Brookdale Rose Valley Scappoose

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 1 of 1 sampled resident (#3) whose ADL care was observed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 04/2023 with diagnoses including paranoid schizophrenia and diabetes. During an ADL observation on 06/10/26 at 1:05 pm, the following was noted: * Staff 12 (CG) provided incontinence care for Resident 3; * Staff 12 started to remove Resident 3’s soiled brief without performing hand hygiene, then placed the soiled brief on the floor; * Staff 12 removed a clean brief from a bag, placed it on the chair near the resident, and then picked up the soiled brief from the floor, and disposed of it in a trash can in the bathroom; and * Staff 12 returned and applied the clean brief without performing hand hygiene from dirty to clean tasks and did not utilize gloves throughout the incontinence care. The observation and the need to implement effective methods of infection control were discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN), and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings.

1. Staff 12 was re-educated on proper infection control measures including glove use on 6/26/26. 2. Current direct care staff were re-educated on hand hygiene, infection control practices and glove use on 6/23/26 3. Routine observations of resident care will be conducted twice weekly for 30 days, then weekly for 60 days to validate use of proper infection control measures. 4. Executive Director, Health & Wellness Directoror designee is responsible for this plan of correction.

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 orders were carried out as prescribed for 3 of 6 sampled residents (#s 3, 4, and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2023 with diagnoses including paranoid schizophrenia and diabetes. The resident’s 05/01/26 through 06/08/26 MARs, current physician’s orders, and clinical record were reviewed. The following was identified: Resident 3 had a physician’s order to change Dexcom (a continuous blood sugar monitor) every 10 days. Documentation on the MAR had a code of 18 (indicating other/see progress notes) on three occasions between May and June. There was no documentation in the progress notes to verify if the device was changed as ordered and no exception was documented. On 06/10/26 at 3:30 pm, Staff 2 (RN) verified there was no documented evidence to indicate if the device was changed as ordered. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN), and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings. No additional information was received. 2. Resident 4 was admitted to the facility in 03/2024 with diagnoses including dementia and diabetes. The resident's 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: a. Resident 4 had an order to apply a lidocaine 5% patch topically, remove after 12 hours as needed for pain. The resident received the PRN order on 4 occasions between May and June; however, there was no indication the patch was removed per prescriber's orders. On 06/10/26 at 12:45 pm, Staff 1(ED) and Staff 2(RN) confirmed the MAR or progress notes did not provide evidence the patch was removed 12 hours following administration. b. Resident 4 had an order dated 01/19/2026 to check blood sugar three times daily for blood sugar monitoring. The order was not transcribed into the MAR; therefore, the resident’s blood sugar was not checked as prescribed. On 06/10/26 at 1:30pm Staff 7(District RN) confirmed the order for blood sugar check three times daily was not transcribed to MAR. c. Resident 4 had a physician's order to obtain the resident’s weight daily, directing staff to notify the physician if the resident gained two pounds in two days or five pounds in a week. There was no documented evidence the facility had notified the physician when the resident gained two or more pounds in two days and/or five pounds in one week on three occasions. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings. No additional information was received. 3. Resident 5 moved into the facility in 01/2026 with diagnosis of congestive heart failure. The resident’s 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: Resident 5 had a physician's order to obtain the resident’s weight daily, directing staff to notify the physician if the resident gained two or more pounds overnight or five pounds in a week. During an interview on 06/09/26 at 1:45 pm, Staff 10 (MT) confirmed the facility’s process to notify the physician if the resident gained more than two pounds in overnight was to fax the physician’s office, and then document the fax was sent in the progress notes. There was no documented evidence the facility had notified the physician when the resident gained two or more pounds overnight on five occasions. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (RN), Staff 7 (District RN), Staff 8 (Regional Director of Operations), and Staff 9 (MT) on 06/10/26 at 1:45 pm. They acknowledged the findings.

1.The medication administration record for Resident #3, 4 and 5 have been reconciled with physician orders and revised as applicable. Provider notification has occurred as indicated. 2. Remaining resident medication administration records will be reviewed for accuracy. Additional education will be provided to medication technician staff on folowing physician orders, documentation processes including documenting exceptions to orders and physician notification when results are outside parameters. 3. Medication orders with documented exceptions will be reviewed daily in conjunction with clinical review meeting at minimum of 3 times per week. Executive Director or designee will conduct random review of medication admninistration records and associate documentation weekly for 60 days to monitor ongoing compliance. 4. Executive Director, Health & Wellness Director or designee is responsible for this plan of correction.

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 orders for 3 of 3 sampled residents (#s 3, 4, and 5) who had documented medication or treatment refusals. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 01/2026 with diagnosis of congestive heart failure. The resident's 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: Staff documented the resident refused nystatin powder (for rash) on 11 occasions in May. During an interview on 06/09/26 at 1:40 pm, Staff 10 (MT) confirmed the facility was to inform the prescriber of every medication or treatment refusal via a fax. However, there was no documented evidence staff notified the prescriber of Resident 5’s refusals. The need to notify the practitioner when a resident refused to consent to an order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 7 (District RN), Staff 8 (Regional Director of Operations), and Staff 9 (MT) on 06/10/26 at 1:45 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2023 with diagnoses including paranoid schizophrenia and diabetes. The resident's 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: Staff documented the resident refused the following treatments; * Bag balm ointment for (dry skin) on 34 occasions in May and 10 occasions in June; and *Desitin cream for (irritated itch or rash) on 13 occasions in May and four occasions in June. During an interview on 06/10/26 at 1:00 pm, Staff 9 (MT) confirmed the facility was to inform the prescriber of every medication or treatment refusal via a fax. However, there was no documented evidence staff notified the prescriber of Resident 3’s refusals. The need to notify the practitioner when a resident refused to consent to an order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 03/2024 with diagnoses including dementia and diabetes. The resident's 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: Staff documented the resident refused the following treatment; * Nystatin powder for (rash) on 15 occasions in May and five occasions in June. During an interview on 06/10/26 at 1:00 pm, Staff 9 (MT) confirmed the facility was to inform the prescriber of every medication or treatment refusal via a fax. However, there was no documented evidence staff notified the prescriber of Resident 4’s refusals. The need to notify the practitioner when a resident refused to consent to an order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN), and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings.

1. The primary care provider for Resident #3, 4 and 5 have been notiifed of medication refusals in May and June. 2. Remaining resident medication administration records have been reviewed for the last 30 days to assure physician notification for refusals. Medication technicians will be re-educated on requirements of notifying providers of refusals. 3. Medication and treatment refuals will be reviewed daily in conjunction with clinical review meeting at minimum of 3 times per week to assure physician notification. Executive Director or designee will conduct random review of medication admninistration records and associate documentation weekly for 60 days to monitor ongoing compliance. 4. Executive Director, Health & Wellness Director or designee.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR which included resident-specific parameters for 1 of 6 sampled residents (# 4) whose MARs were reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 03/2024 with diagnoses including dementia and diabetes. The resident's 05/01/26 through 06/08/26 MARs, current prescriber orders, and clinical record were reviewed. The following was identified: The following PRN medications for pain lacked the sequential order for administration: * Celebrex; * Diclofenac; * Hydrocodone/Acetaminophen; * Lidoderm patch (for pain); and *Acetaminophen (for pain). Resident 4 was administered Celebrex on seven occasions in May and two occasions in June, hydrocodone/acetaminophen on three occasions in May and four occasions in June and Lidoderm patch once in May and three occasions in June. During an interview on 06/10/26 at 3:30 pm, Staff 2 (RN) confirmed the lack of specific parameters for the PRN medications used for the same diagnosis. The need to ensure MARs were accurate and included resident specific parameters for PRN medications used for the same diagnosis was discussed with Staff 1 (ED), Staff 2, Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations) on 06/10/26 at 3:50 pm. They acknowledged the findings.

1. The medication administration record for Resident #4 has been updated to reflect nursing clarification and instruction for as needed medications. 2. The medication administration records for remaining residents will be reviewed to assure nursing clarification and instruction are present for as needed medications. Medication technicians will be educated on referencing these instructions prior to administering as needed medications. 3. Nursing clarification and instruction will be added in conjunction with the transcription order review process. Executive Director or designee will conduct a random review of medication administration records weekly for 60 days to monitor ongoing compliance. 4. Executive Director and Health & Wellness Director/RN are responsible for this plan of correction.

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 4 of 4 newly hired staff (#s 9, 10, 11, and 16) completed fire safety training prior to beginning job responsibilities. Findings include, but are not limited to: Staff training records were reviewed on 06/08/26 at 1:24 pm with Staff 6 (Business Office Manager) and the following was identified: There was no documented evidence Staff 9 (MT) hired on 04/06/26, Staff 10 (MT) hired on 04/27/26, Staff 11 (CG) hired on 04/09/26, or Staff 16 (Housekeeper) hired on 04/20/26 completed a fire safety training prior to beginning their job responsibilities. On 06/10/26 at 1:20 pm Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations) acknowledged fire safety training had not been performed with staff prior to beginning job responsibilities. ?

1. Staff # 9, 10, 11 and 16 have completed fire safety training. 2. Remaining staff training files will be reviewed to validate completion of pre-service orientation topics as described in rule. Business office coordinator was educated on pre-service training requirements per rule and associated community orientation training documents. Newly hired staff training compliance will be discussed in manager meeting weekly in order to assure pre-service requirements are met before job specific training begins. 3. Executive Director will conduct random audits of pre-service training documentation weekly for 30 days and monthly for 60 days. 4. Executive Director, Business Office Coordinator or designee are responsible for this plan of correction.

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

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternate months from fire drills and written fire drill records included all required elements according to the Oregon Fire Code (OFC). The findings include, but are limited to: Fire drill records from 12/2025 to 05/2026 were reviewed with Staff 5 (Maintenance Supervisor) on 06/09/26 at 12:30 pm. The following was identified: a. Fire drill records lacked one or more of the following required components: * The time of the fire drill; * The location of the simulated fire origin; * Escape route use; * Evacuation time period; and * The number of occupants evacuated. b. The facility lacked documented evidence fire and life safety instructions was provided to staff on alternate months of fire drills. The need to ensure fire and life safety instruction was provided to staff on alternating months from fire drills and written fire drill records included all required elements according to the OFC was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations) on 06/10/26 at 1:20 pm. She acknowledged the findings.

1. Education on rule requirements was completed with Maintenance Supervisor on 6/29/26. 2. Fire drills check list will be updated to include all of the required components. 3. Executive Director or designee will audit fire drill and education documentation monthly for 3 months then quarterly thereafter. 4. Executive Director, Maintenance Supervisor or designee are responsible for this plan of correction.

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 provide fire and life safety reinstruction to residents at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed with Staff 5 (Maintenance Director) on 06/09/26 at 12:30 pm. There was no documented evidence residents were provided fire safety reinstruction annually. On 06/09/26 at 1:20 pm, the need to provide fire and life safety reinstruction to residents at least annually was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Health Services Coordinator/LPN), Staff 7 (District RN) and Staff 8 (Regional Director of Operations). Staff 1 acknowledged the need to provide the residents with fire and life safety training.

1. Fire Education will be provided to resident during care conference annually. 2. Executive Director and Maintenance Supervisor have reviewed rule requirements for fire and life safety instruction to residents at least annually. Fire and life safety instruction will be provided to resident during care conference annually. 3. Executive Director or designee will audit service plan documentation monthly for 3 months then quarterly thereafter. 4. Executive Director, Maintenance Supervisor or designee is responsible for this plan of correction

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 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 07/09/25 from 11:16 am to 2:09 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 spills, splatters, dirt, dust, and black matter was visible on, in, or underneath the following: * Floor to wall transition and under/behind major equipment including dish washing and ware wash areas; * Walls and caulking in dish washing area; * Floor in walk-in refrigerator; * Interior and exterior of the ice machine; * Interior of the microwave; * Industrial can opener housing; * Wire shelving racks; and * Coffee station open shelving. b. The following areas were noted in need of repair: * Ware wash machine was noted to leak due to a missing a part, front right corner was separated, and the plastic cover to the temperature gauge was not attached; * Ice machine had tape on the left side of the machine; * Dish washing area had caulking that was unsealed and/or had missing sections; * Large table mixer coating was heavily chipped; * Industrial can opener blade; * Open shelving below the hot line had missing, broken, chipped, and exposed material; * Cabinets below the hot line on the server side lacked a cabinet door on the right side and the hardware on one cabinet door was not attached securely; * Exterior of the bread warmer was missing hardware; * Plastic blue trays on metal rack holding bread had broken corners and missing material; and * Four large cutting boards were heavily scored and melted in places. On 07/09/25 at 1:14 pm, Staff 2 (Dining Service Coordinator) toured the kitchen with this surveyor and acknowledged areas that were not clean and/or in good repair. On 07/09/25 at 1:40 pm, Staff 1 (ED) toured the kitchen with this surveyor and reviewed areas of the kitchen that were not clean and in good repair. 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 1 on 07/09/25 at 2:11 pm. She acknowledged the findings.

1.a.) - Floor to wall transitions under and behind equipment are cleaned. - Caulking by dishpit is replaced - Floor in walk in refrigerator cleaned - Ice machine cleaned - Microwave cleaned - Can opener housing cleaned - Wire shelving cleaned - Coffee station shelving cleaned. b) - Ecolab contacted to service and repair machine. Leak was already noted and part for that repair on order and awaiting installation. - Ice machine - getting estimates for potential replacement - Caulking by dishpit replaced - Large table mixer getting extimates for repair/replacement - Shelving below hotline is getting estimates for repair/replacement - Cabinet door below hotline getting estimate for repair/replacement - Bread warmer hardware replaced - Plastic trays replaced - Cutting boards replaced

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 interview and record review, conducted during a site visit on 06/24/25 and 06/25/25, the facility's failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to: The facility was placed on license condition ALFCD24-00204 on 05/24/24, which indicated the facility was to staff according to a mandated staffing plan of: · Three caregivers and one med tech on day shift; · Three caregivers and one med tech on swing shift; and · Two caregivers and one med tech on night shift. A review of the facility's staff schedule, facility timecards, and labor detail information, dated 07/12/24 through 07/18/24, indicated the facility was not staffed to the condition-mandated staffing plan for 7 of 21 shifts reviewed. It was determined the facility failed to have 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 3 (District Director of Operations) on 06/25/25.

The findings of the on-site investigation, conducted 06/24/25 through 06/25/25 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 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

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 and had written, signed prescriber's orders for 1 of 5 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 01/2024 with diagnoses including congestive heart failure. Resident 1’s current facility records and 08/01/24 through 08/26/24 MAR revealed the following: a. Resident 1 had a physician order, dated 08/12/24, to obtain weight daily and “notify physician if patient gains 2 pounds in 2 days or 5 or more pounds in a week.” * Progress notes, dated 08/13/24, indicated Resident 1 had fluid removed at the hospital and s/he returned to the facility on 08/12/24 with a new weight of 226.0 lbs. The RN documented “the new weight loss noted here [226.0 lbs] is the new dry weight we are comparing for notification to the provider.” *Review of MARs revealed the following weights: 08/22/24 – 232.8 lbs; 08/23/24 – 231.8 lbs; 08/24/24 – 232 lbs; 08/25/24 – 231.6 lbs; and 08/26/24 – 231.6 lbs On 08/22/24 Resident 1’s weight increased to 232.8 lbs, a weight gain of 6.8 lbs. From 08/23/24 through 08/26/24, Resident 1’s weight was 5.6 lbs or greater from his/her baseline. During an interview on 08/28/24 at 10:45 am with Staff 17 (RCC), she indicated she was not clear what the baseline weight was to reference if Resident 1 had a weight gain that required notifying the physician. During an interview on 08/28/24 at 11:10 am, Staff 3 (RN/Health and Wellness Director) acknowledged the physician was not notified of the weight gain on 08/23/24 when resident had gained greater than two pounds in two days. The resident’s physician was notified of the weight gain on 08/27/24 during a facility visit. b. The discharge instructions, dated 08/12/24, included a signed physician’s order for “Orthostatic- (low blood pressure that occurs when standing up) VS [vital signs] daily X 2 days then PRN dizziness”. Review of Resident 1’s MAR indicated vitals were taken in the evening on 08/13/24, and in the morning on 08/15/24 and 08/16/24. The MAR was blank for morning and evening on 08/14/24 and the resident was out of the building during the evening on 08/15/24. In addition to vitals not being taken on 08/14/24, there was no documented evidence orthostatic blood pressures were taken. During an interview on 08/28/24 at 12:55 pm Staff 17 indicated the resident’s vitals were taken in the sitting position only. No additional blood pressure values were taken in other positions. c. The following medications and/or treatments lacked a signed physician’s order in the record: * Donepezil 5 mg for dementia; and * Oxygen at 1.5 L/min for respiratory failure. d. Resident 1’s MAR showed a discontinued date of 08/12/24 for sodium phosphate enema for constipation. The facility lacked documented evidence of a signed order to discontinue the medication. e. Resident 1’s After Visit Summary, signed by the physician on 08/12/24, indicated the following instructions: * Aspiration (food or drink that accidentally enters into the trachea and can pass into the lungs) precautions that included “Keep upright 90 degrees with any oral intake, small bites and sips”; and * Delirium precautions: “open window shades during the day and maximize sun exposure from 0800 to 1600” and “limit interruptions between 2200 and 0600. During an interview on 08/28/24 Staff 3 acknowledged the instructions were not carried out or clarified with Resident 1’s physician. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2 (District Director of Operations), Staff 3, Staff 6 (LPN/Health and Wellness Coordinator) and Witness 2 (Consultant) on 08/28/24. They acknowledged the findings. No further information was provided.

1. Resident 1: A. The provider was contacted by the Health and Wellness Director and a discussion of current weight, changes in weight, and orders was held. Her daily weights since readmission were reviewed, current lower extremity edema, and SPO2 readings while at rest and while ambulating were evaluated. 2. System Correction: Training with med techs was conducted and education done on : daily or weekly weights, the reason for, and how to monitor and notify appopriatley,. Weekly review by clinical leadership of all person on daily or weekly weights. 3. Review of weights will occur weekly by clinical leadership including RN/LN. When it is determined that a resident has a new baseline weight the new benchmark will be added to the residents electronic medical record by the Health and Wellness Director or designee. 4. Executive Director and Health and Wellness Director Resident 1 B. 1. The standard block discharge orders from the after visit summary were reviewed with the primary care provider and an order was obtained to discontinue these orders. B. 2.System Correction: Staff training for the medication aides as well as the Health and Wellness Director and the Health and Wellness Coordinator was conducted on entering of all signed orders included in the aftervisit summary. Training included sending the after visit summary or orders to the primary care provider for notification of new orders. B. 3. All orders will go through a three step system of verification: Step 1: The person receiving the order during their shift will review and transcribe any new orders that come in during their shift. Step 2- The order is placed in the folder in the medication room that is labeled with the Health and Wellness coordinator or Executive Director for a second check of the accuracy of the orders transcribed. Step 3. Orders are placed in the folder marked Director of Health and Wellness and will have a third and final check for accuracy conducted. C. Monitoring All orders processed will be reviewed in the clinical meeting each morning. In the case of weekends, the Clinical leadership in the building will review the orders for accurracy and contact the licensed nurse on call if any questions or inaccurracies found. Resident 1 C. 1. The written and signed physicians orders for the medication noted were located and placed in the chart. C 2. System Correction: Organization of the medication room area including labeling of folders for orders being processed and seperating of paperwork into separate holders was done to decrease confusion on placement. C. 3 Monitoring C.4. Responsible Party Health and Wellness Director Resident 1 D. 1. Orders were obtained by the provider to discontinue the medications that had been removed from the residents record. D. 2 System Correction Staff education was done on obtaining an order to discontinue unused as needed medications before discontinuing them. D. 3 Monitoring E. Responisible Party Health and Wellness Director E. Resident 1 SEE B ABOVE

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 consent to orders for 1 of 1 sampled resident (# 1), who had documented treatment refusals. Findings include, but are not limited to: Resident 1 was admitted to the facility in 01/2024 with diagnoses including congestive heart failure. Resident 1's MARs, dated 08/01/24 through 08/26/24 were reviewed and revealed facility staff documented Resident 1 refused the following orders: * Miconazole cream twice daily (for rash) on 12 occasions; * Petroleum jelly gel twice daily (for skin dryness) on four occasions; and * Daily weights on one occasion. On 08/28/24, Staff 3 (Health and Wellness Director/RN) confirmed there was no documented evidence the practitioner was notified of the multiple treatment refusals. The need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (Executive Director), Staff 2 (District Director of Operations), Staff 3, Staff 6 (LPN/Health and Wellness Coordinator) and Witness 2 (Elderwise Consultant) on 08/28/24. They acknowledged the findings, and no additional documentation was provided.

1. Hold training with med techs to discuss: how to notify physicians of refusals and how to document refusals. Refusals will be done via fax. 2. Weekly review by clinical leadership/ED of all refusals to ensure notifications have been done. 3. Review of refusals will be done weekly. 4. Executive Director and Health and Wellness Director

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 411-054-0037 (3)(a-v) Acuity Based Staffing Tool: Care Elements (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to: There was no documented evidence the facility was using an ABST that included all the required ABST elements. In an interview on 08/27/24 at 11:15 am, Staff 1 (ED), Staff 2 (District Director of Operations), Witness 1 (Elderwise Consultant) acknowledged the facility's ABST failed to separately list all twenty-two required ADL questions for each resident. On 08/27/24, the need to ensure the facility implemented an ABST which included all required elements was reviewed with Staff 1, Staff 2, and Witness 1. They acknowledged the findings.

1. Community is in process of working with Corrective Action Team on reviewing Brookdale’s Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate our tool as well as where the 22 required elements are identified. 2. As we work through our Acuity Based Staffing Tool (ABST)with the department, we will continue to staff using Brookdale’s tool. 3. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly. 4. Executive Director or designee

OAR 411-054-0037 (3)(a-v) Acuity Based Staffing Tool: Care Elements (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to: There was no documented evidence the facility was using an ABST that included all the required ABST elements. In an interview on 11/25/24 at 2:11 pm, Staff 1 (ED) and Staff 2 (District Director of Operations) acknowledged the facility's ABST failed to separately list all twenty-two required ADL questions for each resident. On 11/25/24, the need to ensure the facility implemented an ABST which included all required elements was reviewed with Staff 1 and Staff 2. They acknowledged the findings.

OAR 411-054-0037 (3)(a-v) Acuity Based Staffing Tool: Care Elements (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the facility was toured on 08/26/24 at 10:40 am. The following was found to be in need of repair: Two light fixtures located on the second floor were missing covers. One fixture was located at the top of the stairwell in the hallway near apartment 233. The second fixture was located in the hallway next to apartment 223. The building was toured with Staff 4 (Maintenance Supervisor) on 08/27/24 at 2:45 pm. During the tour Staff 4 stated the light covers were currently “out of stock”. In an interview with Staff 1 (ED) on 08/27/24 at 3:05 pm, Staff 1 was aware of the missing light covers and stated the facility is “trying to source them” because they are no longer made. The need to ensure all interior materials and surfaces were kept clean and in good repair was discussed with Staff 4 on 08/27/24 at 2:45 pm and Staff 1, Staff 2 (District Director of Operations), and Witness 2 (Elderwise Consultant) on 08/28/24 at 11:40 am. The findings were acknowledged.

1. Light fixtures to be replaced that were missing covers. 2. Light fixtures to be replaced as issues occur. 3. Weekly walk through to be completed. 4. Executive Director and Maintenance Supervisor

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

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 C362.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

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: Observation of the kitchen on 06/13/24 at 09:30 am through 12:00 pm revealed the following: a. The following areas were in need of cleaning and/or repair: * Can opener blade had debris; * Kitchen entrance/exit doors and frames had black scuffs, gouges, and peeling paint, which exposed the door and frame surfaces; * Walk in refrigerator and freezer fans had a buildup of dust and debris; * Hand mixer had a buildup of dried matter and debris; * Vent above the sanitizer test station was coming loose; * Vent above the three compartment sink had paint scrapes and debris; * Exhaust vents of the hood had dust and debris; * Ceiling tiles above the hood had a buildup of yellowish-brown matter; * The walls behind the ware washer had a buildup of debris, dust, and black matter; * Multiple small holes were in the wall above the three compartment sink and dishwashing station; * There was a large, circular hole in the wall by the "Out" door of the kitchen; * There were multiple holes in the cabinet that housed a small, reach-in refrigerator; and * Part of the corner board was missing near the "Out" door of the kitchen. b. Multiple food items in the freezer were found without dates after they were opened. c. Poor infection control practices observed, but not limited to: * Dining room had preset tables with food contact surfaces of cutlery exposed to potential contamination; and * Industrial and commercial stand mixers were not covered when not in use. Staff 1 (ED) and Staff 2 (Dining Services Coordinator) toured the kitchen areas with the surveyor on 6/13/24. They acknowledged the findings.

a. Areas in need of cleaning and repair * Can opener has been cleaned * Kitchen entrance/exit doors cleaned, fixed, and repainted *Walk-in refrigerator and freeaer fans cleaned *Hand mixer cleaned *Vent above sanitzer station secured *Vent above 3 comparment sink cleaned and repainted *Exhaust vents of the hood cleaned *Ceiling tiles cleaned and painted or replaced *Wall behind ware washer cleaned *Holes in walls repaired *area by small reach in was reconfigured *corner board repaired b.Staff trained on freezer dating and storage c. silverware is now being wrapped prior to table setting *covers were purchased for stand mixwers 2. Cleaning schedule posted in kitchen to be completed by staff. 3.Weekly verification of tasks being completed by Dining Services Corrdinator. 4. Dining Services Coordinator and Executive Director are responsible for monitoring.

The findings of the kitchen inspection, conducted 06/13/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit to the kitchen inspection of 06/13/24, conducted 08/27/28 through 08/28/24, 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, interview, and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24, and 05/29/24, it was confirmed the licensee failed to be responsible for the operation of the facility and the quality of services rendered in the facility. Findings include, but are not limited to: The licensee is responsible for the operation of the Assited Living Facility, and responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. During the LCU investigation, conducted on 05/23/24, 05/24/24, 05/28/24, and 05/29/24, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number and severity of citations in the following areas: OAR 411-054-0025(7)(f) Facility Administration; and OAR 411-054-0070 Staffing Requirements and Training. LCU requested plans of correction on 05/24/24 and 05/28/24. Plans of correction were accepted on 05/24/24 and 05/28/24. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. The Department placed a condition on the facility on 05/24/24.

Based on observation, interview, and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility falsified the narcotics log. Findings include, but are not limited to: On 05/23/24, the facility's narcotics log was observed to have numerous entries missing signatures. During an interview on 05/23/24, Staff 4 (Resident Care Coordinator) stated the logbook should be signed by both the incoming and outgoing med tech at shift change and "we need to get better at that [signing the log]." On 05/24/24, the facility's narcotics log was observed to have been signed on the lines of the previously missing signatures, with sticky notes indicating med techs needed to continue to go back and sign the blank entries. In an interview on 05/24/24, Staff 4 stated "I had people go back and sign." It was determined the facility falsified the narcotics log. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. Verbal plan of correction: Staff have been retrained, notices have been posted for staff to not go back and sign documents. All-staff training to be completed by 05/31/24.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to report instances of abuse or suspected abuse to the local Seniors and Peoples with Disabilities (SPD) office for 2 of 2 sampled residents (#s 7 and 14). Findings include, but are not limited to: During an interview on 05/29/24, Witness 2 (Adult Protective Services (APS)) stated: - An incident regarding Resident 14 running out of medication, including pain medication, had not been reported by the facility; and - An incident regarding Resident 7 not being monitored when his/her Furosemide (water retention) had been discontinued had not been reported by the facility. An incident report for Resident 14, dated 04/08/24, indicated s/he had missed medication and been sent to the hospital. There was no documented evidence the facility reported the incident to the local SPD. There was no incident report or documented evidence the facility had reported the incident for Resident 7. It was confirmed the facility failed to report two instances of abuse or suspected abuse. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. Verbal Plan of Correction: RN will be trained on performing self-reports. Events will be reviewed during daily stand-up for the previous 24 hours. All staff to be re-trained on abuse and neglect reporting. Based on interview and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to immediately report instances of abuse or suspected abuse for 3 of 3 sampled residents (#s 1, 8, and 13). Findings include, but are not limited to: Progress notes for Resident 1, dated 08/26/23, indicated s/he had been administered 30mg or Morphine (pain medication) instead of the prescribed 15mg of Morphine. There was no documented evidence the facility investigated the incident or reported the medication error to the local SPD. An incident report, dated 08/16/23, indicated Resident 8 had received Amlodipine (heart medication) twice a day instead of once a day as prescribed for an indeterminate amount of time. The incident report further indicated the facility self-reported the incident to the local SPD office on 08/23/23. An incident report, dated 06/28/23, indicated Resident 13 had gone without his/her Pregabalin (pain medication) for five days. The incident report further indicated the incident had been reported to the local SPD office on 08/08/23. During an interview on 05/28/24, Staff 1 (Executive Director) stated the facility had created incident reports for medication errors for Residents 8 and 13. It was determined the facility failed to immediately report instances of abuse or suspected abuse. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. Verbal plan of correction: RN will be trained on performing self-reports. Events will be reviewed during daily stand-up for the previous 24 hours. Staff to be retrained on abuse and neglect reporting. Based on interview and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to notify the local Seniors and People with Disabilities (SPD) department of an incident of abuse or suspected abuse for 1 of 2 sampled residents (# 12). Findings include, but are not limited to: In an interview on 05/23/24, Staff 1 (Executive Director) stated Resident 12 had moved into the facility on 04/20/24. S/he further stated s/he didn't know the facility needed to report the incident as the local APD had already investigated. During an interview on 05/23/24, Staff 14 stated Resident 12's family member had approached Staff 14 on 04/22/24 with concerns staff didn't know Resident 12 was living in the facility. During an interview on 05/24/24, Staff 11 (Med Tech) stated "I was not aware [Resident 12] was here  ... I don't think anybody knew." S/he further stated the facility "usually" puts new move-ins in the "care book" and that s/he hadn't seen a Temporary Service Plan in the med tech book. A temporary service plan for Resident 12, dated 04/19/24, was not signed by care staff until 04/24/24. In an interview on 05/24/24, Staff 9 (Dining Services Coordinator) stated "One resident we [the kitchen staff] didn't even know she arrived. Pretty sure it was [Resident 12]. I think [s/he] moved in on a Saturday, found out on Monday." There was no documented evidence the facility had investigated the incident or reported it to the local SPD. It was determined the facility failed to notify the local SPD of an incident of abuse or suspected abuse. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. Verbal plan of correction: RN will be trained on performing self-reports. Events will be reviewed during daily stand-up for the previous 24 hours. All staff to be re-trained on abuse and neglect reporting.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to develop a service plan reflective of resident needs for 1 of 1 sampled resident (# 3). Findings include, but are not limited to: During an interview on 05/23/24, Witness 1 (Family Member) stated there had been confusion with the facility regarding wound care for Resident 3, and that s/he had to coordinate with Resident 3's physician to begin treatment. Resident 3's service plan, dated 03/21/24, indicated "[Resident 3] will use family support for transportation to and from medical appointments" under the "Service Coordination" section. During an interview on 05/28/24, Staff 2 (RN) stated Resident 3's family scheduled appointments and it "should be"  in Resident 3's service plan. During an interview on 05/28/24, Staff 8 (Med Tech) stated in regard to Resident 3 "[the receptionist] sets up appointments for us." There was no further documented evidence Resident 3's family was responsible for coordinating health services for Resident 3. It was determined the facility failed to develop a service plan reflective of a resident's needs. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. Verbal plan of correction: Facility to update Resident 3's service plan and include coordination of care responsibilities as other service plans are updated.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to monitor a resident following a discontinued medication for 1 of 1 sampled resident (# 7). Findings include, but are not limited to: During an interview on 05/28/24, Resident 7 stated s/he had been "out of the water pill" and "went for a long time before [the facility] realized." Resident 7's service plan, dated 05/23/24, indicated s/he had a diagnoses of heart failure. Physician orders for Resident 7 indicated s/he was to begin Furosemide 40mg/day (water retention) on 04/24/23 with an end date of 10/20/23. Resident 7's MAR, dated 10/20/23, indicated his/her Furosemide had been discontinued on 10/21/23. During an interview on 05/28/24, Staff 2 (RN) stated there was an "issue" with whether Resident 7's Furosemide was discontinued or not. There was no documented evidence the facility had monitored Resident 7 regarding the discontinuation of his/her furosemide. Resident 7 was admitted to the hospital for heart failure on 11/22/24. It was determined the facility failed to monitor a resident following a discontinued medication. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, and Staff 3 (District Director of Operations) on 05/29/24. Verbal plan of correction: Facility to establish "Medication Mondays" to ensure medications are available for the week, posted plan pharmacy indicating refill times. Re-educating staff on three-step process to ensure at least a double check done in the first 24 hours. Facility to ensure Temporary Service Plans are in place during clinical meetings.

Based on interview and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed a med tech administered insulin prior to being delegated by an RN for 2 of 2 sampled residents (#s 2 and 6). Findings include, but are not limited to: During an interview on 05/22/24, Staff 10 (Med Tech) stated the facility RN "didn't tell me I had to be delegated" and "I didn't get delegated until a month ago." S/he further stated: "When state came [the nurse] put a different date on the paper. I never signed the delegation because it had the wrong date on it." A review of insulin delegations and competency checklists for Staff 10 indicated the following: - Four RN Delegation and Instructions Agreements, dated 03/02/24, were not signed or dated by Staff 10 or Staff 2 (RN); - An "Initial Evaluation and Competency for Delegation of Nursing Tasks" form for Staff 10 had an "initial date of delegation" of 03/02/24. The form was signed by Staff 10, with a signature date of 04/17/24. The "RN signature" line was blank; - Another "Initial Evaluation and Competency for Delegation of Nursing Tasks" form for Staff 10 had an "initial date of delegation" of 04/17/24; - The form was signed by Staff 10, with a signature date of 04/17/24. The "RN signature" line was blank; - Staff 10's delegation for Resident 6 was signed and dated by Staff 10 on 04/17/24. There was no RN signature; - Staff 10's delegation for Resident 2 was dated 03/02/24 and signed by Staff 10 and Staff 2 on 04/17/24 with a note above the RN signature "late entry for 03/02/24;" and - Staff 10's Blood Glucose Testing and Use of Insulin Pens competency checklists were signed and dated by Staff 10 and Staff 2 on 04/17/24, with notes above the RN signature "late entry for 03/02/24." During an interview on 05/23/24, Staff 2 stated it was "correct" that s/he did not sign on the date of delegations, and further stated "if it's not signed it's not done." MARs for Residents 2 and 6, dated 03/01/24 through 04/30/24, indicated Staff 10 had administered insulin approximately 26 times between 03/01/24 and 04/17/24.   It was confirmed a med tech was not delegated prior to administering insulin to residents. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. Verbal plan of correction: Delegations have been completed, any staff member who has not completed competencies and delegation was not administering insulin. Delegations will be reviewed monthly by RN and Executive Director.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to carry out physician orders as prescribed for 1 of 1 sampled resident (# 4). Resident 4 did not receive ordered pain medication resulting in unreasonable pain. Findings include, but are not limited to: During an interview on 05/28/24, Resident 4 stated s/he had missed two doses of "hydro something last Saturday" and had been in "excruciating" pain because of the missed medication. During an interview on 05/23/24, Staff 2 (Health and Wellness Director) stated when med techs received faxes from the pharmacy they initialed the order to indicate the "first check" had been performed. S/he further stated the medication is able to be administered after the first check. A physician order for Resident 4, dated 05/18/24, indicated s/he was to take 2mg of Hydromorphone (pain medication) three times a day. The order was not initialed by the facility until 05/19/24. Resident 4's MAR, dated 05/01/24 through 05/28/24, indicated a start date for the Hydromorphone of 03/20/24 and confirmed the resident had not been administered two doses of Hydromorphone on 05/18/24 at 6:00 am and 3:00 pm. Notes indicated "pharmacy action required." During an interview on 05/24/24, Staff 11 (Med Tech) stated one or two residents "slip through" with regards to medication refills. During an interview on 05/29/24, Staff 1 (Executive Director) stated the facility "typically" didn't reorder medication before the resident had one day left, but had to have Resident 4's Hydromorphone "stat-delivered." S/he further stated the facility "possibly didn't reorder timely." It was confirmed the facility failed to carry out a physician order as prescribed for a resident. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. Verbal plan of correction: Facility to establish "Medication Mondays" to ensure medications are available for the week, and post a chart indicating specific pharmacy refill times. Re-educating staff on three-step process to ensure at least a double check done in the first 24 hours. Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to carry out physician orders as prescribed for 1 of 1 sampled resident (# 7). Findings include, but are not limited to: During an interview on 05/28/24, Resident 7 stated s/he had been "out of the water pill" and "went for a long time before [the facility] realized." A physician order for Resident 7, dated 11/20/24, indicated s/he was to take 40mg of Furosemide (diuretic) beginning on 11/20/24. Initials indicated the facility had reviewed the order on 11/22/24. Resident 7's MAR, dated 11/01/23 through 11/30/23, indicated Resident 7's Furosemide had a start date of 11/23/23. During an interview on 05/29/24, Staff 17 (Health and Wellness Coordinator) confirmed the order had not been processed until 11/22/23. It was determined the facility failed to carry out physician orders as prescribed for Resident 7. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. Verbal plan of correction: Facility to establish "Medication Mondays" to ensure medications are available for the week, and had placed postings in the medication room indicating specific pharmacy refill times. Re-educating staff on three-step process to ensure at least a double check done in the first 24 hours. Based on interview and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to reorder medications timely for 2 of 2 sampled residents (#s 5 and 13). Findings include, but are not limited to: During an interview on 05/28/24, Staff 1 (Executive Director) stated the facility had run out of pain medication for Residents 5 and 13. During an interview on 05/24/24, Staff 11 (Med Tech) stated one or two residents "slip through" with regards to medication refills. Resident 5's MAR, dated 07/01/23 through 07/31/23, indicated s/he had not received Tramadol (pain medication) from 07/24/23 through 07/28/23. Notes indicated "waiting on pharmacy action." An incident report, dated 06/28/23, indicated Resident 13 had been without his/her Pregabalin (pain medication) for five days. It was determined the facility failed to reorder medications timely for residents. The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. Verbal plan of correction: Facility to establish "Medication Mondays" to ensure medications are ordered and available for the week, and post a sheet indicating pharmacy refill times in the medication room. Facility is re-educating staff on three-step process to ensure at least a double check on medications done in the first 24 hours. Based on interview and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility administered the wrong dosage of medications to 2 of 2 sampled residents (#s 8 and 10). Findings include, but are not limited to: During an interview on 05/28/24, Staff 1 (Executive Director) stated Residents 8 and 10 had received incorrect doses of medication in August 2023. An incident report, dated 08/16/23, indicated Resident 8 had received Amlodipine (heart medication) twice a day instead of once a day as prescribed for an indeterminate amount of time. An incident report, dated 08/16/23, indicated Resident 10 had received unknown dosages of Citalopram (antidepressant) for an indeterminate amount of time. It was determined the facility administered the incorrect dosage of medications to residents. The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. Verbal plan of correction: Facility to establish "Medication Mondays" to ensure medications are ordered and available for the week, and post a sheet indicating pharmacy refill times in the medication room. Facility is re-educating staff on three-step process to ensure at least a double check on medications done in the first 24 hours.

Based on observation, interview, and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents. This placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to: The facility's posted staffing plan indicated: - One med tech (MT) and two-and-a-half caregivers (CG) on day shift; - One MT and one-and-a-half CGs on swing shift; and - One MT and one CG on night shift. The facility's census was 52 residents, 20 were identified by staff as requiring bathing assistance, seven required transfer assistance, seven required "frequent checks," and eight required toileting assistance. On 05/23/24, one CG and one MT were observed to be working on day shift and swing shift. During an interview on 05/23/24, Staff 12 (MT) stated "staffing issues suck ... there should be at least three caregivers on day shift ... a lot of stuff gets missed [such as laundry an garbage]." S/he further stated when there are enough staff, showers get done but if not, they get missed. In an interview on 05/23/24, Resident 6 stated  late at night sometimes there's nobody here because they left to get food. " During an interview on 05/23/24, Staff 14 stated the following: - On 05/08/24 there was one CG on day and swing shift; - On 05/09/24 there was one CG on day shift; - On 05/10/24 there was one CG on day and swing shift; - On the night shift of 05/21/24 to 05/22/24, there were no CGs on night shift; and - On 05/22/24 there was one CG on day shift. S/he further stated family members had been observed by staff providing incontinence care for residents who had not been checked on. During an interview on 05/24/24, Staff 13 (CG) stated when caregivers were working by themselves, showers were "postponed." In an interview on 05/24/24, Staff 9 (Dining Services Coordinator) stated the facility had one CG on "more times than I'd like" and that s/he tried to ask care staff if they "have had eyes on residents" multiple times a day. On 05/24/24 at approximately 9:43 am, LCU requested an immediate plan of correction to address the above issues. LCU received a plan at 11:00 am. It was not accepted. Another plan of correction was received at 12:17 pm. The plan was accepted 12:25 pm on 05/24/24. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

The facility's Acuity-Based Staffing Tool was not investigated during the site visit as the facility was already on condition imposed on 12/27/22. ALFCD22-01185.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to evaluate competencies of direct care staff prior to performing duties. Findings include, but are not limited to: During an interview on 05/28/24, Staff 8 (Med Tech) stated s/he had one day of training and then was "on the floor."  S/he further stated no one had observed him/her perform a medication pass. On 05/28/24, LCU asked the facility for competency evaluations for direct care staff. During an interview on 05/28/24, Staff 1 (Executive Director) stated s/he could not find competency evaluations for any direct care staff except for Staff 1, 8, 12 (Med Tech), 16 (Caregiver), and 18 (Caregiver). The facility's failure to evaluate competencies for direct care staff placed residents health and safety at risk. On 05/28/24 at approximately 2:40 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 3:15 pm and was not accepted by the Department. A revised plan of correction was received and accepted at approximately 3:50 pm. The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to include residents in fire drills and had not conduct fire drills every other month. Findings include, but are not limited to: During an interview on 05/23/24, Staff 14 stated residents were not included in fire drills. During an interview on 05/28/24, Resident 4 stated the last time s/he had remembered residents being included in fire drills was 2020. A review of the facility's fire drill "Logbook Documentation" for 2024 indicated the following: - Fire drills had been conducted on 01/09/24, 01/11/24, 01/12/24, 04/06/24, and 04/09/24; - For the fire drill on 01/11/24, the resident head count was "na";  and - For the fire drill on 01/12/24, the resident head count was  "SEE [notes]." There were no additional notes. It was determined the facility failed to include residents in fire drills and conduct fire drills every other month. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24. Verbal plan of correction: Fire drills will be performed monthly going forward. Maintenance Director and ED will be responsible to ensure completion of fire drills. Residents will be included depending on type of fire drill.

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 02/01/22.  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 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

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 02/14/2023.  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 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

Based on interview and record review, it was determined the facility failed to implement a service planning team. Findings include: In an interview with Witness #1 (W1) on 11/01/2022 it was stated: The facility does not notify me of care conferences. I have heard from family members they are also not aware when care conferences are being held. On 11/01/2022 Compliance Specialist (CS) reviewed Resident #1-Resident #3's progress notes for the months of September and October. R1-R3's progress notes state care plans were updated; however, no mention of care conferences being held and who was invited/in attendance. On 11/01/2022 these findings were shared with S1 and S2 who were in agreement. Facility Plan of Correction: S1 states care conferences will be held, all appropriate parties will be invited and documentation will be completed in the form of a progress note.

Based on interview, observation, and record review, it was confirmed the facility failed to ensure the implementation of services.  Findings include: Compliance Specialist (CS) reviewed Resident #2 (R2) Service Plan which states laundry is to be done two times per week.   CS was not able to observe any caregiving task sheets while onsite on 11/01/2022 as they were not filled out. CS looked in the 24 hour binder as far back as September 1st, 2022. During an interview with R2, s/he stated that their laundry is done only one time per week. S/he stated that s/he has to ask staff to wash clothes for them or it doesn ' t get done. The above findings were discussed with Staff #1 and Staff #2 who were in agreement. Facility Plan of Correction: S1 and S2 state retraining will occur for caregivers to ask residents if their laundry is ready for pickup. S2 also stated the facility will look into moving this task to noc shift.

Based on interview, observation and record review, it has been confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of residents. Findings include but are not limited to: During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) reviewed call light logs for 10/02/2022 for all facility residents, which revealed multiple instances of call light response times exceeding 15 minutes. CS interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2 and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated: -We are looking into contracting with agencies again. -There is often only one caregiver for the entire facility. -Staffing is at a crisis level. -If there were a fire, I would be concerned evacuating with this level of staff members. -Medications are late due to staffing issues, sometimes showers are missed. -Laundry is not always done. I have to remind staff to help or it doesn ' t get done. -Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late. CS reviewed Staff Schedules for September and October 2022, which revealed the facility is not staffing to their posted staffing plan. CS reviewed the facilities Acuity Based Staffing Tool (ABST); which revealed the facility is not staffing to the levels required per the facilities ABST. CS observed 2 caregivers and 1 med tech to be present on shift. The above information was shared with S1 and S2 on 11/01/2022. Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job fairs. S2 states utilizing an agency is the next step and will start that process ASAP.

Based on interview and record review, it has been confirmed that the facility failed to adopt and implement an Acuity Based Staffing Tool (ABST) as required by rule. Findings include but are not limited to the following: During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) reviewed Resident #1-Resident #3 ' s service plans against the facilities ABST. CS interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2 and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated: -We are looking into contracting with agencies again. -There is often only one caregiver for the entire facility -Staffing is at a crisis level. -Medications are late due to staffing issues, sometimes showers are missed. -Laundry is not always done. I have to remind staff to help or it doesn ' t get done. -Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late. CS reviewed the facilities staffing schedules for August, September and October, which revealed the facility is not scheduling staffing levels based on the plan created by the facilities ABST. The above was shared with S1 and S2. Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job fairs. S2 states utilizing an agency is the next step and will start that process ASAP.

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 11/01/2022.  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 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

Based on interview and record review, it has been confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of residents. Findings include but are not limited to: During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2, and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated: -We are looking into contracting with agencies again. -There is often only one caregiver for the entire facility. -Staffing is at a crisis level. -If there were a fire, I would be concerned evacuating with this level of staff members. -Medications are late due to staffing issues, sometimes showers are missed. -Laundry is not always done. I have to remind staff to help or it doesn ' t get done. -Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late. CS reviewed Staff Schedules for September and October 2022, which revealed the facility is not staffing to their posted staffing plan. CS reviewed the facilities Acuity Based Staffing Tool (ABST); which revealed the facility is not staffing to the levels required per the facilities ABST. CS reviewed call light logs for 10/02/2022 for all facility residents, which revealed multiple instances of call light response times exceeding 15 minutes. The above information was shared with S1 and S2 on 11/01/2022. Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job fairs. S2 states utilizing an agency is the next step and will start that process ASAP.

Based on interview and record review, it has been confirmed that the facility failed to adopt and implement an Acuity Based Staffing Tool (ABST) as required by rule. Findings include but are not limited to the following: During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) reviewed Resident #1-Resident #3 ' s service plans dated 10/06/2022, 10/05/2022 and 08/31/2022 against the facilities ABST. CS interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2 and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated: -We are looking into contracting with agencies again. -There is often only one caregiver for the entire facility. -Staffing is at a crisis level. -Medications are late due to staffing issues, sometimes showers are missed. -Laundry is not always done. I have to remind staff to help or it doesn ' t get done. -Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late. CS reviewed the facilities staffing schedules for August, September and October, which revealed the facility is not scheduling staffing levels based on the plan created by the facilities ABST. The above was shared with S1 and S2. Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job faires. S2 states utilizing an agency is the next step and will start that process ASAP.

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 11/01/2022.  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 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

Based on interview and record review, it has been confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of residents. Findings include but are not limited to: During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2, and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated: -We are looking into contracting with agencies again. -There is often only one caregiver for the entire facility. -Staffing is at a crisis level. -If there were a fire, I would be concerned evacuating with this level of staff members. -Medications are late due to staffing issues, sometimes showers are missed. -Laundry is not always done. I have to remind staff to help or it doesn ' t get done. -Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late. CS reviewed Staff Schedules for September and October 2022, which revealed the facility is not staffing to their posted staffing plan. CS reviewed the facilities Acuity Based Staffing Tool (ABST); which revealed the facility is not staffing to the levels required per the facilities ABST. During an unannounced site visit on 11/01/2022, CS reviewed call light logs for 10/02/2022 for all facility residents, which revealed multiple instances of call light response times exceeding 15 minutes. The above information was shared with S1 and S2 on 11/01/2022. Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job fairs. S2 states utilizing an agency is the next step and will start that process ASAP.

Based on interview and record review, it has been confirmed that the facility failed to adopt and implement an Acuity Based Staffing Tool (ABST) as required by rule. Findings include but are not limited to the following: During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) reviewed Resident #1-Resident #3 ' s service plans dated 10/06/2022, 10/05/2022 and 08/31/2022 against the facilities ABST. CS interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2, and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated: -We are looking into contracting with agencies again. -There is often only one caregiver for the entire facility. -Staffing is at a crisis level. -Medications are late due to staffing issues, sometimes showers are missed. -Laundry is not always done. I have to remind staff to help or it doesn ' t get done. -Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late. CS reviewed the facilities staffing schedules for August, September and October, which revealed the facility is not scheduling staffing levels based on the plan created by the facilities ABST. The above was shared with S1 and S2. Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job fairs. S2 states utilizing an agency is the next step and will start that process ASAP.

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 11/01/2022.  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 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

Based on interview and record review, it has been confirmed that the facility failed to carry out medication orders as prescribed. Findings include: During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) interviewed Staff #1-Staff #2, Staff #4 and Resident #1 (S1, S2, S4 and R1). The following was stated: -There have been multiple times where my medications were late due to staffing. -Yesterday, 10/31/2022- my medications were really late. I was in pain. -We identified an issue of med techs not following up on ordering medications resulting in medications not being available. -We [the facility] recently held a training with med techs regarding medication ordering. -Often the med techs have to help the caregivers out which results in late medications. CS reviewed the Medication Administration Record (MAR) for R1 for September, October and November 2022; which revealed multiple instances where medications were not administered. The above information was shared with S1 and S2 on 11/01/2022. Facility Plan of Correction: A med tech training will be held within two weeks on the importance of refilling medications in a timely manner. Communication with med techs and the facility RN will also be emphasized as this was part of the issue with the medications not being filled.

Based on interview and record review, it has been confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of residents. Findings include but are not limited to: On 11/1/2022, Compliance Specialist (CS) interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2 and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated: -We are looking into contracting with agencies again. -There is often only one caregiver for the entire facility. -Staffing is at a crisis level. -If there were a fire, I would be concerned evacuating with this level of staff members. -Medications are late due to staffing issues, sometimes showers are missed. -Laundry is not always done. I have to remind staff to help or it doesn ' t get done. -Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late. CS reviewed Staff Schedules for September and October 2022, which revealed the facility is not staffing to their posted staffing plan. CS reviewed the facilities Acuity Based Staffing Tool (ABST); which revealed the facility is not staffing to the levels required per the facilities ABST. During an unannounced site visit on 11/01/2022, CS reviewed call light logs for 10/02/2022 for all facility residents, which revealed multiple instances of call light response times exceeding 15 minutes. The above information was shared with S1 and S2 on 11/01/2022. Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job fairs. S2 states utilizing an agency is the next step and will start that process ASAP.

Based on interview and record review, it has been confirmed that the facility failed to adopt and implement an Acuity Based Staffing Tool (ABST) as required by rule. Findings include but are not limited to the following: During an unannounced site visit on 11/01/2022, Compliance Specialist (CS) reviewed Resident #1-Resident #3 ' s service plans dated 10/06/2022, 10/05/2022 and 08/31/2022 against the facilities ABST. CS interviewed Staff #1, Staff #2, Staff #4, Resident #1, Resident #2 and Witness #1 (S1, S2, S4, R1, R2 and W1) separately. The following was stated: -We are looking into contracting with agencies again. -There is often only one caregiver for the entire facility -Staffing is at a crisis level. -Medications are late due to staffing issues, sometimes showers are missed. -Laundry is not always done. I have to remind staff to help or it doesn ' t get done. -Due to not being enough caregivers, Med Techs help with care needs and then medications are sometimes late. CS reviewed the facilities staffing schedules for August, September and October (2022), which revealed the facility is not scheduling staffing levels based on the plan created by the facilities ABST. The above was shared with S1 and S2. Facility Plan of Correction: S1 and S2 state they are continuing to hire caregivers. They have put out ads and are attending job fairs. S2 states utilizing an agency is the next step and will start that process ASAP.

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 11/01/2022.  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 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