11/27/23 were reviewed and included the following: * MD order dated 11/07/23 was in place for daily weights to monitor for swelling after a brain injury. Weights were not taken on 11/08/23, 11/11/23, 11/18/23, 11/23/23, and 11/25/23; and * The following medications were not administered on the following dates: - 11/08/23 and 11/10/23 - docusate sodium 250 mg (stool softener); - 11/08/23 Lamotrigine 20 mg (antacid), multi vitamin, Vitamin C and Vitamin D (supplements); and - 11/10/23 bumetanide 1 mg (diuretic). The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Coordinator), and Staff 16 (LPN) on 11/30/23. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder. Review of Resident 2's current physician orders and MARs from 11/01/23 through 11/27/23 revealed the following: * Atenolol 50mg (for blood pressure) two tabs orally twice daily was discontinued on 11/02/23 per legally recognized practitioner order. However, according to the MAR, the medication was administered on 11/03/23 and morning pass 11/04/23; * Atenolol 50mg was ordered to be administered one tab orally daily on 11/02/23 per legally recognized practitioner order. According to the MAR, the medication administration started on 11/07/23; * Senna 8.6mg (for bowel care) was ordered to be administered one tablet orally daily and held for loose stool. According to Observation notes, Resident 2 had diarrhea 11/15/23 and 11/16/23, and Senna 8.6mg was administered on 11/15; * Loperamide 2mg (for diarrhea) was ordered to be administered one tab orally after each subsequent loose stools and if loose stools accompanied by abdominal pain, fever, or blood in stools, alert RN and PCP immediately. According to Observation note on 11/16/23, Resident 2 "stated she still has stomach pain and diarrhea." There was no documented evidence RN and PCP were notified immediately as ordered; and * Resident 2 had two contradicting medications orders: Senna 8.6mg (for bowel care) and Loperamide 2mg (for diarrhea as needed). According to the MAR, both medications were administered on 11/11/23, 11/15/23, and 11/27/23. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

1. In depth MT training to ensure all MT's are completing medication and treatment orders. Complete MAR audit to be completed. 2. Staff are instructed and trained to notify the clinical team of any medication / treatment orders. Staff continue to follow 3 Step medication approval. 3. Monthly MAR audits to be completed as well as any medication/treatment orders to be addressed when sending the 90 day orders. 4. MT's, and Clinical Team (ED, RCC, LPN, RN)

3. Resident 4 was admitted to the facility in 2022 with diagnoses including mild cognitive impairment and muscle weakness. Resident 4's current physician orders, dated 11/06/23, and MARs from 11/06/23 through 11/27/23 revealed on 11/08/23 Resident 4 refused docusate sodium (stool softener). There was no documented evidence the facility notified the physician or other legally recognized practitioner each time the resident refused to consent to the orders. The need to ensure the facility notified the physician or other legally recognized practitioner of medication and treatment refusals was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner if a resident refused consent to an order for 3 of 3 sampled residents (#s 1, 2 and 4) who had documented refusals. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 08/2022, with diagnoses including Parkinson's Disease, anxiety, and dementia. Review of Resident 1's MAR, dated 11/01/23 through 11/27/23, revealed the resident refused prescribed doses of medication on five occasions. These included three doses of Sinemet (for Parkinson's symptoms) and two doses of Seroquel (mood stabilizer). There was no documented evidence the facility notified the physician/practitioner when the resident refused consent to the orders. In an interview on 11/29/23, Staff 3 (Resident Care Coordinator) presented the surveyor with a written policy for informing physicians about refusals, and a fax form used to do so. However, Staff 3 stated there was no evidence of notification for any of the refusals for Resident 1. On 11/30/23 the need to ensure residents' physicians were notified of all refusals, unless otherwise directed, was discussed with Staff 1 (Administrator) and Staff 3. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including asthma, hypertension, neurofibromatosis, cataract, and depressive disorder. Resident 2's MARs from 11/01/23 through 11/27/23 and corresponding Observation notes were reviewed. The resident's records showed the Silvadene 1% cream (for skin care) was refused on 12 occasions. There was no documented evidence the facility notified the physician or other legally recognized practitioner each time the resident refused to consent to the orders. The need to ensure the facility notified the physician or other legally recognized practitioner of medication and treatment refusals was reviewed with Staff 1 (Administrator), Staff 3 (Resident Care Manager), and Staff 16 (LPN) on 11/29/23. They acknowledged the findings. No further information was provided.

1. PCP will be faxed regarding all missed medications 2. New forms to be faxed to pcp for notification of missed medications to determine when the pcp would like to be faxed. Once fax is returned, RN will add when to notify to the MAR. Form to be utilized for all residents. Missed medication form to be pulled weekly to assure compliance with any missed medications for the week and to assure notifications were completed. 3. PCP notification form to be reviewed or sent upon move in, frequent missed medications, or during 90 day eval. 4. MT,  and Clinical Team (ED, RCC, LPN, RN)

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly hired staff (#s 7, 8, and 9) completed pre-service and 30 day competency training as required. Findings include, but are not limited to: Training records for Staff 7 (CG), hired 7/20/2023,  Staff 8 (CG), hired 06/15/23, and Staff 9 (MT), hired 03/20/23, were reviewed with Staff 4 (Business Office Manager) on 11/29/23. There was no documented evidence Staff 7, 8, and 9 had completed the following required Memory Care Community pre-service training: *  Pre-service Infectious Disease Prevention for community based care; *  Environmental factors for a resident's well being; *  Family support and role of the family; *  Behaviors that require evaluation and assessment; *  Use of supportive devices with restraining qualities, and *  Changes associated with normal aging. The need to ensure staff completed all required pre-service training before working independently was discussed with Staff 1 (Administrator) on 11/30/23. She acknowledged the findings.

1. Currently working on receiving an updated training plan and add to Relias. 2. We will have an updated training list to follow that is reflective of state requirements. 3. Training plans and updates checked weekly, added to BOM weekly checklist. 4. To be completed by BOM and ED to ensure completed.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252,  C260, C270, C303, and C305.

Refer to C252, C260

Based on interview and record review, it was determined the facility failed to fully evaluate each resident for activities and develop an individualized activity plan based on their activity evaluation, for 1 of 1 sampled resident (#1) whose records were reviewed. Resident 1 was admitted to the MCC in 08/2022, with diagnoses including Parkinson's Disease, anxiety, and dementia. Resident 1's service plan, dated 11/26/23, included information about past and current hobbies and interests. However, the facility had not fully evaluated the resident regarding: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities, based on information gathered from the evaluation. On 11/30/23, the need to ensure the facility completed a thorough activity evaluation, developed an individualized activity plan, and provided meaningful daily activities for each resident was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Coordinator). They acknowledged the findings.

1. Service Plan and Care Plan to be updated to include an individualized acitivity plan for each resident. 2. Service/Care Plan to address history, likes & dislikes, etc. Life enrichment manager or Clinical team will update life stories and current care plans to be reflective of activity needs, likes, and dislikes. 3. Initally, then 30, 60, and 90 days and every 90 dyas thereafter. 4. Clinical Team (ED, RCC, RN, LPN)

The findings of the re-licensure survey, conducted 11/27/23 through 12/01/23, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. 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 12/01/23, conducted 05/13/24 through 05/15/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

The findings of the desk review, conducted on 10/23/23, 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 CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

The findings of the on-site investigation, conducted 05/22/23 through 05/22/23, 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

The findings of the on-site investigation, conducted 05/22/23 through 05/22/23, 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

The findings of the on-site investigation, conducted 05/22/22 through 05/22/22, 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 and interview, it was determined the facility failed to maintain the kitchen clean and in good repair and follow food safety guidelines in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: During the tour of the kitchen on 04/04/23, the following was observed: 1. The temperature gauge on the outside of the triple refrigerator closest to the kitchen entrance read 46 degrees Fahrenheit. The temperature gauge on the inside of the refrigerator read 30 degrees Fahrenheit. Staff 1 (Administrator) was apprised of the malfunctioning refrigerator. Staff 2 (Dietary Director) obtained temperatures of containers of milk and mayonnaise using a probe thermometer which measured 48 degrees Fahrenheit and 47 degrees Fahrenheit respectively. During an interview with Staff 2, he indicated he did not know how long the refrigerator temperatures had exceeded the maximum allowed temperature to ensure food safety. The facility was instructed to dispose of all protein-based food. Staff 1 stated the maintenance director would evaluate the malfunctioning refrigerator and repair it or refer to the manufacturer to fix the issue prior to resuming food storage. 2. The following areas were noted to be in need of cleaning and repair: * There was build-up of brown/black matter and food particles on multiple food carts; * The handles on the triple refrigerator by the entrance were broken and covered with duct tape; * The garbage cans were uncovered; and * The coating on an attachment for the stand mixer had an area where the rubber coating had torn and metal was exposed. 3. The following unsafe food handling and infection control practice were observed: * Plates of pie were transported to the memory care uncovered; * Servers were not wearing aprons; * Staff 3 (Facility Service Aide) was observed to wash her hands with gloves on and then to dry out a clean coffee pot with a paper towel; and * Staff 2 was observed to touch a clipboard and a pen with gloves on and then plate ready to eat foods. The need to ensure the kitchen was maintained clean and in good repair and follow food safety guidelines in accordance with the Food Sanitation Rules discussed with Staff 1 on 04/04/23. She acknowledged the findings.

C240 1. New temperature monitors have been ordered for each refridgerator and freezer to be placed in proper locations once arrived. All protien- based food has been disposed of that exceeded proper temperatures. Refridgerator temperature has been adjusted by refrideration company to proper temperature. C240 2. Food carts to be cleaned weekly and monitored for completion by dining manger and overseen by executive director. Replacement for triple refridgerator enterance to be ordered by 4/17/2023 and installed immedietly. Replacement for stand mixer ordered and will be installed once arrived. Explosed cabenets will be filled and covered in epoxy to prevent debris. C240 3. All food transported to be covered at all times and ensoured by dining manager. Servers to all wear approns at all times when serving meals ensured by dining manager. Proper retraining on glove procedures and plating procedures to be implimented and overseen by dining manger. Weekly cleaning audit implimented and repares complete by 5/10/23

Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Refer to C240.

The findings of  the kitchen inspection, conducted on 04/04/23, 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 re-visit to the kitchen inspection of 04/04/23, conducted 08/28/23, 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.