Springs at Clackamas Woods ALF

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 4) who’s initial evaluation was reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 09/2024 with diagnoses including atrial fibrillation and hypothyroid. The resident's 09/11/24 move-in evaluation was reviewed. There was no documented evidence the following elements were addressed: * History of unexplained weight loss or gain; * Complex medication regimen; The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), and Staff 5 (Resident Services Coordinator) on 10/16/24. They acknowledged the findings.

1) Based on interview and record review, resident #4 was found to not have documentation in the initial evaluation. A) Personalilty, History for unexplained weight loss or gain, complex medication regimen, unsuccessful prior placements, elopement risk or history, recent losses, and environmental factors. Resident #4 had her service plan updated to include all missing items. 2) To ensure complaince, Community RN, Executive Director, Admninstrator, and RSC will be trained on the OAR in order to ensure all items will be documented on each new move in. The Initial Assessment within the Point Click Care system requires us to check these pompts upon assessmenmt of each resident. 3) To ensure compliance each move-in evaluation will be reviewed prior to move in and 3 charts will be pulled monthly to ensure proper documentation. 4) RN, Administrator, RSC, or Designee

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

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 maintain infection prevention and control protocols for multiple unsampled residents who received meal service. Findings include, but are not limited to: Observations of meal service, completed on 10/14/24 and 10/15/24, revealed the following: Multiple care staff served food and provided assistance to residents both in Aspen and Dogwood houses without donning a protective barrier over potentially contaminated clothing. In interview with Staff 8 (CG) on 10/15/24 at 12:45 pm, she reported “we don’t have aprons for serving residents.” The need to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator) and Staff 5 (Resident Services Coordinator) on 10/16/24 at 1:15 pm. They acknowledged the findings.

1) This rule was not met as evidenced by staff not seen wearing aprons during meal service. Aprons will be worn by all staff during meal service and delivery of meals. 2) Aprons were purchased the same day and implemented at the next meal service. They are laundered each night by our NOC shift staff. 3) Staff will be monitored daily during all meal services to ensure correct usage. 4) Med Techs, RSC, Executive Chefs, Administrator, Executive Director or Designee.

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

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 medications used to treat a resident's behavior had written, non-drug interventions attempted with ineffective results prior to administering a PRN psychoactive medication, for 1 of 1 sampled resident (# 4) who was prescribed a PRN medication to address anxiety. Findings include, but are not limited to: Review of Resident 4's 09/01/24 through 10/14/24 MARs and progress notes showed the following: Resident 4 was prescribed Alprazolam 0.25 mg twice daily as needed for "anxiety disorder." The facility administered the Alprazolam to the resident 22 times between 09/01/24 and 10/14/24. There were no non-pharmaceutical interventions documented as having been attempted prior to administering the medication, and no information for the staff related to how the resident's anxiety was displayed. The need to ensure staff documented non-drug interventions were attempted with ineffective results prior to administering a PRN psychoactive medication, and staff were aware of the signs of the resident’s anxiety was discussed on 10/16/24 with Staff 1 (ED), Staff 2 (Health Services Administrator), and Staff 5 (Resident Services Coordinator). They acknowledged the findings.

Resident #4 was found to not have 3 non-drug interventions in place for her prescribed PRN medication. 3 interventions have been added to the MAR to use prior to dispensation of the PRN medication. 2) An audit has been done to ensure all residents with PRN pyschoactive medications have 3 non-drug interventions in place. RSC's and RN will also make sure that when performing 2nd checks on orders, that interventions are in place on any new orders received after move. 3) An audit will be done upon move in to ensure interventions are in place and an audit of 3 random residents monthly. RSCs and RN will be trained to ensure interventions are in place upon move-in and during second checks on new psychotropic meds received after new orders. 4) RSC, RN, Administrator, Executive Director, or Designee

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.

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

Based on observation, interview, and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) evaluation before a resident moved in for 1 of 1 sampled resident (#4) and failed to have an accurate number of minutes for 1 of 3 sampled residents (# 2). Findings include, but are not limited to: 1. Review of the facilities ABST records revealed Resident 4, who admitted to the facility in 09/2024 did not have an ABST evaluation completed. During an interview with Staff 2 (Health Services Director) on 10/15/24 she confirmed Resident 4 had not had an ABST evaluation. 2. A review of Resident 2’s ABST record showed the resident required zero minutes on multiple care areas. However, observations, interviews, and review of clinical records for Resident 2 revealed the resident required staff assistance in multiple care areas and the ABST tool did not accurately reflect the amount of staff time needed to provide care. On 10/15/24 at 2:20 pm, the surveyor reviewed the resident’s ABST record with Staff 2 (Health Services Administrator) and discussed to ensure the accurate amount of staff time needed on all required areas. Staff 2 acknowledged the findings. The requirements of the ABST were discussed with Staff 1 (ED), Staff 2 (Health Services Administrator) and Staff 5 (Resident Services Coordinator) on 10/16/24 at 1:15 pm. They acknowledged the findings.

1) Resident #4 was found to have been not entered into the ABST. Resident #4 was added into the ABST with accurate times while the survey team was on site. Resident #2 showed multiple areas with zero minutes. Resident #2 was reviewed and updated to reflect her current needs that reflects with accuracy of the time needed to provide care. 2) Each New move in will be added at time of move in approval. They will then have cares updated the day before move in. a) All residents will also be audited for accuracy of care provided times. 3) ABST will be reviewed daily to ensure accuracy of time needed to provide care. Once monthly there will be a review of 3 residents to also ensure accuracy. 4) RSC, Administrator, Executive director or Designee.

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

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 staff members (#s 10 and 11) had completed the infectious disease prevention training prior to beginning job responsibilities. Findings include, but are not limited to: Staff training records were reviewed on 10/16/24. Staff 10 (Caregiver), hired 08/19/24 and Staff 11 (Prep Cook), hired 08/22/24 lacked documented evidence of completing the infectious disease prevention training. The need to ensure staff completed the infectious disease prevention training prior to beginning job responsibilities was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator) on 10/16/24 at 1:15 pm. They acknowledged the findings.

1) Staff member # 10 and staff # 11 were found not to have completed their infectious disease training prior to beginning their job. Due to a techinical error this training had not been assigned to the staff. Staffing Development Coordinator did an Immediate audit to ensure no other staff were missing documentation. Staff members completed this training as soon as they found out and before working their next shift. 2) All staff members will check in with their supervisor before moving to floor training. The supervisor will check with the staffing coordinators to ensure all training has been completed. 3) Staffing Coordinators will do a monthly audit of training records to ensure proper documentation is complete. 4) Staffing Coordinators, Business Office Manager, Administrator, or Designee

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

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

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 7 and 10) had documentation of demonstrated knowledge and performance in all required areas within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 10/16/24 and identified the following: Staff 7 (Caregiver) and Staff 10 (Caregiver), hired 05/24/24 and 08/19/24, failed to complete demonstrated knowledge and performance in the following topics within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation, and reporting. The need to ensure staff completed demonstrated knowledge and performance in all required areas within 30 days of hire was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator) and Staff 5 (Resident Services Coordinator) on 10/16/24 at 1:15 pm. They acknowledged the findings.

1) Staff #7 and staff # 10 were found to have not completed their compentency checklist document that demonstrated knowledge and perfomance within 30 days of hire. Both compenteny checklists were completed outside of the 30 day requirements, thus unable to further correct at this time, but please see plan going forward. 2) Moving forward, all newly hired staff will complete their compentency checklist demostrating ADL knowledge and performance within 30 days of hire. Staff will be removed from the schedule if they have not completed this within 30 days, until it is accomplished. *Roles of service plan in providing care, changes associated with normal aging, identification, documentation and reporting changes of condition and conditions that require assesment, teatment, observation are all part of our CARES training. 3) Staffing Coordinators will complete audit before staff member works the floor on their own and will do monthly training record audit. 4) Staffing Coordinators, Business Office Manager, Administrator, Deparment lead and Designee

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 observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 08/24/23 at 11:20 am, the main kitchen and the Aspen kitchen were observed and the following was noted: a. In the dry storage area:   *Scoops were stored in containers of powdered sugar, gluten-free pancake mix and brown sugar; *The outside of the containers and lids containing powdered sugar and gluten-free pancake mix had accumulation of food debris; and *The rolling cart held four trays of cookies which were uncovered.   b. Main kitchen prep area: *Scoops were stored in the large bins of flour, oatmeal and granulated sugar. c. In the walk in refrigerator: *The rolling cart held two trays of waffles which were uncovered. d. The kitchen was in midst of remodeling and the back area of the kitchen was open to the outside, creating a potential for rodent/pest infestation and cross contamination to uncovered food items.   e. Three garbage cans in food prep areas were uncovered when not in use. f. Aspen kitchen: *The ceiling had heavy build up of dust surrounding the vent. The findings were observed and discussed with Staff 1 (Dining Services Director) and Staff 2 (Executive Director) on 08/24/23. The findings were acknowledged.

1a. Dry storage area: - Holders for the scoops have been purchased for scoops to be placed in when not in use. - All accumulation of debris has been removed and staff will be checking it daily. - Cookies that were left uncovered were removed and disposed of. Cookies will be covered while cooling and removed to a covered container as soon as cooling has completed. b. Main kitchen prep area: Holders for the scoops have been purchased for scoops to be placed in when not in use. c. Walk in refrigerator: Waffles that were stored uncovered were removed and disposed of. d. Remodel completed same day as survey visit and open area was closed up. e. New garbage can lids were ordered for all uncovered garbage cans. f. Plant ops had the vent cleaned and set up on routine maintenance to assure that it will be free of build up. All of these will be monitored daily by staff and weekly by dining managers to assure compliance.

The findings of the kitchen inspection, conducted 08/24/23, are documented in this report. The survey was conducted to determine compliance with 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 08/24/23 kitchen inspection, conducted on 10/27/23,  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.

b. During the acuity interview on 05/09/22 at approximately 9:35 am, the facility identified residents with diagnosis including dementia living in the assisted living community. The kitchens in Aspen and Dogwood buildings were toured on 05/09/22 between 10:30 am and 11:15 am. There were cleaning chemicals being stored in unlocked cupboards below the sink in both kitchens. The kitchens were unsecured and next to a common area where residents moved about freely, which posed a risk of harm to the residents. The need to ensure there was locked storage for all chemicals was discussed with Staff 1 (Executive Director) on 05/09/22 at 11:20 am. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to: a. Observations were made during the survey to determine adherence to universal precautions. On 5/10/22, the surveyor obtained permission and observed a CG providing incontinent care to Resident 3. During the observation, the CG failed to change their protective gloves after providing perineal care to the resident and proceeded to touch the resident's clean incontinence supplies with the same soiled gloves. The CG removed their gloves after changing the supplies. The surveyor instructed the CGs on appropriate infection control procedures and the importance of hand hygiene when providing care to residents. On 5/11/22, the above observations and the need to ensure universal precautions for infection control were followed was discussed with Staff 2 (Health Services Administrator). She acknowledged appropriate infection control practices were not implemented.

a. Caregiver in question was spoken to and understands the importance of changing gloves after providing perineal care. Additional training to be given to all health services staff by Administrator at next staff meeting on 6/7/22. Moving forward, this will be something that is monitored at 30 day evaluations by Administrator or other trained staff. b. Cabinets with chemicals had locks but no keys. All cabinets were re-keyed and are locked. This was done prior to the survey team leaving the community. All staff to check the cabinets when on their shifts to confirm they are locked.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 05/09/22 between 9:30 am and 11:15 am, the main kitchen and two small kitchens, (Aspen and Dogwood buildings), were toured and observed to need cleaning and repairs in the following areas: 1. Areas identified as needing cleaning included food spills, splatters, buildup of debris, dust, and black matter on or underneath the following: a. Main kitchen * All floor surfaces including beneath the dishwasher, ice machine and steam table; * The drain underneath the dishwasher; * Pipes beneath the dishwasher and sinks; * Food warming area and food prep table; * Inside the microwave; * All window blinds and sills. There was dust buildup and dead insects on a windowsill in a dry food storage room; * Air conditioning unit; * Ceiling vents; * The oven grills, burners and inside the oven; * Surface of the light switch by the kitchen entrance; * Fans in the refrigerator; * Inside a knife drawer; * Hot food carts; and * Baseboards and walls. Main Kitchen, additional observation pertaining to proper food storage: * In the main kitchen freezer, frozen meat and other frozen food items were stored on the floor. The items were relocated by staff at the request of the surveyor.   a. Aspen building kitchen, areas identified as needing cleaning; * Inside the oven: * Inside the microwave; * Inside and outside of all cabinets and inside drawers: * Inside the refrigerator;   * The industrial can opener; * The metal food warmers; * Floor surface in the dry food storage room. c. Dogwood Building kitchen, areas identified as needing cleaning: * Inside the microwave; * Inside all drawers; * Metal food warmers; * Inside refrigerator; * The floor surface by the dishwasher; * Industrial can opener; * Inside the oven; * Inside floor surface of the cupboard underneath the sink; and * The area above the ice machine. 2. The following areas were observed as needing repairs: a. Main kitchen * Exposed sheetrock in multiple areas including underneath all sinks; * Floor panel molding located outside dry food storage room. * Scraped and peeling paint in multiple areas including door jams; and * Wooden door frame panels had chips, cracks, and gouges with exposed wood. a. Aspen building kitchen * Outside of wooden cabinets and wood surfaces had scrapes, chipping and gouges; and * Floor molding was cracked. b. Dogwood building kitchen * Outside of wooden cabinets and wood surfaces had scrapes, chipping and gouges; and * A pipe underneath the sink was leaking. A plastic container placed below the pipe was filled with dark brown water and there was pooled water on the floor surface under the sink. The need to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed and the kitchen was toured with Staff 1 (Executive Director) on 05/09/22  at 11:20 am. He acknowledged the findings.

1. A cleaning team  brought in to deep clean all kitchens including but not limited to: ovens, microwaves, cabinets, drawers, floors, ice machines, food carts, window sills, baseboards, walls and appliances. Any food items that were stored on the floor of the freezer were relocated at the time of survey. 2. Walls and doors will be repainted and corner protectors added as needed. Cabinets will be sanded, guages filled and restained or painted or . Leaking pipe and exposed sheetrock to be fixed by Director of Plant Ops. Cracked floor panels to be repaired or replaced by the Director of Plant Ops. Director of food and beverage services will monitor on a monthly basis for any repairs needing to be made and weekly for cleanliness. Kitchen staff to make sure that they are wiping down every surface after each shift. Director of Plant Ops or Executive Director will walk the kitchens weekly to look for exposed areas that may need repair.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Fire and life safety records for 12/2021 through 04/2022 were reviewed and lacked the following components: * Documented evidence fire and life safety training was conducted on alternating months of fire drills; * Escape routes used; * Problems encountered or comments relating to residents who resisted or failed to participate in the drills; * Number of residents evacuated; * Alternate exit routes used during fire drills to react to varying potential fire origin points; and * Identifying residents who were unwilling or failed to participate in fire drills and a documented plan to make an immediate effort to make changes to ensure the evacuation standard was met. The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator) and Staff 7 (Plant Operations Director) on 05/10/22 and 05/11/22. They acknowledged the findings.

Fire and life safety is performed by Plant Operations. All fire drills and and corresponding documentation has been done as required however, documentation was lacking. Director of Plant Ops reviewed this with his team and showed them proper documention that is needed and how to complete it. He will be reviewing them as they are done to assure completion.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to: Fire drill records from 12/2021 through 04/2022 were reviewed. The facility lacked documentation that residents were being instructed on fire and life safety procedures within 24 hours of admission and annually. The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator) and Staff 7 (Plant Operations Director) on 05/10/22 and 05/11/22. They acknowledged the findings.

Training is done with new residents within 24 hours but has not been documented in the past. This was reviewed with the Plant Ops team and documentation will be provided for each resident moving forward. This will be reviewed monthly by the Plant Ops director for accuracy.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways in the ALF's common-use areas were maintained in good repair. Findings include, but are not limited to: The facility grounds were toured on 05/09/22, at 11:00 am. There were drop-offs of up to three inches from the pavement to the bark dust bed or grass, depending on location. The most notable areas were the side and back of the "Aspen" Building, but multiple pathways around the campus had excessive drop-offs. These created a potential tripping or fall hazard for residents. On 05/10/22 at 11:15 am, the surveyor showed Staff 1 (Executive Director) the drop-offs, and explained the issue. Staff 1 acknowledged the findings, and stated immediate plans to rectify the problem. On 05/11/22 the need to maintain exterior pathways in good repair was discussed with Staff 2 (Health Services Administrator), Staff 5 (Resident Services Coordinator) and Staff 6 (Director of Health Services). They acknowledged the findings.

Soil and mulch will be brought in to fill all drop-off areas in the community. This will be maintained by Plant Ops as well as the Executive Director on weekly walk throughs.

The findings of the re-licensure survey, conducted 05/09/22 through 05/11/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 05/11/22, conducted on 09/27/22, 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.