Avamere Living at Newberg

Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner and ensure food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). Findings include, but are not limited to:

On 09/03/25, from 10:35 am to 1:25 pm, interviews with staff and observations of the facility kitchen, food storage areas, food preparation, and food service were conducted. The following was identified:

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:

* Interior and exterior of all large equipment on the hot line and serving line;
* Flooring throughout including under, behind, and in-between large equipment on the hot line;
* Walls throughout including behind and around large equipment on hot line and ice machine;
* Backside of the refrigerator located on the hot line;
* Cart located between the deep fryer and convection oven;
* Caulking in the dish pit;
* Walls under the dish pit area;
* Ceiling, wall, and vent above the ware wash machine;
* Walk-in refrigerator flooring and storage racks;
* Walk-in freezer flooring;
* Interior of the microwave;
* Large meat slicer;
* Metal cart that stored the large meat slicer;
* Knife holders located on the side of food preparation areas;
* Industrial can opener and casing;
* Flooring in dry storage;
* Large standing and table top mixers;
* Exterior of all large rolling storage bins and interior of one;
* Base of all rolling storage racks throughout the kitchen and meal preparation areas;
* Ceiling vents throughout the kitchen and food preparation areas;
* Fire sprinklers throughout the kitchen; and
* Floor drain under the ice machine.

b. The following areas were noted in need of repair:

* Oven located on the hot line was reported inoperable;
* Kitchen entry door had multiple holes;
* Ceiling above the dish pit had peeling material;
* Flooring near the serving line had approximately 16 inch crack/break;
* Flooring near the back exit door had missing material approximately three quarters of an inch by 36 inches long;
* Coved wall base had missing material to the right of the back exit door;
* Lower left side of the back exit door frame was broken, chipped, and cracked; and
* Ceiling, wall, and vent above the ware wash machine.

c. Staff were observed to use a probe thermometer to take internal food temperatures, however there were no observations of staff sanitizing the thermometer before or after use.

d. Staff were observed to wear disposable gloves throughout the observation, however staff did not change gloves in-between touching dirty and clean surfaces, including multiple kitchen appliances, cooking tools, and items dropped on the floor.

e. The large meat slicer and large standing mixer were observed uncovered while not in use.

f. Food contact and non-food contact surfaces were observed to have significant clutter and were noted unclean.

On 09/03/25 at 12:50 pm, Staff 1 (Executive Director), Staff 2 (Memory Care Administrator), Staff 3 (Dietary Services Manager), and Staff 4 (Plant Operations Supervisor) completed a walk-through of the kitchen and reviewed the above noted areas.

The need to ensure the kitchen was maintained in a sanitary manner and food was prepared and served in accordance with Food Sanitation Rules was reviewed with Staff #s 1, 2, 3, and 4, on 09/03/25 at 1:11 pm. They acknowledged the findings.

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:

Based on observation and interview, it was determined the facility failed to ensure residents were treated with dignity and respect when receiving meal delivery to their apartments. Findings include, but are not limited to:

During an observation, on 04/07/25 at 12:05 pm, meals delivered to resident rooms were served in disposable containers, drinks were in disposable cups and utensils were plastic. The meals served to residents in the dining room were served on ceramic dishes with stainless steel flatware.

During an interview on 04/08/25 at 10:10 am, Staff 4 (Dietary Services Manager) stated all meals delivered to residents in their room, were served on disposable products on a daily basis.

Ensuring residents were treated with respect and dignity with regards to meal service was discussed on 04/08/25 at 10:10 am with Staff 4 and on 04/08/25 at 10:15 am with Staff 1 (ED). They acknowledged room trays were served with disposable service items and indicated the facility would proceed with purchasing more service items for room trays.

OAR 411-054-0027 (1) Resident Rights and Protection - General

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear instructions to staff for 3 of 4 sampled residents (#s 2, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2022 with diagnoses including diabetes.

Resident 2's service plan was reviewed, and caregiving staff and the resident were interviewed. The service plan which was available to direct care staff was dated 10/21/24, and not quarterly. Additionally, the service plan was not reflective of the resident's current status and/or lacked clear instructions to staff in the following areas:

*Dressing;
*Bowel care; and

On 04/10/25 at approximately 11:30am, the need to ensure service plans were reflective of the resident's current status, provided clear instruction to staff, and the most recent service plan was available to staff was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN). They acknowledged the findings.

2. Resident 4 was admitted to the facility in 11/2023 with diagnoses including insulin dependent diabetes mellitus type 2 and dysphagia.

Observations were made of the resident's care on 04/08/25 and 04/09/25, interviews with the resident and facility staff were conducted, and the service plan dated 02/20/25 was reviewed.

Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Current diet texture and liquid consistency;
* Instructions for proper maintenance of blood sugar monitor on right upper extremity and how to monitor for malfunctions;
* Instructions on whom to report signs and symptoms of hypo- and hyperglycemia;
* Instructions to staff on blood glucose monitoring protocol when resident sleeps late and skips meals;
* Instructions on signs and symptoms of depression to report while on anti-depressant therapy;
* Instructions on whom to report skin impairments;
* Incorrect reference to resident self-administering medications;
* Ambulation and use of assistive devices;
* Electric wheelchair equipment precautions and instructions for proper maintenance;
* Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety;
* How side rails were to be used and monitored for safety; and
* Instructions for aspiration precautions and interventions while choking.

The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (LPN/Director of Health Services), and Staff 3 (RN) on 04/10/25 at 11:35 am. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 07/2022 with diagnoses including Type 2 diabetes, rheumatoid arthritis, and spinal stenosis.

Observations of the resident, interviews with staff and resident and review of the resident’s most recent service plan, dated 03/21/25 was completed.

The following areas were not reflective of residents’ current care needs and/or failed to provide clear directions to staff regarding the delivery of services:

* Mental health;
* Personality and behaviors;
* Dressing;
* Laundry related to frequency; and
* Transferring.

The need to ensure service plans were reflective of the resident's care needs and provided clear instruction to staff was discussed with Staff 1 (ED) and Staff 2 (LPN/Director of Health Services) on 04/10/25 at 11:00 am. The findings were acknowledged.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

On 04/07/25, fire drill and fire and life safety records for the previous six months were requested.

Review of the documentation provided revealed:

* Fire drills were not conducted every other month;

* Fire drill records did not include location of simulated fire origin; and

* Staff was not evacuating or relocating residents during fire drills; therefore, the facility's fire drill documentation did not include information on escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, and number of occupants evacuated.

The requirements regarding fire drills were discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 04/07/25 at 1:37 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

On 04/07/25, wall-mounted heaters were noted in resident one bedroom units. Heaters in three resident units (#104, #115, and #202) were tested by the surveyor reached temperatures above 200 degrees Fahrenheit on the wall heater cover grate.

On 04/08/25 at approximately 11:15am, the need to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit was discussed with Staff 1 (ED) and Staff 5 (Maintenance Director). They acknowledged the findings. On 04/09/25, Staff 5 reported wall heaters in one bedroom units had been disconnected.

OAR 411-054-0300 (8) Heating and Ventilation

(8) HEATING AND VENTILATION SYSTEMS. An ALF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction.
(a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit.
(A) An ALF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours.
(B) During times of extreme summer heat, fans must be made available when air conditioning is not provided.
(C) Each unit must have individual thermostatic heating controls.
(b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside.
(c) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by individuals or with combustible material. Effective 01/15/2015 wall heaters are not acceptable in new construction or remodeling.
(d) VENTILATION. Ventilation in each unit must occur via an open window to the outside, or with a mechanical venting system capable of providing two air changes per hour with one-fifth of the air supply taken from the outside.

This Rule is not met as evidenced by:

The findings of the on-site investigation, conducted 09/17/24 through 09/18/24 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 and Division 57 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on observation, interview, and record review, conducted during a site visit on 03/18/25, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated for 2 of 2 sampled residents (#s 4 and 5). Findings include, but are not limited to:The facility's posted staffing plan was:Day shift: two med techs and two caregivers;Evening shift: two med techs and two caregivers; andNight shift: one med tech and one caregiver.The facility's staff schedule, dated 06/30/23 through 07/13/23, indicated 52 shifts where the facility did not schedule to their posted staffing plan.Call light logs for resident's 4 and 5, dated 07/03/23 through 07/10/23, indicated four instances of call lights longer than 15 minutes.Staff 6 (Resident Care Coordinator) stated call lights were supposed to be answered within seven minutes.Resident 5 stated s/he waited 15 to 20 minutes for calls "on a good day," and had been left in the restroom so long his/her legs fell asleep.It was determined the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (Regional Director of Operations).Based on interview and record review, conducted during a site visit on 03/18/25, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated for 1 of 1 sampled resident (# 6). Findings include, but are not limited to:The facility's posted staffing plan indicated:Day shift: two med techs and two caregivers;Evening shift: two med techs and two caregivers; andNight shift: one med tech and one caregiver.The facility's staff schedule, dated 02/11/24 through 02/17/24, indicated 12 shifts where the facility did not schedule to their posted staffing plan.Call light logs for Resident 6, dated 02/11/24 through 02/18/24, indicated six instances of call lights longer than 15 minutes.Staff 6 (Resident Care Coordinator) stated call lights were supposed to be answered within seven minutes.Resident 6 was unavailable for interview.It was determined the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (Regional Director of Operations).

Based on interview and record review, conducted during a site visit on 03/18/25, the facility's failure to fully implement and update an acuity-based staffing tool (ABST) was substantiated. Findings include, but are not limited to:The facility's census was 44.24 out of 44 residents were not updated quarterly as required.Staff 6 (Resident Care Coordinator) stated s/he was behind on updating the facility's ABST.It was determined the facility's failure to implement and update an ABST was substantiated.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (Regional Director of Operations).

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 09/25/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas:

* Walk in refrigerator and freezer floors – food debris, black matter buildup;
* Ceiling vents and ceiling areas located near serving area – heavy buildup of dust;
* Sprinkler head near serving area – heavy buildup of dust;
* Hood vents above stove/grill/deep fat fryer – buildup of grease and dust;
* Deep fat fryer – sides and front significant grease drips/splatters;
* Oven doors – drips/splatters;
* Three-tiered rolling cart shelves stored between cooking equipment – food debris/grease;
* Interior and exterior of microwave – food splatters;
* Grill on back of refrigerator near serving area – heavy buildup of dust;
* Flooring throughout the kitchen including underneath counters, prep areas, cooking equipment and dishwashing area – build up of black matter and grease (under cooking equipment);
* Drains throughout kitchen – buildup of black/brown matter/stained;
* Top of booster in dishwashing area – rusty and tray holding chemicals rusty;
* Hood above dishwasher – dusty;
* Top of dishwasher - buildup of debris;
* Sandwich prep refrigerator – interior drips/spills;
* Commercial and counter mixers – buildup of dried food splatters;
* Knife holder next to sandwich refrigerator – food crumbs;
* Lids of food bins containing flour and brown sugar – food debris buildup;
* Commercial can opener blade – black matter;
* Three-door refrigerator exterior doors – smears/drips/splatters;
* Garbage can lids – splatters/spills/black matter;
* Steamer top/sides and shelf below – spills/debris; and
* Lowest shelves on wire shelving – significant dust buildup.

Other areas of concern included:

* White cutting boards on steam table and sandwich refrigerator – heavily scored and stained;
* Red and green cutting board – heavily scored and colored finish worn off to white; and
* Lack of using beard restraints.

The areas of concern were discussed with Staff 1 (Dietary Services Manager) and Staff 2 (Executive Director) on 09/25/24. The findings were acknowledged.

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:

Based on interview and record review, conducted during an off-site review on 07/16/24 and 07/17/24, it was confirmed the facility failed to immediately notify the Department Central Office and local public health authority of the occurrence of epidemic disease in the facility. Findings include, but are not limited to: In a telephone interview on 07/16/24 at 1:15pm, Staff 1 (Executive Director) stated the following: * There was a current "GI outbreak". * Nineteen residents were affected and two staff members. * The range of symptoms included vomiting and diarrhea.* Residents were notified via flyer of an outbreak and the dining room was being closed. * The Infection Control Specialist was onsite. * Local public health was notified, and the facility has received outbreak guidance. * The precautions were implemented included dining room closure, encouraged quarantine in room, encouraged hand-hygiene, and standard precautions per public health guidance.* The Department Central Office was not notified. A review of the facility's "CBC Infection Control Manual", dated 07/18/2021, indicated "an outbreak occurs when there are more cases of an infectious disease in a designated population than usually occur at a given time" and "a single case of....an illness that causes nausea, vomiting, and diarrhea (such as norovirus) can quickly escalate into an outbreak. "In an email on 07/16/24, Staff 1 stated s/he "was informed Saturday [7/13/24] there were a few residents with [nausea/vomiting/diarrhea] " and proceed to close the dining room "to avoid further illness." Staff created a flyer for the dining room doors and care staff took flyers to the residents to inform them of the illness. But after review, s/he saw the staff member who made the flyer failed to include the reason for the closure was due to illness. An updated flyer was sent out today. On Monday, s/he was informed there were more people with the same symptoms and then reached out to county public health. In a telephone interview on 07/17/24 at 2:23 pm, Staff 1 stated the following: * People being sick on the 11th wasn't consistent and an outbreak was not recognized then. * On Saturday, 7/13, s/he was onsite to do some work, and learned three more individuals had the same symptoms. * By Monday, it was a full outbreak when another six people were reportedly sick. * The nurse made a list and tracked symptoms back to the 7/11.* An outbreak is defined with Covid if it's two or more cases, then facility notifies public health. But s/he was not sure how it works with unidentified illnesses. * Typically, if you have 3 or more within 24 hours it is considered an outbreak. * Symptoms only last about 24 hours. * So far, a total of 27 people have been sick and currently three are still having symptoms. On 07/17/24 at approximately 2:40 pm, these findings were reviewed with and acknowledged by Staff 1. The facility failed to immediately notify the Department Central Office and local public health authority of the occurrence of epidemic disease.Verbal Plan of Correction: Staff 1 will provide training to Med-Techs and the nurses and will review the facility's protocol now s/he knows if there are any people experiencing similar symptoms by an unknown cause to reach out to LPH and make sure the Operation Policy Analyst is notified on day one.

The findings of the re-licensure survey conducted 12/06/21 through 12/08/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 12/08/21, conducted 02/22/22 through 02/23/22, 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.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the re-licensure survey of 12/08/21, conducted 05/09/22 through 05/13/22 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.

Based on interview and record review, it was determined the facility failed to conduct investigations of injuries of unknown cause to rule-out abuse or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 1 sampled resident (#4). Findings include, but are not limited to:Resident 4 was admitted to the facility in 04/2021 and was dependent on staff for transfers and ADL assistance. On 11/23/21, facility charting notes indicated the resident had an unwitnessed fall resulting in an approximately 9 inch by 12 inch skin abrasion. There was no documented evidence the facility immediately investigated and documented the injury was not the result of abuse. The facility did not report the injury to the local SPD office as suspected abuse/neglect.The need to ensure injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the facility had not investigated to rule out abuse/neglect. The surveyor directed Staff 1 to self-report the incident. Verification the facility had reported the incident to the local SPD office was received during the survey.

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 (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 11/2021 with diagnoses including hypertension, pain in ankle and joints of left foot. Resident 1's move-in evaluation failed to address the following:* Customary routines including eating and bathing; * List of medications and PRN use; * Vital signs if indicated by diagnosis, health problems or medications;* Mental health issues including history of treatment and effective non-drug interventions; * Pain relating to pharmaceutical and non-pharmaceutical interventions; and * Complex medication regimen. The failure to address all required elements in the move-in evaluation was shared with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.
Based on observation, 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 (#7) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 7 moved into the facility on 01/2022. The move-in evaluation failed to address the following areas:* Customary eating and bathing routines;* Mental health issues including history of treatment and effective non-drug interventions;* Memory and confusion;* Dental status;* Pharmaceutical and non-pharmaceutical pain interventions; and* Environmental factors that may impact the resident's behavior including, but not limited to: noise, lighting, room temperature.The need to ensure move-in evaluations included all required elements was discussed on 02/23/22 with Staff 1 (ED) and Staff 3 (LPN). They explained additional evaluation tools and documents were used that were not currently included in the resident record and acknowledged the facility needed to review its move-in process.

2. Resident 1 moved to the facility in 10/2021 with diagnosis including pain in ankle and joints of left foot, and macular degeneration. Review of the resident's service plan, dated 10/28/21, interviews with staff and Resident 1, revealed the service plan was not reflective of the resident's current health status and lacked clear direction to staff in the following areas: * Pain;* Dietary and nutrition relating to a self reported diverticulitis diagnosis; and * Use of hearing aids.The need to ensure resident service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.3. Resident 5 moved into the facility in 02/2018 with diagnosis including atrial fibrillation and chronic obstructive pulmonary disease. Review of the resident's service plan, dated 11/01/21 and interviews with staff, indicated the service plan was not reflective of the resident's current health status, was not being followed or lacked clear direction to staff in the following areas:* Bed making; * Who checks the resident's weight each morning; * Assistance with clothing selection; * Unwillingness to ambulate; * The oxygen tanks and equipment delivery times; and* Resident 5 arranges his/her own transportation. The need to ensure resident service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.
4. Resident 4 was admitted to the facility in 04/2018 and was dependent on staff for transfer and ADL assistance. Review of the resident's service plan, dated 10/24/21 and interviews with staff, indicated the service plan was not reflective of the resident's current health status, was not being followed or lacked clear direction to staff in the following areas:* Incontinence, bowel and bladder care; and* Pain management. The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' status and needs, were being followed, and provided clear direction for staff regarding the delivery of services for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 2016.Interviews with care staff and review of the resident's clinical records revealed s/he had recently undergone treatments related to difficulty swallowing and throat pain. The resident's service plan, dated 09/27/21, was not reflective of the resident's status and needs in the following areas:* Weight loss due to difficulty swallowing and decrease in food intake and nutritional supplement use; and* Meals, including decrease in food intake, and the need for soft textured foods when requested. The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1(ED) and Staff 3 (LPN) on 12/09/21. They acknowledged the findings.
5. Resident 3 was admitted to the facility in 12/2020.Review of the resident's service plan, dated 09/27/21, interviews with staff and Resident 3, indicated the service plan was not reflective of the resident's current health status and lacked clear direction to staff in the following areas: * Emergency evacuation;* Current skin issues; * Diet; and* Home health status. The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 10/2021 and was put on a 14 day quarantine due to a COVID-19 protocol. Progress notes, dated 10/29/21 through 11/26/21 were reviewed. The following was noted:* 10/30/21 - the resident expressed wanting to meet everyone;* 11/02/21 - the resident reported feeling lonely; and* 11/04/21 - the resident "can't wait to get out and meet more people."There was no documented evidence the status of Resident 1's new admission and the 14 day quarantine were monitored at least weekly through resolution.The need to ensure the facility had a system documenting changes of conditions at least weekly until resolved was reviewed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.
3. Resident 4 was admitted to the facility in 04/2018 with a unilateral leg amputation and was dependent on staff for transfer and ADL assistance. A review of Resident 4's clinical records, 09/08/21 through 12/07/21, revealed the resident had ten falls. The resident sustained a skin tear with the fall on 11/23/21. There was no documented evidence the facility had monitored the falls for latent injury and weekly through resolution. In interview on 12/07/21 with Staff 3 (LPN), she acknowledged that alert charting was not completed for the falls, and the resident was no longer being monitored for the skin tear. The need to ensure all changes of conditions were monitored to resolution was discussed with Staff 1 (ED) and Staff 3 on 12/08/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure short-term changes were monitored for effectiveness, and/or failed to consistently monitor changes through to resolution for 3 of 4 sampled residents (#s 1, 3 and 4) who had changes of condition. Findings include, but are not limited to: 1. Resident 3's progress notes, dated 09/08/21 through 12/06/21 revealed the resident experienced the following changes of condition:* Missed medications; and* Multiple medication changes.There was no documented evidence the missed medications or multiple medication changes were monitored until resolution.The need to ensure the facility had a system documenting changes of conditions at least weekly until resolved was reviewed with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents, for 2 of 3 newly hired staff (#s 11 and 17). Findings include, but are not limited to:The facility's training records reviewed on 12/07/21 revealed:Staff 11 (CG) hired 07/23/21, and Staff 17 (MT) hired 11/23/21, lacked documented evidence they had completed the required pre-service dementia training prior to providing direct care to residents.The training program and requirements were discussed with Staff 1 (ED), Staff 3 (LPN) and Staff 5 (Business Office Manager) on 12/08/21. They acknowledged the required training had not been completed.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 11 and 18) had demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:Review of the facility's training records on 12/07/21 revealed the following:Staff 11 (CG), hired on 07/23/21, and Staff 18 (MT), hired on 07/19/21, did not have documented evidence of demonstration of competency in assigned duties, including medication and treatment administration training, completed within 30 days of hire date.Staff 11 did not have documented evidence of completion of First Aid certification and abdominal thrust training within 30 days of hire.The need to ensure staff had documented evidence of competency demonstration in all assigned duties, within 30 days of their hire date, was discussed with Staff 1 (ED), Staff 3 (LPN) and Staff 5 (Business Office Manager) on 12/08/21. They acknowledged the required training had not been completed.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 veteran staff (#s 10, 12, 13 and 15) completed the minimum required 16 hours of annual in-service training. Findings include, but are not limited to:Facility training records were reviewed on 12/07/21 and revealed the following:Staff 10 (CG) hired on 09/18/20, Staff 12 (CG) hired on 02/10/20, Staff 13 (CG) hired on 09/21/20 and Staff 15 (MT) hired on 04/10/18 did not have documented evidence of completing the required 16 hours of annual in-service training. The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 1 (ED), Staff 3 (LPN) and Staff 5 (Business Office Manager) on 12/08/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month at different times of the day, evening and night shifts, failed to include required components on fire drill records, and failed ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:Fire and life safety records, reviewed between 05/2021 - 10/2021, revealed the following:* Fire drill records lacked documentation of the following components: - Problems encountered, including comments relating to residents who resisted or failed to participate in drills; - Staff members on duty and participating; - Number of occupants evacuated; and * Fire and life safety instruction was not consistently provided to staff on alternate months. The requirements regarding fire drills and fire/life safety instruction for staff was reviewed with Staff 7 (Environmental Services) on 12/07/21 and with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* Documentation that fire and life safety training was provided to residents within 24 hours of move-in; and * Documentation that annual fire and life safety training was provided to residents, including all required training topics. Additionally, staff interviewed during the survey were not aware of the designated point of safety.The need to ensure residents received fire and life safety training within 24 hours of admission, were re-instructed at least annually, and all staff were aware of the designated point of safety was discussed with Staff 7 (Environmental Services) on 12/07/21 and with Staff 1 (ED) and Staff 3 (LPN) on 12/08/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 252.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 05/26/2021. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review it has been determined the facility failed to comply with proper infection control. Findings include: During an offsite interview with Resident #1 (R1) it was stated: Facility staff do not wear their face shields or masks appropriately, especially when coming into resident's apartments. There is a widespread disregard for wearing the proper protection here at this facility. During an offsite inspection on 05/26/2021; the Compliance Specialist (CS) reviewed six photos of unsampled staff members wearing PPE incorrectly while in R1's apartment; one unsampled staff member without any face mask and/or eye protection. These photos were dated 05/21/2021 and 05/24/2021 respectively.