The Estates at Town Center

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

Based on interview and record review, it was determined the facility failed to ensure all resident incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office if abuse and/or neglect could not reasonably be ruled out for 1 of 1 sampled resident (# 1) with incidents which required an investigation. Findings include, but are not limited to: Resident 1 was admitted to the facility in 11/2019 with diagnoses including transient ischemic attack (brief stroke like attack), congestive heart failure and fall risk. The service plan dated 08/06/24 noted Resident 1 required one person assist for dressing, bathing, transfers, and escorts in a wheelchair. The service plan also noted Resident 1 was at risk of falls, and of suffering severe injury from a fall, care staff were to monitor for falls more than once a shift, remind resident to use her/his call pendent, and provide a safe environment that was clutter free and personal items were within reach. Review of the resident's 06/10/24 through 09/05/24 progress notes, and incident reports for the same time period were conducted during the survey. Resident 1 had the following unwitnessed falls: * On 06/30/24 the resident was found lying down on the floor between her/his recliner and the window and sustained a left shoulder fracture. * On 09/02/24 Resident 1 was found on the ground between the toilet and shower. The resident was sent to the ED for an evaluation due to the resident complained of pressure to the back of her/his head. The facility completed investigations at the time of the unwitnessed falls and determined the resident was unable to state how s/he ended up on the floor. The investigations did not rule out abuse and/or neglect, and the incidents were not reported to the local SPD office. On 09/10/24, survey requested the facility report the incidents to the local SPD office. At approximately 11:07 AM on 09/10/24, confirmation of the facility reporting the incident to the local SPD office was provided. On 09/10/24 at 3:30 PM, the need to ensure all incidents for which abuse and/or neglect could not be ruled out were reported to the local SPD office was discussed with Staff 1 (Executive Director) and Staff 2 (Business Office manager). They acknowledged the findings.

1/ Inservice conducted with all team members on 9/24 and 9/26 2/ Process implemented: During the initial incident report, if the resident cannot verbally state the cause, a initial report will be filed with APS 3/ED(Executive Director) and DHW (Director of Health and Wellness) to audit all incidents within 7 days 4/Separate binder to be held in the ED office to record any investigation notes permanently

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

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 interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated, resident-specific interventions determined and documented, those actions conveyed to staff on all shifts, and the conditions monitored at least weekly through resolution for 3 of 3 sampled residents (#s 1, 2 and 3) who had documented changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 07/2020 with diagnoses including atrial fibrillation, cardiac pacemaker, and acute renal failure. Review of Resident 2’s service plan, dated 07/09/24, and progress notes, dated 06/09/24 through 09/09/24, revealed the following changes of condition: *A progress note dated 06/26/24, reported a CG had seen a “smear of blood when wiping the bottom”; and *A progress note dated 07/18/24, identified the resident had an episode of “nausea, vomiting, loose stool, and stomach spasms”. There was no documented evidence the conditions were evaluated and monitored, with necessary interventions developed and conveyed to staff, and progress noted at least weekly, to resolution. On 09/10/24 at 3:45 pm, the need to ensure short-term changes of condition were evaluated, necessary resident-specific interventions determined and documented, those actions conveyed to staff on all shifts, and the conditions were monitored, at least weekly, through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Business Office Manager). They acknowledged the findings. 2. Resident 1 was admitted to the facility in 11/2019 with diagnoses including transient ischemic attack (brief stroke like attack), congestive heart failure and fall risk. During the acuity interview on 09/09/24, Resident 1 was identified as being on a puree texture diet. Resident 1's progress notes, dated 08/27/24 through 09/05/24 were reviewed and interviews with staff revealed the following changes of condition: *08/27/24 – The resident was noted to chew and spit out regular texture foods, trial of puree texture initiated; and *08/28/24 – Physician order for change of diet texture from regular to mechanical soft texture. There was no documented evidence the facility monitored the changes of condition at least weekly until resolved. On 09/10/24 at 2:25 PM, Staff 8 (Certified Caregiver/MT) confirmed there was no documentation of monitoring the trial of puree texture. The need to monitor and document at least weekly until changes of condition were resolved was discussed with Staff 1 (Administrator) and Staff 2 (Business Office Manager) on 09/10/24 at 3:30 PM. They acknowledged the findings. 3. Resident 3 moved into the facility in 07/2024 with diagnoses including right heel pressure ulcer, permanent atrial fibrillation and chronic kidney disease. Staff were interviewed and the resident's record was reviewed including the current service plan dated 09/02/24 and temporary care plans, task updates, and progress notes dated 07/30/24 through 09/10/24. The facility failed to determine resident-specific actions or interventions needed, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions: * 07/30/24 – New move-in; * 07/30/24 – Bruises and scabs to right and left lower extremities; * 08/20/24 – Ongoing medication refusals; and * 09/01/24 – Significant weight gain. The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and the changes of condition were monitored at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 2 (Business Office Manager) in-person and Staff 3 (Director of Health and Wellness/RN) via phone at 12:40 pm on 09/10/24. They acknowledged the findings.

1/inservice for all Care team members completed on 9/26. 2/process: Alert charting to be done for residents with change of condition every other day until resolution. 3/DHW will print weekly the alert charting and review for accuracy 4/Monitoring to ensure that the change of condition process has been implemented as follows: - DHW to keep the record of the weekly audit until Dec 2024 .

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.

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

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and had documentation of all required components. Findings include, but are not limited to: Fire and life safety records dated 02/2024 through 08/2024 were reviewed with Staff 4 (Maintenance Director) on 09/09/24 at 1:35pm. The facility fire drills lacked documentation of the following required components: * Location of simulated fire origin; * Problems encountered and comments related to residents who declined to participate in the drills; * Evacuation time period needed; * Number of occupants evacuated; * Evidence alternate routes were used during the fire drills; and * Documented evidence immediate changes were made to ensure the evacuation standard was being met. During an interview on 09/09/24 at 1:35pm, Staff 4 reported he was unaware of the standard for the evacuation time period. Staff 4 acknowledged he was not keeping a written fire drill record that included all the required components of a fire drill. The need to ensure fire drills were conducted according to the OFC and documentation included required components was reviewed with Staff 1 (Administrator) on 09/10/24 at 8:30 am. She acknowledged the findings.

1/ inservice to be conducted with ED and FD (Facilities Director) by Facility Divisional Director on 10/8 about the required components to be included in the drills according to OFC. 2/Acknowledgment form implemented to document that within 24 hour of admission the FD or designee has reviewed the initial evacuation /alternate route with resident and update the fre drill form to include documentation of all the components. 3/ Fire dill to be conducted in October and follow up review to be done with Facility Divisional Director before 10/31/2024 4/Evaluation and review conducted every quarter in 2025 with FD and ED

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

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 measures were taken to prevent the entry of rodents, flies, mosquitoes, and other insects and there was a locked storage for all toxic materials. Findings include, but are not limited to: During a tour of the interior of the building on 09/09/24 at 9:55 am the following was observed: 1. Toxic chemicals were observed in the following areas and accessible to residents: * The central laundry room doors were unlocked and/or the doors were propped open. The laundry room contained multiple five-gallon buckets of disinfectant, laundry sanitizer and other toxic chemicals; * The housekeeping and storage closet on the second floor, near room 203, was unlocked and had multiple spray bottles filled with disinfectant and a one gallon bottle of chloride bleach; * The kitchenette located near the pool table had multiple bottles of toxic chemicals in the unlocked cabinets; and * The activity room office was unlocked and had a disinfectant spray bottle on the counter. 2. The following areas allowed for the entry of rodents, flies, mosquitoes, and other insects: *Multiple resident unit and common area window screens were threadbare, torn or missing; * The window across from the laundry room on the first floor was broken and the screen was misaligned; * Two entryway doors, one leading to the parking lot and the other to the pet relief area had gaps between the door threshold and the bottom of the door; and *The window mechanism near the bookcases upstairs was broken, preventing the window from opening and closing properly. The need to ensure measures were taken to prevent the entry of rodents, flies, mosquitoes, and other insects and there was a locked storage for all toxic materials was observed and discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director) on 09/10/24 at 11:13 am. They acknowledged the findings.

1/ Locks for all areas containing chemicals and door swipers to be istalled by 10/15 2/Windows mechanism to be audited by FD by 10/15 and necessary repaired completed by 10/31 3/ weekly walkthrough checklist to be conducted by ED and FD until 12/31/2024 4/ED and FD to keep documentation of the weekly walkthroughh checklist

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.

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 lever-type door handles were provided on all doors used by residents and 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 residents was kept clean and in good repair. Findings include, but are not limited to: During a tour of the environment on 09/09/24 at 9:55 am the following was observed: 1. Lever-type door handles were not installed on multiple resident unit bathroom doors on the second floor, eight exterior doors leading to the interior courtyard and on the television lounge door. During the tour of the facility with Staff 1 (Administrator) and Staff 4 (Maintenance Director), lever-style door handles was discussed. They reported when the doors leading to the courtyard were replaced, they would make sure the doors had a lever-style door handle installed. 2. The interior environment on the first floor required cleaning and/or repair in the following areas: * Lobby and sitting areas including: multiple blue chairs which had stains, a brown vinyl chair which had torn fabric on the seat, and multiple gouges and chipped paint below the reception counter; * Handrail near the kitchen and across from the dining room had black scuff marks and the corner of the handrail next to the dining room had an approximate four-inch gouge with exposed wood; * Multiple areas of baseboard were scuffed, gouged and had chipped paint; * Public bathroom doors were scuffed, gouged and had chipped paint; and * Each elevator located on the north and south end of the building had scuffed and gouged interior and exterior doors and walls and burnt-out ceiling lights. 3. Dining room: * Both fire doors leading into the kitchen had multiple areas of gouges and chipped paint; * Two wall-hung hand sanitizer stations near each entrance to the dining room were empty and had a buildup of dirt; * Alcove kitchenette cabinets had misaligned cabinet doors, broken drawers, the walls and paint were chipped, inside the cabinet below the sink there were stains, and the interior cabinet wood was damaged; * Gouges in the walls, chipped paint and multiple areas of baseboard had black scuff marks, chipped paint and gouges throughout the dining room; * Multiple carpet stains and dead bugs laying on the floor near the stairs in the back of the dining room; * Multiple air ventilation covers (e.g. near the alcove kitchenette and the back side of the fireplace) had a buildup of dirt and debris; * The fireplace in the dining room had a buildup of dust and debris on the chain fire screen and multiple areas of chipped mantle tile; * The wall behind the staircase with a water feature mural had multiple areas of chipped paint; and * The exterior entryway behind the staircase had missing floor covering with exposed concrete, had a buildup of cobwebs, insects, yard debris and the doors had areas of rust, gouges and chipped paint; and * Eight interior doors leading into the courtyard were unaligned and would not open and shut securely. 3. First floor main laundry room: * A large area of floor covering in front of the commercial washing machines was removed with exposed concrete floor; * Clinical flushing rim sink had a buildup of brown matter and dirty water; * The utility sink and eyewash sink were dirty with smeared brown matter; and * One of the two commercial dryers was not operational. 4. The interior environment on the second floor required cleaning and/or repair in the following areas: * Staircase leading to the second floor had chipped and worn paint and dirt buildup on the railing, spindles and carpet stains; * Multiple chandeliers hanging above the staircase had cobwebs and dead bugs and debris buildup inside the light covers; * Carpet throughout the second floor had multiple areas with stains, dirt buildup, tears and/or the carpet was uneven which created the potential for a tripping hazard; * Multiple doors and/or door frames had gouges, scrapes and chipped paint including but not limited to: Rooms 202, 206, 210, 213, 214, 218, 228, 230, bathroom door across from room 246, 250, 254, 255, and 257; * Common use bathroom across from room 246 had scuffs, chips and gouges in the wall and paint; * Fire sprinkler riser door near room 257 had a missing threshold which exposed the concrete floor beneath; * Baseboards throughout the second floor had scuff marks and or gouges; * A large area of exposed plywood on a platform across from room 253; * The fireplace had buildup dust and debris on the fire screen and multiple areas of missing and/or cracked mantle tiles; * Multiple air ventilation covers had a buildup of dust and debris; and * Kitchenette (near the pool table) had water damage inside the cabinet below the sink. 5. Second floor resident use laundry room: * The door seal was torn and falling off; * The floor had brown stains near the washing machine and behind the water heater; * The floor drain was removed; and * The utility sink was stained and dirty. 6. The exterior courtyard off the dining room was toured and the following was observed: * A four-drawer brown plastic organizer was broken and left discarded in the courtyard; * Numerous dead plants and overgrown vegetation were scattered throughout; * Brown paper lawn bag filled with dead plant matter; * Two large water fountains were not working and were covered in overgrown moss; * The walking path was covered in overgrown moss and vegetation, creating a tripping hazard; * A wooden bench was rough and had numerous splintered areas; * An exterior electrical outlet was missing an outlet cover; and * Multiple areas of missing, loose or buckled siding and flashing where the ground and building join. The need to ensure lever-type door handles were provided on all doors used by residents and all interior and exterior materials and surfaces necessary for the health, safety, and comfort of the residents was kept clean and in good repair was discussed and the environment was toured with Staff 1 and Staff 4 on 09/10/24 at 11:13 am. They acknowledged the findings.

1/ Meeting held with divisional directors on 9/25 to address the needing repairs and replacement orders: Lever type handles, furniture, carpet and flooring, doors in the dining room, commercial dryer contract painting cleaning tasks scheduled for the fireplace, light fixtures and utility sinks replacement of all hand sanitizers Repair of the tiles, door seals and removal of debris to be completed by 10/15 Vegetation to be trimmed by 10/15 2/Addition of missing areas on the Housekeeping tasklist in the public area and inservice of the HSK team on 10/01/2024 Weekly inspection of the courtyard to be conducted until winter and to resume in the spring 3/Repairs and new equipment weekly walkthrough checklist conducted by ED and FD starting 10/03 until 12/31/2024 . 4/ monthly environement checklist to be conducted by the ED and the FD in 2025

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.

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

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: The facility was toured on 09/09/24 at 9:55 am. Multiple resident unit windows and throughout the common use areas including the puzzle area, library, and resident corridors on the second floor opened vertically, and windowsills were lower than 36 inches. The windows had old mechanisms installed that had failed and were no longer operating as designed which allowed for multiple windows to be fully opened therefore, the facility lacked a system which limited how much the window could be opened to prevent accidental falls. The lack of a mechanism to prevent accidental falls was discussed with and the environment was toured with Staff 1 (Administrator) and Staff 4 (Maintenance Director) on 09/10/24 at 11:13 am. They acknowledged the findings.

1/Inspection of all window units to be completed by 10/31 2/Install stoppers to cap opening to 6 ' 3/Monthly walkthrough conducted by ED and FD to inspect that the window stoppers are in place. 4/ED to audit quarterly in 2025

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

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 ensure a manually operated emergency call system was provided in all public-use restrooms. Findings include, but are not limited to: The facility was toured on 09/09/24 at 9:55 am. The following was observed: Two public-use restrooms on the first floor near the television lounge lacked a manually operated emergency call system to alert staff of an emergency. The need to ensure a manually operated emergency call system was provided at each resident and public-use restroom was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director) on 09/10/24 at 11:13 am. They acknowledged the findings.

1/10 Emergency call devices have been programmed and are to be installed by 10/31 The public restrooms in the lobby were never equipped with a call system. 2/All bathrooms including visitors' bathrooms will be equipped with an emergency pull cord device. 3/ Quarterly test audit to ensure that the emergency pull cords are operating. 4/Audit to be conducted by DHW and ED quarterly in 2025

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 interview and record review, conducted during a site visit on 03/27/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Findings include, but are not limited to. During a phone interview on 03/27/24, Staff 3 (Executive Director) stated the facility was using the ODHS ABST tool. Residents 1, 2 and 3's ABST profiles had not been updated in the last quarter as required by rule. Resident 4 moved into the facility on 03/22/24 and as of 03/27/24 had not yet been entered into the tool. The findings were reviewed with and acknowledged by Staff 3 by phone on 03/28/24. The facility failed to fully implement and update an ABST.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to: On 02/14/24 at 10:50 am, the kitchen was observed to need cleaning in the following areas: Food spills, splatters, debris, black matter, grease and/or dust were observed on, in or underneath the following: * The floor of the refrigerator with two roll in carts; * The walls, ceiling, floor, wire shelves, pipes and fans in the walk in refrigerator; * The floor in the walk in freezer; * The ice maker; * The exterior doors of the sandwich/salad refrigerator; * Lower shelves throughout the kitchen; * Flooring throughout the kitchen, including underneath counters, stove/grill, sinks and storage shelves; * The wall behind the spray hose, under the sink and around the handwashing soap dispenser in the dishwashing room; * The ceiling, light fixture and vent in dishwashing room; and * The back of stove grill, piping next to the stove and side of the stove. There was a hole in the ceiling between the stove and the grill. The seals on the doors of the roll in cart refrigerator were loose. There were uncovered, unbaked rolls on a baking sheet, in the walk in refrigerator. The findings were observed and discussed with Staff 1 (Food & Beverage Manager) and were discussed with Staff 2 (Executive Director) on 02/14/24. The findings were acknowledged.

1/review of the cleanning and repairs conducted on 02/06/2023  with regional team: Weekly and Monthly checklist provided 02/15/2024 Repairs for seals and hole in the ceiling to be completed  by 03/08/2024. The ceiling tiles will be cleaned by  03/08/2024, new tiles to be ordered. Inservice for the cleaning tasks conducted with the cooks on 02/15/2024 2/ weekly inspection conducted and documented from ED or Culinary director implemented on 02/29/2024 and to be conducted until 05/16/2024. ongoing: weekly checklist for Cook to start 03/04/2024 and Monthly checklist for DCS to start 03/03/2024 3/ weekly inspection and monthly sanitation checklist 4/Culinary Director and ED

Based on observation and interview, it was determined the facility failed to ensure the facility kitchen was clean and maintained in good repair, in accordance with the Food Sanitation Rules OAR 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 04/05/24 at 11:05 am, the kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, black matter, grease and/or dust were observed on, in or underneath the following: * The interior shelves and door seals of the sandwich/salad refrigerator; * Flooring throughout the kitchen, including underneath spray sink and prep sink; * The wall behind and underneath the warewash machine and counters in the dishwashing room; * Floor and wall behind the stove, grill and steamer; and * The walls, ceiling, floor, wire shelves, and pipes in the walk in refrigerator had a build up of food debris and dust. b. The following areas were in need of repair: * The roll in cart refrigerator door seals were broken and falling off; * The reach-in refrigerator doors (connected to the walk-in) had broken and deteriorating door seals; * The walls and wire shelves in the walk-in refrigerator had multiple areas of brown discoloration (rust); * The wall of the walk-in refrigerator had multiple small holes; * A leaking pipe in the walk-in refrigerator that was causing a large buildup of ice on the walk-in refrigerator floor; * Broken floor tiles in the right corner of the walk-in refrigerator; * Broken floor tiles in the walk-in freezer located to the left of the door and around the freezer door threshold; * Multiple holes and missing seals between the wall and stainless steel counters surrounding the dishwashing area located near the front of the kitchen; * Multiple holes and missing seals between the wall and stainless steel counters surrounding the dishwashing machine, located near the back of the kitchen; * The floor drain under the prep sink was rusted and had missing tile grout surrounding the drain; * Multiple tile baseboard grout was missing throughout the kitchen, including, but not limited to areas near the walk-in refrigerator and dishwashing areas; and * Multiple ceiling tiles, tile framing, smoke alarms and sprinklers throughout the kitchen had brown and black discoloration (all areas). The findings were observed and discussed with Staff 2 (Executive Director) and Staff 3 (Maintenance Director) on 04/05/24. The findings were acknowledged.

Food spills & Splatters, debris, black matter, grease and/or dust on the following: oInterior shelves & Door seals of sandwich refrigerator, oFlooring throughout the kitchen, including underneath spray sink and prep sink oWall behind & underneath warewash machine and counters in dishroom oFloor behind stove, grill, & steamer oWalls, ceiling, floor, shelving, and pipes in walk-in refrigerator ->In progress, added to daily and weekly checklist. Deep cleaning scheduled 4/25-26. Daily/weekly and monthly cleaning audits to be implemented by 4/23 and reviewed monthly for 3 months by the culinary director Repairs: : oRoll in cart refrigerator door seals broken and falling off-Quote submitted 4/19, oReach-in doors to walking deteriorating door seals-vendor quote submitted 4/19, (custom -made) oWalls and wires shelves in walk-in had multiple areas of discoloration-being repainted oThe wall of walk-in refrigerator has several small holes-to be completed on 4/25-26 oLeaking pipe in walk-in refrigerator that is causing buildup of ice-vendor scheduled on 04/23 oBroken floor tiles in right corner of walk in refrigerator and freezer-Expected Vendor quote on 04/22 and scheduled on 4/25-26 to repair both Fridge and freezer oMultiple holes in and missing seals between wall and stainless steel counters surrounding dishwashing area near front of kitchen-caulking and sealing in progress as of 4/11, to be completed by 4/26 oMultiple holes and missing seals between the wall and stainless steel counters located near back of the kitchen-caulking and sealing:  in progress as of 4/11, to be completed by 4/26 oFloor drain under the prep sink was rusted and missing tile grout-completed on 4/15 oMultiple tile baseboard grout missing throughout the kitchen-completed on  4/16, oMultiple ceiling tiles, tile framing, smoke alarms and sprinklers throughout kitchen had discoloration-painting done on 04/18 and 4/19   Repairs will be completed under the supervision of the Maintenance Director

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 C 240.

see C 240

The findings of the kitchen inspection, conducted 02/14/24, 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 02/14/24, conducted on 04/05/24, 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 re-visit to the kitchen inspection of 02/14/24, conducted on 05/23/24, are documented in this report. The facility was found in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen, food storage areas, food preparation, and food service on 01/31/23 revealed splatters, spills, drips, and debris noted on:   - Can opener casing and blade; - Walls in prep areas; - Reach in refrigerator handles; - Wire rack shelving; - Legs and underneath shelving; - Equipment throughout kitchen; and - Walls, floors, and equipment in the dish washing room. * There were undated and unlabeled foods in the walk in refrigerator. * There was missing and damaged tile flooring in the walk in refrigerator. Staff 2 (Food and Beverage Director) and the surveyor toured the kitchen. Staff 2 acknowledged the kitchen was in need of cleaning and repair. The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) on 1/31/23.

1/ -Inservice conducted on 02/06/2023  with review/retraining  of cleaning tasklist, food -Tiles to be repaired by 03/15/2023 2/ weekly inspection conducted and documented from ED or Culinary director implemented on 02/16/2023 and to be conducted until 03/30/2023 3/ weekly inspection 4/Culinary Director and ED

The findings of the kitchen inspection, conducted 01/31/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection survey of 01/31/23, conducted 04/20/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Serviced - Meals and Oregon Health Service Sanitation Rules OARs 333-150-0000.