The Oaks at Lebanon

Based on interview and record review, it was determined the facility failed to ensure the RN performed an assessment and developed interventions based on the condition of the resident for 1 of 4 sampled residents (#6) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 02/2021 with a diagnosis of aphasia.

Review of Resident 6's weight records from 05/2025 through 08/2025 revealed the following weights:

*05/26/25 weighed 160.6 pounds;
*06/06/25 weighed 152.9 pounds;
*06/15/25 weighed 153.2 pounds; and
*07/09/25 weighed 151.5 pounds.

On 08/07/25 the resident weighed 147.9 pounds. The resident experienced a 12.7 pound weight loss from 05/2025 to 08/2025 which constituted a severe 7.9% loss in three months and required an RN assessment.

There was no documented evidence the RN had assessed the status of the resident, documented findings, and developed interventions as a result of the assessment.

On 09/10/25, survey requested a current weight for Resident 6 and h/she weighed 147.3 pounds.

On 09/11/25, the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations). They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview, observation, and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) accurately captured the care time and care elements that staff were providing to each resident as outlined in each individual service plan for 1 of 6 sampled residents (#5) whose ABST data was reviewed. Findings include, but are not limited to:

Resident 5’s service plan, dated 07/03/25, ABST data, and clinical record was reviewed during the survey.

The service plan noted the resident required hands-on assistance with feeding and staff would assist with feeding at all meals. On 09/09/25 and 09/10/25, care staff were observed providing hands-on assistance to the resident with eating his/her meals. Review of the resident’s ABST revealed zero minutes were accounted for feeding assistance.

The service plan noted the resident needed assistance with from person and may require two persons to provide hands-on assistance with all transfers. On 09/10/25, the resident was observed needing two staff members to provide transfer assistance. Review of the resident’s ABST care time indicated the facility was only accounting for one staff member providing transfer assistance. The resident ABST was found inaccurate in transfers.

The facility failed to accurately capture ABST minutes related to Resident 5’s needs in supervising, cueing, or supporting while eating and transfers.

On 09/11/25, the need for the ABST to accurately capture care time and care elements that staff were providing to residents was discussed with Staff 1 (ED) and Staff 2 (Vice President of Operations). They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated at least quarterly for multiple sampled and unsampled residents, to address activities of daily living and other tasks. Findings include, but are not limited to:

Review of the facility's ABST entries, staff schedule, calculated staffing hours, posted staffing plan, and interviews with staff were conducted during the survey, and showed the following:

It was determined 15 of the 62 residents currently residing in the facility had not been updated in the ABST since 12/2024 (over eight months).

In an interview on 09/10/25 at 1:35, Staff 1 (ED) and Staff 2 (VP of Operations) confirmed the residents had not been updated correctly.

On 09/11/25, the need to ensure all residents ABST entries were updated at least quarterly was discussed with Staff 1 and Staff 2. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure exterior surfaces were maintained in good repair. Findings include, but are not limited to:

Observations, from 09/09/25 through 09/10/25, of the exterior of the facility revealed the following:

* Concrete pathways in the parking lot, perimeter of the building, and courtyard of the facility were observed with broken pieces of concrete and uneven surfaces. Uneven pathways and broken pieces of pathways created potential fall hazards.

On 09/10/25, the building's exterior was toured with Staff 1 (ED) and Staff 6 (Maintenance Director). They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure 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 was clean and in good repair. Findings include, but are not limited to:

During the survey, from 09/09/25 through 09/11/25, the following was observed:

* Multiple doors and door frames throughout the facility were observed with scratches and damaged paint;
* Ceiling tiles on the 1st floor near the nurses station, restroom, and apartments 107, 308, 310, and 311 had brown stains;
* The popcorn machine, on the second floor, had debris inside and was in need of cleaning; and
* An excess of cobwebs was observed throughout the exterior of the building.

On 09/04/25, the need to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents was clean and in good repair was discussed with Staff 1 (ED) and Staff 6 (Maintenance Director). They acknowledged the findings.

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.

This Rule is not met as evidenced by:

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

Observation of the facility kitchen on 11/20/24 at 10:10 am thru 1:20 pm revealed the following:

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

* Floors throughout main kitchen area;
* Floors under/behind equipment;
* Floors in dry storage;
* Floors, walls, and drain in dish machine area;
* Fire sprinklers;
* AC units and ceiling vents;
* Stove/oven knobs, handles and, interiors;
* Walls throughout kitchen with food debris/splatter;
* Warming drawers interior and exterior;
* Industrial can opener and housing;
* Walls with visible high dust accumulation in food prep and service areas;
* Stainless steel open shelving;
* Interior and exterior of reach in coolers and freezers;
* Metal can racks in dry storage;
* Interior of drawers in dining room with food debris;
* Underneath tables, bench seating, chairs with noted food debris from previous meal/s and not cleaned between meal services.

b. The following areas were in need of repair:

* Multiple areas where pipes inter/exit celling or walls with open areas and not sealed allowing potential entry for pests.
* Right oven not operational.
* Large areas in dishwashing area with cracked/missing/black caulking;
* Caulking behind stainless steel prep spaces cracked/missing or with black debris build up;
* Pieces of tile coving near floor missing on doorways/thresholds;
* Juice machine not working properly;

c. Kitchen staff member observed to not wash/rinse iceberg lettuce prior to service in a ready to eat salad. Same cutting board and knife were used to cut outer portions of the head of lettuce and then the inner portions. No washing of this ready to eat produce was observed. This practice potentially contaminated the ready to eat lettuce with surfaces/utensils.

d. Raw pasteurized shell eggs were observed stored directly above multiple packages of ready to eat romaine lettuce. One “ready to cook” turkey was observed stored above a large package of whole beef roast. Both items could have potentially contaminated the items stored below.

e. Multiple potentially hazardous food items were stored in reach in cooler near dining room and across from stove and did not have dates when opened or prepared as required.

f. Multiple staff drinks were noted throughout the kitchen space and not in a designated area for eating/drinking. All observed drink containers were not of approved containers with lids/straws and handles as directed to minimize hand to mouth contact.

g. Care staff assisting residents in the dining room as well as serving plates/drinks and coming in and out of the kitchen did not have on aprons to create clean barrier from other personal care provision duties.

h. Utility cart used for transporting beverages to dining rooms noted placed/stored directly next to hand washing sink. No splash guard or other method was observed to protect equipment from potential contaminated splash from sink. Industrial can opener was located on the end of a stainless steal table directly next to a prep sink. No splash guard observed to protect the food contact surface from potential contamination from splash from the food prep sink.

Staff 2 (Dining Services Director), toured kitchen with surveyors and acknowledged the areas identified. At approximately 1pm, the surveyors and Staff 1 (Administrator) reviewed areas of concern. Staff 1 acknowledged the above areas that needed to be cleaned and repaired and practices that needed addressed.

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

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

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 6/9/23, 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.

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observation of the kitchen on 06/09/2023 at 9:15 am through 11:45 am revealed the following:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* Hand wash sink inside kitchen;* Ice and water dispenser;* Cupboards, walls and drawers in dining room beverage area;* Handle of serving cart;* Propane tank, vent unit, pipes, walls and ceiling in dishwashing room;* Ceiling fire sprinklers;* Open stainless steel shelving in multiple areas in kitchen used for storing dishes, cooking electronics, baking racks;* Exterior surfaces of convection oven, oven, steamer, reach in cooler storing eggs, and warming drawers;* Interior of microwave;* Grill shelf;* Black stains on wall just above stainless steel shelf across from grill;* Brown stains on wall in janitor closet;* Multiple vents throughout kitchen and in dining room;* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges;* Inside of drawers holding utensils were rusty with debris; and* Multiple electrical cords, outlets, pipes with dust and debris.b. The following areas were found in need of repair:* Tile missing by janitor closet, backside of grill, right side of stove and near dry storage room causing unclean surfaces with noticeable debris buildup;* Two sections of metal plates on hood vent were damaged;* Screen door dusty and did not stay latched;* Racks storing dishes were rusty and caused unclean surfaces;* Freezer in dry storage leaking water onto floor;* Black grout on baseboard tile at end of beverage area; * Multiple holes found in ceiling, in and around piping and electrical conduits;* Peeling paint and gouges on walls in dry storage, by knife holder, service area, on ceiling, in janitor closet and on floor near reach in fridges and freezers; and* Lid to grease trap on the floor was rusted.c. Cardboard used as liners on racks in dry storage area which was not a cleanable surface.d. Staff food stored in reach-in refrigerator. e. Food items in glass in the reach-in refrigerator was not properly labeled and/or dated. f. Food items in reach-in refrigerators and freezers stored incorrectly: pork was being stored on top of jello, ready to eat food stored on bottom of fridge under raw bacon, and ground beef stored on top of vegetables in the freezer. g. Staff was observed to potentially contaminate hands and food items while washing dishes as staff did not wash or sanitize hands when switching from dirty to clean tasks. A server touched a sanitizing rag on tray line several times during service. This rag was used to wipe area with food products, etc. No hand washing step was observed after handling this potential contaminated rag and then touching food during plating.f. Multiple kitchen staff preparing and/or serving food did not have hair and/or facial hair effectively restrained as required. Staff 1 (Dietary Services Director) toured kitchen with surveyors and acknowledged areas needing to be addressed. At 11:45 am, Staff 1, Staff 2 (Business Office Manager) and the surveyor reviewed areas in need of continued cleaning, maintenance and infection control practices. Staff acknowledged the areas of concern.