Avamere at Sherwood Assisted Living Facility

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

Based on observation and interview, it was determined the facility failed to 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 02/03/26 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas: * Wall and caulking behind spray hose in dishwasher area above splash guard – build up of black matter; * Wall below dishwashing sink – drips/spills black/brown matter build up; * Shelf below steam table – accumulation of food and debris; * Doors and handles on convection oven and stove – spills/grease build up/sticky matter; * Steamer table and slates for holding trays below – debris build up/spills/food crumbs; * Flooring underneath and behind cooking equipment and under food storage shelving throughout the kitchen – debris/food matter; * Sides of stove and convection oven – drips/spills/grease build up; and * Garbage can lid – food spills/splatters. Other concern included: * Commercial can opener blade – finish worn off. The areas of concern were observed and discussed with Staff 1 (Dietary Services Manager) and discussed with Staff 2 (Memory Care Administrator) on 02/03/26. The findings were acknowledged by Staff 1 and Staff 2 at 12:15 pm and 12:30 pm respectively.

1. All identified areas in the kitchen will be deep cleaned and needed repairs are scheduled to be completed. 2.Daily and weekly cleaning check list have been updated to ensure focus on the needed area. The Dietary Manager will staff appropriately to address extra deep cleaning needs. Random cleaning audits will be conducted on a monthly basis by either the Dietary Manager, Executive Director, Arbor Admin, or Director of Plant Ops monthly to ensure cleaning is completed and deficiencies can be corrected timely. 3. System will continue to be reviewed monthly after audit for any areas of improvement. 4. Executive director, Abor Admin, Dietary Manager and Director of Plant operations will be responsible for maintaining this system as well as completing check list that are provided in the current maintenance log.

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).

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, included resident preferences that supported the principles of choice and individuality, and provided clear directions to staff regarding the delivery of services for 3 of 5 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 12/2024 with diagnoses including type 2 diabetes mellitus with diabetic nephropathy, chronic kidney disease, and long-term use of insulin. During the acuity interview on 10/27/25, Resident 4 was identified as self-administering all of his/her medications, including insulin (to control blood glucose level). Observations were made of the resident's self-administration of medication on 10/28/25, interviews with the resident and facility staff were conducted, and the service plan, dated 10/09/25, 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: * Instructions on signs and symptoms of hypo- and hyperglycemia to report; * Instructions for proper maintenance of blood glucose monitor on left upper extremity and how to monitor for malfunctions; * Instructions to staff on blood glucose monitoring protocol when resident slept late and skipped meals; * Electric wheelchair equipment precautions and instructions for proper maintenance; and * Assistance required with dressing. During the interview with the resident on 10/28/25 at 11:29 am, s/he stated the need for one-person assistance with dressing and putting his/her left knee brace on. S/he also expressed a fear of blood glucose level dropping in the morning around 5:00 to 6:00 am: “I don’t know when my blood sugar goes low. I feel and know when it is low during the day. I have glucose tablets, but they don’t work fast. I like to have Pepsi. Then it [blood glucose] is up in five minutes.” Staff 14 (MT/CG) was interviewed on 10/30/25 at 12:25 pm and confirmed Resident 4 required one-person assist with “morning routine especially dressing, getting up, putting brace on … and reminders to go to meals because [s/he] likes to nap a lot.” Staff 14 and Staff 8 (MT), in an interview on 10/29/25 at 3:38 pm, both stated Resident 4 was fully independent with blood glucose monitoring and administration of all medications. 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 (Executive Director), Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 2:14 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2025 with diagnoses including atrial fibrillation and hypertension. The resident’s record was reviewed, including the current service plan, dated 08/21/25, and interviews with staff and the resident were conducted. The following was identified: The service plan was not reflective of the resident’s current care needs and/or preferences in the following areas: * Activities in relation to preferred activities; and * Hearing deficit. The need to ensure service plans were reflective of the residents’ current care needs and preferences was reviewed with Staff 2 (Director of Health Services/RN), Staff 3 (LPN), Staff 6 (Arbor Administrator), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 4:00 pm. They acknowledged the findings. 3. Resident 2 moved into the community in 05/2022 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease stage 3, neuromuscular dysfunction of bladder, and disorientation. The resident’s record was reviewed, including the current service plan, dated 09/18/25, observations were made, and interviews with staff were conducted. The following was identified: The service plan was not reflective of the resident’s current care needs and/or was not implemented in the following areas: * Fortified meals; * Meal set-up and as-needed assistance with preparing meals delivered to the resident’s room; and * Smoking status. On 10/28/25 at 10:57 am, Staff 19 (Cook) reported he had not been preparing fortified meals for the resident. The need to ensure service plans were reflective of the residents’ current care needs and were implemented, was reviewed with Staff 1 (ED), Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 3:18 pm. They acknowledged the findings.

1. Service plans for resident 2, 3 and 4 have been updated to include all required information and to be reflective of current needs, preferences and interventions, including clear instructions to staff and have been printed for staff to review. Staff training has been completed that includes implementation of service plans. 2. To prevent recurrance, All residents’ service plans will be audited against their current care needs and preferences and updated to be reflective. Verifying all interventions provided clear directions regarding the delivery of services. Training will be completed with care staff and medication techs on reporting service plan discrepancies and changes in residents' care needs with health services team. Training will be conducted with Health Services Team on Arete policy and procedure related to resident service planning. 3. Service plans will be evaluated and reviewed upon admission, at 30 days, quarterly and with significant change of condition. 4. The Executive Director will be responsible for maintaining this system and will coordinate with the Health Services Team

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.

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

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 5 sampled residents (# 2) whose orders were reviewed. This resulted in unnecessary pain and a visit to the emergency department for Resident 2. Findings include, but are not limited to: Resident 2 had a history of urinary tract infections (UTI) and had a standing, as-needed order to obtain a urine specimen if the resident showed signs or symptoms of a UTI, including frequency, burning, urgency, painful urination, blood in urine, or change in behavior, and if the licensed nurse determined a positive result, to send it in for a culture and sensitivity test. On 07/14/25, staff requested the resident’s legally authorized prescriber for a urinary analysis (UA) and culture and sensitivity order due to the resident having blood in his/her catheter bag, urge to urinate, complaints of pain, and increased confusion. On 07/15/25, the facility received a signed order for a UA and culture and sensitivity test. Staff continued to document the resident’s status including increased confusion. There was no documented evidence a urine sample was collected as ordered. On 07/28/25, a home health nurse reported blood in the resident’s urine bag and tubing, and a urine sample was collected for a UA and culture and sensitivity test. Staff continued to document the resident’s status, including that the resident had a possible UTI, had blood in his/her urine, and had increased confusion. On 08/01/25 the facility received the resident’s UA report indicating multiple abnormal results. Upon receipt of the UA results, there was no documented evidence the legally authorized prescriber was notified. On 08/01/25 the resident was placed on alert for possible UTI. Staff continued to document the resident’s status, including increased confusion and blood in his/her urine, from 08/01/25 through 08/04/25. On 08/05/25, Resident 2 was sent to the emergency department for “extreme pain,” signs of infection, and increased confusion. The resident was diagnosed with a UTI and provided an order for antibiotics. The facility failed to carry out physician orders as prescribed, which resulted in unnecessary pain and a visit to the emergency department. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 3:18 pm. They acknowledged the findings.

1. Resident 2 had been treated prior to the time of survey. Health Services staff have been trained and given instruction on signs and symptoms for when to send out resident 2 in the future. Service plan has been updated. 2. Re-education provided to med techs on 11/11/25 and 12/10/25 reviewing the importance of following treatment orders and following up with the LN if there is any barrier to following a treatment order so this can be corrected as soon as possible.Training will be completed with medication techs and health services team on policy and procedure related to the 'Triple Check Process' for verifying all orders are implemented and followed up on timely with nurse review. The 24-hour/72-hour report will be reviewed during Daily Clinical Stand-up Monday-Friday to identify documentation requiring urgent follow-up. 3. This system will be reviewed 5 days a week during daily stand up by reviewing 24 hour summary. 4. Executive Director and Health Care Team are responsible to monitor

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

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order for 1 of 1 sampled resident (# 3) with documented refusals. Findings include, but are not limited to: Resident 3 was admitted to the facility in 08/2025 with diagnoses including atrial fibrillation and hypertension. The resident’s MAR, dated 10/01/25 through 10/27/25, and physician’s orders were reviewed. The following was identified: Resident 3 had documented refusals on his/her MAR for the following orders: a. Polyethylene glycol powder (for bowel care), take 17 grams by mouth every morning. The resident refused the medication nine times during the reviewed period. There was no documented evidence the provider was notified of refusals on six occasions. b. Senna (for bowel care), 8.6 mg tablet, take two tablets by mouth at bedtime. The resident refused the medication 14 times during the reviewed period. There was no documented evidence the provider was notified of refusals on the 14 occasions. During an interview on 10/30/25 at 1:45 pm, Staff 3 (LPN) and Staff 18 (VP of Clinical Operations) acknowledged there was no documented evidence the facility notified the provider when Resident 3 refused to consent to physician’s orders. The need to notify the provider when a resident refused to consent to an order was reviewed with Staff 2 (Director of Health Services/RN), Staff 3, Staff 6 (Arbor Administrator), and Staff 18 on 10/30/25 at 4:00 pm. They acknowledged the findings. No further documentation was provided.

1. All of Resident #3 refusals for 30 days has been sent to the provider. 2. All Med techs trained on 11/11/2025 regarding notifying providers of resident refusals of medications and treatments timely, unless there is a signed order specifying not to notify of refusals. All residents have been audited for refusals and physicians have been notified of all resident refusals in October, November and December.A list of all residents that require provider notification for refusals has been created and posted in the medication rooms. The 24-hour/72-hour report will be reviewed during Daily Clinical Stand-up Monday-Friday to identify any resident refusals and verify notifications have been made. MAR audits will be conducted weekly to verify appropriate notification of resident medication and/or treatment refusals 3. This system will be reviewed 5 days a week during daily stand up by reviewing 24 hour summary and clinical alerts. 4. Executive Director and LNs will be responsible for maintaining this system.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

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 pre-service orientation in all required topics was completed prior to beginning job duties for 2 of 3 newly hired staff (#s 12 and 13) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 10/28/25 through 10/30/25. The following was identified: a. There was no documented evidence Staff 12 (CG), hired 04/04/25, had completed the following required pre-service orientation training prior to beginning their job responsibilities: * Approved Home and Community Based Services (HCBS) course; and * Pre-service dementia related to specific aspects of dementia including addressing pain, providing fluids, and use of person-centered approach. b. There was no documented evidence Staff 13 (CG/MT), hired 08/05/25, had completed the following required pre-service orientation topics prior to beginning their job responsibilities: * Resident rights and values of Community Based Care (CBC); * Fire safety and emergency procedures; and * Pre-service dementia training. On 10/30/25 at 11:15 am, Staff 7 (Business Office Manager) confirmed Staff 12 and Staff 13 had been working independently and stated they would be removed from the schedule, until they completed pre-service orientation. The need to ensure staff completed all required pre-service orientation and training prior to beginning their job responsibilities and for direct care staff to complete required pre-service dementia training prior to providing care to residents was reviewed on 10/30/25 at 1:05 pm with Staff 1 (ED) and Staff 7. They acknowledged findings.

1. Staff 12 and 13 were removed from the floor until all training was completed. 2. Business Office Manager reviewed all employees to ensure all pre-service has been completed. Updated the training grid to ensure all required courses are accounted for. The Business Office Manager will not allow staff to work the floor prior to completing all of their pre-service training. 3. During each new hire as they start their onboarding until they have verified completion. 4. Executive Director, Business Office Manager

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 13 and 17) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 10/28/25 through 10/30/25. The following was identified: a. There was no documented evidence Staff 13 (CG/MT), hired on 08/05/25, and Staff 17 (MT), hired on 05/06/25, demonstrated competency within 30 days of hire in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting changes of condition; and * Conditions that require assessment, treatment, observation and reporting. b. Staff 17 (MT), hired on 05/06/25, demonstrated competency in medication passing on 08/20/25, 108 days after his/her hire date. The need to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire was reviewed on 10/30/25 at 1:05 pm with Staff 1 (ED) and Staff 7 (Business Office Manager). They acknowledged the findings.

1. Staff #13 and 17 have completed all of their 30 day training and their competencies. 2. Relias training system was reviewed and updated with appropriate training plans for 30 day requirements, training grid updated to track all appropriate courses are being monitored and completed 3. Followed for all new hires throughout their onboarding and will not be scheduled to work the floor alone without finishing the training and competency 4. Executive Director and Business Office Manager

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.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed about fire and life safety procedures within 24 hours of admission in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 10/30/25 at 11:10 am. On 10/30/25 at 11:50 am, Staff 1 (Executive Director) and Staff 5 (Director of Maintenance) were asked to explain the facility's process for providing residents with instructions on fire and life safety procedures within 24 hours of admission. Staff 5 reported he was responsible for providing fire and life safety training to all residents. However, the facility was unable to produce any documented evidence confirming the training had been provided within 24 hours of admission. The need for residents to be instructed about fire and life safety procedures within 24 hours of admission per the OFC was discussed with Staff 1, Staff 2 (Director of Health Services/RN), Staff 3 (LPN), and Staff 18 (VP of Clinical Operations) on 10/30/25 at 2:14 pm. They acknowledged the findings.

FIRE AND LIFE SAFETY TRAINING FOR RESIDENTS 1. Fire and Life Safety training conducted for residents every 6 months through Environmental Evals. 2. Audited all current residents to make sure everyone was updated on their Fire and Life Safety training. All new residents will receive training within 24 hours of move-in. Leadership team have received re-education on the process and expectation for completing this training. 3. During move-in process, follow environmental evaluation schedule every 6 months 4. Executive Director and Maintenance Director are responsible for maintaining this system

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

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

Based on observation and interview, it was determined the facility failed to 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 01/30/25 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * Flooring throughout the kitchen, including underneath/behind prep counters, cooking equipment, storage racks, dishwasher and sink units – spills/drips/splatters/grease/food debris/build up of black matter; * Wall and caulking surrounding the dirty dishes side of the dishwasher – significant build up of black matter; * Operating air conditioning unit vent above ice maker – significant build up of dust; * Exterior doors and handles of reach in refrigerator – spills/drips; * Commercial can opener – blade finish worn off/build up of black matter surrounding casing; * Hood area above and behind stove top and grill – significant build up grease/dust; * Shelves below steam table – drips/spills/splatter; *Oven and convection oven doors, knobs and handles – drips/spills/sticky/dust build up; * Sides of oven – drips/spills/grease; * Interior of refrigerator on steam table line – food debris/spills/splatter; Other areas of concern include: * Ceiling light above three sink area – uncovered. * Improper storage: - Two sheet pans of individual servings of cake uncovered in high traffic area; and - Two boxes of disposable cups and lids on floor in hallway between kitchen and MC unit. The areas of concern were discussed with Staff 1 (Dining Services Manager) and discussed with Staff 2 (Interim Executive Director) on 01/30/25 The findings were acknowledged.

Plan of correction for the deficiencies found on 1/30. Deep cleaning event was scheduled prior to survey arrival. Event will focus on cleaning items that were pointed out during inspection. Updated cleaning lists have been provided to the staff. Daily cleaning lists will highlight exterior doors and handles of refrigerator, flooring, oven and convection oven doors, knobs and handles, and sides of oven.Weekly cleaning lists will highlight air conditioning unit above ice maker, deep cleaning of floors, hood area, shelves below steam table, and interior of refridgerator. Cleaning lists attached. Dietary Manager will conduct cleaning audits every Monday to ensure tasks are being completed. Maintenance has repaired caulking surrounding the dirty dish area and it will be added to DM audit to report to maintenance if it needs to be redone again. Commercial can opener was replaced as well as a new cover for ceiling light above the three sink area. A new rack was purchased to provide additional storage for items in the hallway.

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

Based on observation and interview, it was determined the facility failed to 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 09/27/23 at 11:05 am, the facility kitchen was observed to need cleaning in the following areas: * The walk in refrigerator floor had black matter in the corners; * The walk in freezer door handle had orange matter; * The ceiling vent near entrance had dust build up; * The wall behind the stove had build up of grease; * The front of deep fat fryer had grease build up; * The wall beside deep fat fryer had splattered grease and black matter; * The lower shelves throughout the kitchen had food debris and splatters; * The top and cover of ice machine had spills/debris/drips; * The area behind and the shelves underneath the steamer, next to the stove had debris/dust; and * The exterior doors of the reach in refrigerator had streaks/splashes/drips. The ceiling light fixture in the prep area was uncovered. Boxes of Styrofoam cups and food containers were sitting directly on the floor in kitchen service area. The findings were discussed with Staff 1 (Dietary Manager) on 09/27/23 and were acknowledged.

1. All identified areas in the kitchen have been deep cleaned, and all repairs have been completed. 2. Routine cleaning schedules for kitchen have been updated to include areas that were missing. Dietary Manager will be reviewing cleaning schedules weekly, at a minimum, and will follow up as needed. Dietary Mananger will complete a monthly kitchen sanitation audit, to include repair work needed, and ensure any deficencies will be corrected timely. 3. System will be evaluated monthly as part of the Continuous Quality Improvement process to include a review of the monthly kitchen sanitation audits. 4. Executive Director, Director of Housekeeping and Dietary Manager will be responsible for maintaining this system

The findings of the kitchen inspection, conducted 09/27/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 09/27/23, conducted on 01/29/24, 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.

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 333-150-0000. Findings include, but are not limited to: Based on observations on 08/22/22 at 10:20 am, the facility kitchen needed cleaning and repair in the following areas: a. Food spills, splatters, dirt, dust and black matter was observed on or beneath the following: * Walls and light switch in dish washer area; * Handwashing sink to the right of the ice machine: * Inside of microwave; * Air conditioning unit vents above ice machine; * The underside of the motor housing on the stand mixer; * Telephone located on a shelf above rear prep counter; * Floor around the deep fryer; * Lower storage shelves of the steam table; * Inside of the plate warmer; * Handles and shelves of multiple serving carts; * Large round floor fan; and * Grates on the exhaust fans in the walk-in refrigerator. b. The following areas needed repair: * Caulking around the warewashing area; * Weather strip on trim of the "In" door; * Scoop holder next to the ice machine; * Laminate was missing on the steam table cabinet; * Paint was peeling from the "Out" door; c. The following areas in the beverage/serving stations in the Dining Room needed repairs: * Hole in the wall of the beverage station; * Laminate was worn exposing bare wood in the beverage station cabinet where the garbage can was stored; and * Laminate was missing on the serving station cabinets. The areas needing cleaning and repair were reviewed with Staff 12 (Dietary Services Manager) on 08/22/22 and Staff 1 (ED) and Staff 8 (Plant Operations Assistant) on 8/24/22. They acknowledged the findings.

1. All identified areas in the kitchen have been deep cleaned, and all repairs have been completed or scheduled. 2. Routine cleaning schedules for kitchen and diet`ary carts have been updated to include areas that were missing. Dietary Manager will be reviewing cleaning schedules weekly, at a minimum, and will follow up as needed. Dietary Mananger will complete a monthly kitchen sanitation audit, to include repair work needed, and ensure any deficencies will be corrected timely. 3. System will be evaluated monthly as part of the Continuous Quality Improvement process to include a review of the monthly kitchen sanitation audits. 4. Executive Director and Dietary Manager will be responsible for maintaining this system

Based on interview and record review, it was determined the facility failed to evaluate service-planned interventions for effectiveness, initiate new interventions following a series of repeated falls, and monitor conditions through resolution for 2 of 4 sampled residents (#s 3 and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 07/2022 with diagnoses including Multiple Sclerosis, chronic urinary tract infections and muscle weakness. The service plan noted a history of falls and identified the resident as a fall risk. The resident's service plan, dated 08/03/22, progress notes, dated 07/12/22 through 08/22/22, interim service plans, and incident reports were reviewed. The records indicated Resident 4 experienced three falls from 07/14/22 through 07/18/22. Interim service plans were created, which initiated the following interventions: * Staff will perform safety checks on the resident every 2-3 hours (07/18/22); * Staff will encourage the resident to use pendant to call for assistance (07/18/22); and * The resident should wear non-skid shoes/slippers and socks to promote secure footing (initiated 07/19/22). Resident 4 had six additional falls from 07/19/22 through 08/12/22 which occurred after these interventions were in place. There was no documented evidence these service-planned interventions were evaluated for effectiveness, and interim service plans written after these subsequent falls did not include new interventions to help prevent further falls. On 08/24/22 the need to implement resident-specific interventions following changes of condition, and to evaluate those interventions for effectiveness was discussed with Staff 1 (ED), Staff 2 (RN/ Director of Health Services) and Staff 3 (LPN). They acknowledged the findings. 2.  Resident 3 was admitted to the facility in 05/2022. Review of the resident's progress notes, dated 05/23/22 through 08/17/22 revealed the resident experienced the following injuries: * 05/27/22- Skin tear to right hand; and * 05/29/22-Skin tear to left hand. The facility lacked documented evidence interventions were determined and communicated to staff on all shifts, and the injuries monitored at least weekly, through resolution. In an 08/23/22 Interview with Staff 2 (RN), she confirmed the resident's injuries were not properly recorded, and therefore were not monitored by the facility. The need to ensure short term changes of condition were evaluated, interventions determined, communicated to staff on each shift and monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 2 and Staff 3 (LPN) on 08/24/22. They acknowledged the findings.

1. A complete root cause analysis for resident #4 has been completed including a review of all falls and efficacy of interventions. RN initiated change of condition assesment for significant falls. RN to follow weekly to review plan and evaluate interventions. RN has updated and reviewed service plan. Care conference is scheduled with resident and son to review current interventions and service plan. Resident #3 has been assessed by LN and service plan has been updated with current interventions to reduce the risk of injury. 2. To prevent recurrence, 24 hour summary and alert charting audit will be reviewed five days a week as part of daily standup meeting. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a change of condition is identified, such as a skin tear, the resident will be placed on alert charting. A LN assessment will be done and initiate any changes in the plan of care. The change of condition will be monitored until resident is stable or condition resolves in a weekly skin integrity note. Incident report investigations will include a review of any previous interventions and their efficacy and interventions will be updated as needed. Any changes to service plans as a result of a change of condition will be communicated to staff via either an ISP or updated full service plan to review and sign. 3. This system will be evaluated five days a week as part of daily stand up meeting. 4. The Executive Director and LNs are responsible for maintaining this system.

2. Resident 9 was admitted to the facility in 08/2022. Review of the resident's progress notes, dated 10/23/22 through 12/20/22, revealed the resident experienced the following: * 11/25/22 -  Moved into the assisted living from memory care facility; and * 12/08/22 - Returned from a hospital stay (12/01/22 - 12/08/22). The facility lacked documented evidence the short term changes of condition were evaluated and monitored with progress noted at least weekly through resolution. The need to ensure short term changes of condition were evaluated and monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Executive Director) and Staff 2 (RN/Director of Health Services) on 12/20/22. They acknowledged the findings .

Based on interview and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition were evaluated, actions or interventions were determined and communicated with staff on all shifts, and/or were monitored through resolution with at least weekly documentation for 2 of 4 sampled residents (#s 6 and 9) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 07/2022 with diagnoses including asthma, atrial fibrillation, and arthritis. A review of the resident's clinical record, including progress notes dated 10/23/22 through 12/20/22 and staff interviews revealed the following; * The resident had a physician's order to self-administer his/her medications without supervision. * Between 11/08/22 and 11/28/22 staff documented five occasions where caregivers were assisting the resident with taking his/her medications by "putting them in [the resident's] mouth" and reminding him/her to take them. According to a progress note dated 11/28/22 the resident "was struggling to take them [medications] and dropping them on the floor." * On 11/30/22, Staff 2 (RN/Director of Health Services), documented she had spoken with the resident's sister about facility staff having to remind him/her to take their medications often. The RN asked the sister if she thought the facility needed to start administering the resident's medications. The sister stated she would speak with the family about the issue. * Between 12/03/22 and 12/19/22, staff documented an additional three occasions on which staff assisted the resident with his/her medications. * On 12/19/22, Staff 4 (Resident Care Coordinator) documented she spoke with the resident about his/her medications and asked if s/he " ... would like for us to manage them  ..." The resident responded, "not right now I just need to be woke up earlier so I can take them on time". The RCC documented she "set up a wake time of 7am" in the resident's service plan. In an interview with Staff 2 on 12/20/22, she stated she was aware of staff assisting the resident with taking medication on several occasions. She reported she had observed the resident taking his/her medications without assistance on more than one occasion, and s/he was able to self-administer without any difficulties. Staff 2 reported she had not evaluated the resident's ability to safely self-administer their medications during the time period reviewed. The need to ensure changes of condition were evaluated and monitored through resolution, with at least weekly documentation of progress, was discussed with Staff 1 (Executive Director), Staff 2, and Staff 24 (Regional Nurse Consultant) on 12/20/22. They acknowledged the findings.

1. Resident #6 now realizes she is having difficulty taking her medications and agreed for community to manage. After a thorough medication review is conducted to reconcile her doctor's medication list to her list of medications she is self administering, and we have acccurate orders, Resident #6's medications will be managed by community. Evaluation and service plan will be updated to reflect community is managing her medications. Resident #9 has been placed on alert and staff have been adding updates on her in progress notes. 2. To prevent recurrence, the 24 hour summary, communciations, and alert charting audit will be reviewed five days a week as part of daily standup meeting with the clinical management team. A list of residents on alert will be printed and reviewed during standup. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a resident change of condition is identified, the resident will be placed on alert charting which will include a LN assessement and any changes to the plan of care. Any changes to service plans as a result of a change of condition will be communicated to staff via either an ISP or updated full service plan to review and sign.   3. This system will be evaluated five days a week as part of daily stand up meeting. This system will further be evaluated monthly as part of the facility CQI process which includes a review of all residents who require change of condition monitoring. 4. The Executive Director and LNs are responsible for maintaining this system.

2.  Resident 3 was admitted to the facility in 05/2022. The resident's physician's orders, dated 05/02/22 and MAR, dated 08/01/22 through 08/22/22 were reviewed, and it was determined there were no signed physician's orders for the following PRN bowel medications and treatments: * Bisacodyl Laxative suppository; * Mi-Lanta suspension; * Loperamide suspension; * Milk of Magnesia suspension; and * Polyethylene Glycol powder. In an interview on 08/24/22, Staff 2 (RN/Director of Health Services) acknowledged the facility lacked written, signed orders in the resident's record for the medications. The need to ensure written, signed orders were in the resident's record for all medications and treatments administered by the facility was discussed with Staff 1 (Executive Director), Staff 2 and Staff 3 (LPN) on 08/24/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer, for 2 of 4 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 08/2018. A review of the 08/01/22 through 08/22/22 MAR and current physician's orders revealed the following medications were not documented to be administered as prescribed: * Humalog (insulin); * Gabapentin (anticonvulsant); * Acetaminophen (pain reliever); and * Velphoro (end stage renal disease). The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (RN/Director of Health Services) on 08/24/22. They acknowledged the findings.

1. Physician orders for residents #1 and #3 have been reconciled to original orders to ensure accuracy and have been sent to provider for review and signature. A review was completed of all resident Physician Orders to ensure quarterly POs are up to date. 2. To prevent recurrence, all clinical staff will be re-educated on the regulation that all medications entered in the MAR must have signed physician order. When taking over medication administration, staff will enter medications using signed orders only. Orders will then go through the triple check process, which includes LN review for accuracy of order transcription. 3. All medication and treatment orders will be reconciled quarterly and sent to provider for review and signature. 4. Executive Director and LNs will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 1) who had documented medication refusals. Findings include, but are not limited to: Resident 1 was admitted to the facility in 08/2018 with diagnoses including diabetes and end stage renal disease. Resident 1's MAR was reviewed for the time period of 08/01/22 through 08/22/22. Staff documented Resident 1 refused the following medications multiple times: * Humalog (insulin); and * Velphoro (end stage renal disease). There was no documented evidence the facility notified Resident 1's physician/practitioner of the refusals. The need to notify the physician of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (RN/Director of Health Services) on 08/24/22. They acknowledged the findings.

1. Resident #1's provider has been notified regarding all recent medication refusals. A fax form has been created for Med Aides to use to notify providers of refusals. Med Aides have been re-educated regarding the need to communicate refusals to the provider, unless the provider has requested not to be notified. 2. To prevent recurrence, 24- hour summary will be reviewed at daily standup which includes all documented medication refusals. On Mondays 72-hour summary will be reviewed to include documentation from the weekend. Resident Care Coordinator will verify that all necessary provider notifications have been made. 3. This system will be evaluated 5 days a week as part of daily standup meeting. Medication refusals will also be reviewed as part of evaluation process at 30 days, quarterly or with significant change of condition to ensure providers have been notified if needed. 4. Executive Director and LNs are responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 8) who had documented medication refusals. This is a repeat citation. Findings include, but are not limited to: Resident 8 was admitted to the facility in 08/2022 with diagnoses including anxiety. Resident 8's MAR was reviewed for the time period of 12/01/22 through 12/20/22, and signed physician orders and progress notes were reviewed from 10/23/22 through 12/20/22. Staff documented Resident 8 refused the following medications multiple times in several days consecutively: * Citalopram (antidepression);  * Retaine MGD eye drops; and  * Systane complete solution eye drops. The resident's signed physician order, dated 08/23/22, indicated to notify if the resident refused any medications or treatment "for more than 2 days in a row". There was no documented evidence the facility notified Resident 8's physician/practitioner of the refusals as ordered. The need to notify the physician of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (RN/Director of Health Services) on 12/20/22. They acknowledged the findings.

1. Resident #8's provider has been notified regarding all recent medication refusals. A fax form has been created for Med Aides to use to notify providers of refusals. Med Aides have been re-educated regarding the need to communicate refusals to the provider, unless the provider has requested not to be notified. 2. To further prevent recurrance, 24- hour summary will be reviewed at daily standup which includes all documented medication refusals. A clipboard has been placed on the top of each medcation cart and treatment cart for blank medication refusal PCP orders forms to be completed by medication technicians, to be placed in faxed refused meds box in medication room, to be reviewed by LNs before standup every morning.  On Mondays 72-hour summary will be reviewd to include documentation from the weekend. Resident Care Coordinator will verify that all necessary provider notifications have been made. 3. This system will be evaluated 5 days a week as part of daily standup meeting. Medication refusals will also be reviewed as part of evaluation process at 30 days, quarterly or with significant change of condition to ensure providers have been notified if needed. 4. Executive Director and LNs are responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly-hired direct care staff (#22) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 08/23/22 and revealed the following: Staff 22 (CG), hired on 07/05/22, lacked documentation of demonstrated competency in: * 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 have documented evidence of competency demonstrated in assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 5 (RCC) and Staff 10 (Business Office Manager) on 08/23/22.  They acknowledged the findings.

1. A complete audit will be done of all training and competency records.  All trainings and competencies will be complete and up to date for current employees no later than 10/23/22. 2. To prevent recurrence, all staff will be required to complete the required training and job specific competencies within 30 days of hire. Incomplete trainings and competencies will be reviewed five days a week as part of daily standup meeting to identify missing components, to review the status of new hires' trainings to ensure all training is completed within 30 days of hire. 3. This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their required trainings. 4.  The Executive Director and Business Office Manager will be responsible for maintaining this sytem.

Based on interview and record review, it was determined the facility failed to ensure 12 hours of annual in-service training, including 6 hours of dementia care training, had been completed for 2 of 3 long-term staff (#s 16 and 23) whose records were reviewed. Findings include, but are not limited to: On 08/23/22, training records were reviewed and revealed the following: * Staff 16 (MT), hired 05/11/18, and Staff 23 (CG), hired 12/07/20, lacked documentation of having completed a minimum of 12 hours annual in-service training, including 6 hours of the dementia care training. The need to ensure that all staff had documented evidence of completing a minimum of 12 hours annual in-service training, including 6 hours of dementia care training, was discussed with Staff 1 (ED), Staff 5 (RCC), and Staff 10 (Business Office Manager). They acknowledged the findings.

1.  A complete audit will be done of all annual training records.  All trainings will be complete and up to date for current employees no later than 10/23/22. 2.  To prevent recurrence, training grid will be utilized to ensure that all staff have required monthly and annual trainings completed within the specified timeframe including Relias trainings which meet the requirement for 12 hours of annual training, including 6 hours of dementia training and 6 hours of CBC training. 3.  This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their monthly required trainings. 4.  The Executive Director and Business Office Manager will be responsible for maintaining this sytem

Based on interview and record review, it was determined that the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records from 03/2022 through 07/2022 were reviewed. The fire drill records did not consistently include documentation of the following required components: * Location of simulated fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills;   * Evacuation time-period needed; and * Number of occupants evacuated. In an interview on 08/24/22, Staff 7 (Plant Operations Manager) reported that the facility was not relocating or evacuating residents as part of the fire drill process. While the facility had completed one full evacuation drill in April 2022, resident participation was not documented, and fire drill records revealed that residents were not consistently involved in the fire drill process. The need to ensure the facility conducted and documented fire drills according to the OFC was discussed with Staff 1 (ED) and Staff 7 on 08/24/22.  They acknowledged the findings.

1. A training was done with Maintenance Director that included a review of all required components related to the correct procedure for fire drills and all required components that must be documented. All staff were re-educated at staff meeting in September on the fire drill procedure. 2. To prevent recurrence, company fire drill form has been updated to include all required components and computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts. 3. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance. 4. The Executive Director and Maintenance Director will be responsible for maintaining this system.

Based on record review and interview, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to: On 08/22/22, Staff 1 (ED) was asked to explain the process of providing resident instruction upon admission and reinstruction annually. Staff 1 (ED) stated that fire drill and safety procedures were reviewed with the resident within the first week of admission, and not within the first 24 hours of admission. Staff 1 (ED) stated that re-instruction was not provided annually. The need to ensure residents were instructed on general safety procedures within 24 hours of admission and re-instructed at least annually was discussed with Staff 1, Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22. They acknowledged the findings.

1. Fire and life safety training has been completed and documented for all current residents. 2. To prevent recurrence, admission packet has been updated to include a form to document fire and life safety training within 24 hours of admission. Environmental evaluation, which is completed semi-annually for all residents was also updated to include documentation of re-instruction on fire and life safety training. 3. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance. 4. Executive Director and Maintenance Director will be responsible for maintaining this system.

Based on observation and interview, it was determined the facility failed to ensure the exterior pathways were accessible and maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 08/22/22.  The following was noted as needing repair: * A section of the exterior pathway at the rear of the facility had standing water and was not easily passable. The exterior was toured with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22 at 10:15 am. They acknowledged the findings.

1.  Cause of standing water has been identified and repaired. 2. To prevent recurrence, grounds will be walked 5 days a week to identify issues. A comprehensive walkthrough will be done once a week to be reviewed at standup meeting and a monthly groundskeeping audit has been implemented. 3. This system will be evaluated monthly as part of our CQI process, which will now include a monthly groundskeeping audit. 4. Executive Director and Maintenance Director will be responsible for maintaining this system.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair.  Findings include but are not limited to: Observations of the facility on 08/22/22 revealed the following: * The following doorframes, doors or walls were gouged or scraped: - Dining room entrance and exit doors; - First, second and third floor elevator doors; - Facility main entrance doorways; - Corners of the wall in the hallway next to the Activity Room; and - Resident apartments 308 and 310. * Light fixtures throughout the dining room had visible debris in the fixture; * Second and third floor laundry rooms had a large amount of debris behind the machines; * A washing machine in the second floor laundry room was full of standing water; * There were holes in the wall on the right side of the third floor game room above the puzzle table; and * There were long screws protruding from the bases of several of the legs of the pergola on the back patio. The facility was toured with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22 at 10:15 am.  They acknowledged the findings.

1. All identified areas including doors, walls, light fixtures, machinery, and courtyard have been deep cleaned, and all repairs have been completed or scheduled. 2.  To prevent future occurrence, routine cleaning schedules for common areas have been updated to include areas that were missing.  A comprehensive walkthrough will be done once a week to be reviewed at standup meeting and a monthly groundskeeping audit has been implemented. Maintenance Director will also conduct monthly groundskeeping audit, monthly exterior inspections and monthly interior safety inspections to include repair work needed, and ensure any deficencies will be corrected timely. 3. System will be evaluated monthly as part of the Continuous Quality Improvement process to include a review of the monthly sanitation and repair audits. 4. Executive Director and Maintenance Director will be responsible for maintaining this system

Based on observation and interview it was determined that the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.  Findings include, but are not limited to: The facility was toured on 08/22/22. Resident windows and common area windows on the second and third floors opened vertically and windowsills were lower than 36 inches. The windows lacked a mechanism to prevent the window from opening fully to prevent accidental falls. The lack of a mechanism to prevent accidental falls was discussed with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant).  They acknowledged the findings.

1.  All windows located on 2nd and 3rd floors have been repaired with a latching mechanism preventing risk of falls. 2. To prevent future occurrence, locking mechanisms will be inspected for efficacy during yearly window latch gap inspection. Windows located in resident apartments will be inspected twice a year during the environmental evluation. 3. All windows will be inspected during routine, semi-annual environmental evaluations to ensure compliance. 4. Executive Director and Maintenance Director will be responsible for maintaining this system.

Based on observation and interview it was determined that the facility failed to ensure that covers, grates or screens of wall heaters do not exceed 120 degrees Fahrenheit.  Findings include, but are not limited to: During a tour of the facility on 08/22/22, the following observations were made: * At 2:40 pm, a wall heater was observed in apartment 102.  When turned on, the surface temperature was 220 degrees Fahrenheit. * At 2:55 pm, a wall heater was observed in apartment 220.  When turned on, the surface temperature was 200 degrees Fahrenheit. * At 3:00 pm, a wall heater was observed in apartment 313.  When turned on, the surface temperature was 240 degrees Fahrenheit. The need to ensure that all covers, grates or screens of wall heaters and associated heating elements do not exceed 120 degrees Fahrenheit was discussed with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/24/22.  They acknowledged the findings. Staff 7 stated he would disconnect any wall heaters that were in resident apartments.

1. All wall heaters in resident apartments have been disconnected. 2.  Electricity to all resident wall heaters has been permanently disconnected. 3. All units will be inspected during routine semi annual enviromental evluations. 4. Executive Director and Maintenance Director will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 270 and C 305.

1. All C tag violations will be resolved no later than 1/19/23. 2. To prevent recurrence, refer to systems put in place for tags C270 and C305. 3.All systems pertaining to C tags will be evaluated as part of the monthly facitlity CQI program to ensure compliance. 4. Executive Director will be responsible for maintaining all systems.

The findings of the re-licensure survey, conducted 08/22/22 through 08/24/22, 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 08/24/22, conducted 12/20/22, 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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

The findings of the 2nd revisit to the re-licensure survey of 08/24/22, conducted on 03/21/23 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.