Mckay Creek Assisted Living

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 a clean and sanitary kitchen in accordance with Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 06/02/25 and 06/03/25 showed the following areas needed cleaning or repair: * The beverage station had an open cabinet containing stored items such as water pitchers, plates and other supplies; * The edges of the open cabinet shelves had missing laminate, exposing the raw material underneath; * Throughout the kitchen, the walls and ceiling had grease buildup and accumulated dust; * The light fixture located directly above the food preparation area had accumulated dust; * Vents throughout the facility had accumulated dust; * The walls in the dish pit area had black substance and the caulking showed discoloration; * The dishwasher had unidentified matter on its surface and accumulated dust beneath; * Two drains were covered with black matter; * The wall near the three-compartment sink, where utensils were stored, had accumulated dust; * Cleaning chemical products were stored in the food preparation area; * Janitorial supplies including brooms, mops, chemical cleaning products and a floor mat were stored next to the ice machine; * The walk-in freezer had ice buildup on the floor and around the vent area; * Janitorial supplies including brooms and mops were stored in the dry food storage area; and * The inside of the three-compartment sink was stained with brown matter. A walk-through of the kitchen was conducted on 06/03/25 at 2:08 pm with Staff 1 (ED) and Staff 6 (Dietary Director) to review the areas needing cleaning and repair. The need to ensure the kitchen was kept clean and in good repair was discussed, and they acknowledged the findings.

Maintenance Director or designee will install cabinet doors and repair laminate on cabinet. Executive Director or designee will ensure quality of repair by 8/3/2025. Dishes will not be stored in area until repairs are complete. Dietary Manager or designee to update and implement new kitchen cleaning tasks for both the cook and dietary aide by 08/03/2025. Dietary Manager or designee to review task sheets three times a week. Executive Director or designee to ensure quality assurance twice a month. All cleaning checmicals and janitorial supplies will be stored in the chemical closet. Dietary Manager or designee to ensure procedure is followed once a week. Maintenance Director or designee to evalaute and clear ice build up twice monthly.

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

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were monitored until resolution for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2016 with diagnoses including diabetes. The resident's 04/11/25 service plan, 03/01/25 through 06/02/25 progress notes, Service Plan Addendums (SPAs) and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved in the following areas: * Falls; and * A medication change. Additional documentation was requested during the survey. During an interview with Staff 3 (Regional Health and Wellness Director) on 06/03/25 at 1:30 pm, she stated she reviewed the record and was unable to find documentation that the short-term changes of condition were monitored until resolved. The need to ensure short-term changes of condition had documentation of weekly progress until resolution was discussed with Staff 1 (ED) and Staff 2 (ED in Training) on 06/04/25. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 04/2022 with diagnoses including Multiple Sclerosis. The resident's 04/09/25 service plan, 02/22/25 through 06/02/25 progress notes, SPAs, and physician communications were reviewed. The resident experienced short-term changes without noted progress at least weekly until resolved in the following areas: * A fall on 02/22/25; and * Emergency room visit on 04/05/25 related to constipation and abdominal pain. Additional documentation was requested during the survey. On 06/03/25 at 4:30 pm, Staff 3 (Regional Health and Wellness Director) stated she reviewed the record and was unable to find documentation that the short-term changes of condition were monitored until resolved. The need to ensure short-term changes of condition had documentation of weekly progress was discussed with Staff 1 (ED) and Staff 2 (ED in Training) on 06/04/25. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 06/2019 with diagnoses including dementia, type 2 diabetes and chronic diastolic heart failure. The resident’s progress notes, dated 03/02/25 through 06/02/25, were reviewed and identified the following: * 03/02/25: An emergency visit and returned from hospital with changes to the resident’s medication regimen including the addition of prednisone; * 03/07/25: A fall and was sent to the emergency room; * 03/08/25: Returned from the emergency room with a prescribed antibiotic; * 03/13/25: Lethargic and unconscious and was sent to the emergency room. Returned to the facility with a prescription for anti-nausea medication; * 04/10/25: Returned from the hospital after a two-week stay; * 04/17/25: Was not feeling well and was sent to the emergency room for evaluation and returned to the facility; * 04/18/25: Redness on the inner thighs and pelvis area; * 04/21/25: A new medication: potassium; * 05/02/25: Emergency room visit due to diarrhea; * 05/09/25: A fall and was sent to the emergency room; * 05/14/25: Returned from the hospital with antibiotic prescribed for a urinary tract infection; * 05/15/25: Bruises on multiple areas of the arms; * 05/17/25: Hospital stay due to unconsciousness. The resident received blood transfusions at the hospital; and * 05/21/25: Returned to the facility with a medication, including antibiotics for a urinary tract infection. There was no documented evidence the facility monitored the resident’s short-term changes of condition until resolution. The need to ensure the resident’s changes of condition were monitored until resolved was discussed with Staff 1 (ED) and Staff 2 (ED in Training) on 06/04/25 at 9:35 am. They acknowledged the findings.

Resdients with short term changes will have service plan addendums with progress notes made three times a week. Progress notes will be monitored until resolution by the Health Services Director or designee twice a week. The Executive Director or designee and the Health Services Director or designee will provide resolution with notes to complete monitoring.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated no less than quarterly for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to: The facility’s ABST data was reviewed during the survey. The ABST data did not show documented evidence that ABST data was updated at least quarterly to correspond with the quarterly service plan updates for Residents 2 and 3. The need to ensure residents’ ABST was updated no less than quarterly was discussed with Staff 1 (ED) and Staff 2 (ED in training) on 06/04/25. They acknowledged the findings.

New procedure is to update the ABST within 48 hours of a change to a residents individual service plan. When service plans are updated during quarterly evaluations, resdient change requests, and during change of condition the Health Services Director or designee will update the ABST. The Executive Director or designee and Health Services Director or designee will review the ABST to ensure individual service plans correspond with ABST once a week for data accuracy.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

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, 11, 13 and 16) completed all required pre-service orientation training and pre-service dementia training prior to beginning their job responsibilities. Findings include, but are not limited to: Staff training records were reviewed on 06/03/25 and revealed the following: Training records for Staff 9 (CG), Staff 11 (Cook), Staff 13 (CG), and Staff 16 (CG), hired 05/21/25, 03/03/25, 05/21/25 and 05/01/25, respectively, identified the following: a. Staff 9 lacked documented evidence pre-service orientation and pre-service dementia training was completed prior to beginning job responsibilities in the areas of: * Abuse reporting requirements; * Infectious Disease Prevention; * Approved LGBTQIA2S+ course; * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understating, communicating and responding to behaviors, reducing use of antipsychotics; * Strategies for addressing social needs & engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing flood/fluids, preventing wandering, use of person-centered approach. b. Staff 11 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of: * Resident right and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency preparedness; * Approved Home and Community-Based Services (HCBS) course; and * Approved LGBTQIA2S+ course. c. Staff 16 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of: * Approved LGBTQIA2S+ course. d. Staff 9, 11, 13 and 16 lacked documented evidence of a written job description. The requirements for pre-service orientation and pre-dementia training for all employees prior to starting their job duties was discussed with Staff 1 (ED) and Staff 2 (ED in Training) on 06/03/25. They acknowledged the findings.

A revised New Hire Orientation Checklist will be implemented to clearly outline and track all required pre-service trainings and documentation prior to staff being placed on the schedule. The orientation process will include all pre-service and dementia training modules to be completed using our state-approved training platform, signing the new hires job description, and being checked off for completion prior to starting on the schedule. The Office Manager or designee may approve and sign off on scheduling a new employee once the completed checklist and training certificates are on file. A comprehensive audit of all staff files will be completed by 08/03/25 to ensure no additional staff are missing required pre-service documentation. Any staff missing the preservice documentation will be pulled from unsupervised duties and reassigned to complete all outstanding pre-service and dementia training modules. The Office Manager or designee will complete the audit on all staff files.

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

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

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 15, 17, 18 and 19) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 06/03/25. There was no documented evidence Staff 15 (CG), Staff 17 (CG/MA), Staff 18 (CG), and Staff 19 (CG/MA), hired 10/28/24, 09/27/24, 09/17/24 and 10/14/24, respectively, demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; * Conditions which require assessment, treatment, observation, and reporting; * General food safety, serving and sanitation; and * First aid/abdominal thrust. The need for staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (ED in Training) on 06/03/25. They acknowledged the findings.

All new hires will complete required training using our state approved training platform within 30 days of hire. Office Manager or designee will utilize a check of list for trainings. All competency checks will be completed under supervision by the Resident Care Coordinator or designee, with signed evaluations placed in each staff member’s training file.The Office manager or designee will ensure completion and file the competency. Competency evaluations include videos, hands-on demonstrations, and scenario-based assessments in all required care areas. New procedure will be implemented by 8/3/2025.

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

OAR 411-054-0090 (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 drills were conducted and documented every other month, and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: On 06/02/25, fire drill and fire/life safety training records for the previous six months were requested. Review of the documentation provided identified the following: * Two fire drills had been completed during the six-month time frame reviewed; and * Fire and life safety instruction was not consistently provided to staff on alternate months. The requirements regarding fire drills and fire/life safety instruction for staff was reviewed with Staff 1 (ED) on 06/03/25 at 3:50 pm. She acknowledged the findings.

A complete fire drill schedule will be created for the remainder of 2025, ensuring unannounced fire drills are held every other month, alternating between day, evening, and night shifts. Schedule to be completed by 8/3/2025. A fire and life safety training schedule will be implemented to ensure monthly education is provided on the months fire drills are not held. Schedule to be completed by 8/3/2025. Quarterly audits will be conducted by the Executive Director or designee to ensure fire drills are being completed as well as fire and life safety education is delivered consistently on alternating months from fire drills. Maintenance Director or designee and Executive Director or designee to conduct a fire drill every other month. The drill will be completed by the end of the month. Maintenance Director or designee to complete doccumentation and give a copy of the doccumentation to the Executive Director or designee. Maintenance Director or designee to complete fire and life safety inservice meetings on alternate months during all staff meetings. Maintenance Director or designee to provide completed copy of inservice doccumentation to the Executive Director or designee.

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 observation and interview, it was determined the facility failed to ensure the kitchen was clean, in good repair and food was stored appropriately in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility's kitchen was toured on 05/24/23 at 12:30 pm. a. An accumulation of food spills, splatters, loose food debris, grease, dirt, dust and garbage was observed on, in or underneath the following: * Flooring throughout the kitchen; * Walls throughout the kitchen; * Ceiling throughout the kitchen; * Venting units throughout the kitchen; * Lighting fixtures throughout the kitchen; * Floor drains; * Fire sprinkler heads; * Coffee pot; * Toaster; * Plastic and stainless steel utility carts; * Shelving unit between doors to the dining room; * Clean glassware holder in shelving unit between doors to the dining room; * Plate warmer; * Steam table, including knobs, legs and shelves; * Stove; * Griddle; * Spice rack; * Shelving unit below large stand-up mixer; * Cutting board holder; * Drawers in prep area; * Small Kitchen Aid mixer; * Containers for bulk dry goods; * Floor of walk-in freezer; * Baker's racks in walk-in refrigerator; * Exhaust fan grates in walk-in refrigerator; * Warewasher, including plumbing, mechanics and shelving; and * Venting hood above warewasher. b. The following kitchen items required repair: * Exit door to dining room had chipped paint; * Shelving unit between doors to the dining room had chipped paint with bare wood exposed; * Two lighting fixture covers near steam table had chipped corners; * Drywall in dry storage area was gouged; * Cooling unit of walk-in freezer had build-up of condensation; and * Warewasher was observed to operate multiple times and inconsistently registered the required temperature for sanitation. c. The following items required replacement: * Plastic spatulas near the three compartment sink had gouges; * Color-coded cutting boards had deep scores and a burn mark; and * Cutting board near steam table had deep scores. d. Observation of the facility's walk-in refrigerator and freezer revealed the following foods were not covered, dated, and/or labeled appropriately : * Hard boiled eggs; * Cottage cheese; * Prune juice; * Multiple single servings of canned peaches and applesauce; * Sliced lemon; * Salad greens; * Waffles; and * Hamburger patties. e. Garbage cans throughout the kitchen remained uncovered when not in use and two of those garbage cans did not have lids. Staff 1 (Executive Director) was unavailable for the kitchen walkthrough and requested the tour be completed with Staff 2 (Dietary Service Manager) and Staff 3 (Office Manager). The items that required cleaning, repair, replacement, dating, labeling and covering were observed and discussed with Staff 2 and Staff 3 on 05/24/23 at 2:06 pm. They acknowledged the findings.

C 240 SS=F  OAR 411-054-0030 (1)(a-e)  Resident Services Meals, Food Sanitation Rule 1  (a)All kitchen surfaces will be cleaned and maintained with a kitchen cleaning schedule. 2.  (a)Dining Services Manager will complete weekly sanitation audits and forward results to ED and RDO. 3.  (a)ED and DSM will complete the weekly walk-thru of the refrigerator and freezer to ensure cleanliness. 4.  (a)The cleaning schedule is in place for all components of the kitchen. 5.  (a-e)Regional support visits will include a kitchen audit.  This can be done by the Regional Director of Operations, Regional Support Nurse, operations Specialist, and the Regional Director of Dining Services. 6.  (b)All items listed as needing repair, are currently in process.  Drywall to be repaired and all painting to be completed.  Light fixture covers have been ordered and will be replaced.  Cooling unit condensation is being addressed, as are the water temps for the Warewasher. 7.  (c)Cutting board equipment and spatulas have been replaced, and cutting board near the steam table has been order.  New garbage containers with lids have been ordered. 8.  (a-e)All dining staff will receive additional training on all aspects of cleaning, hygiene, and cross-contamination. 9.  (a-e)ED, DSM, Maintenance Director, and CRD will monitor all aspects of kitchen cleaning and repair.

The findings of the kitchen inspection, conducted 05/24/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 05/24/23, conducted 08/07/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review it was confirmed that the facility failed to carry out mediation and treatment orders as prescribed.  Findings include: In an interview on 02/06/23, Staff #1 (S1) reported the following: *Resident #1 (R1) received an additional of a scheduled medication. Record review on 02/06/23 or R1's Medication Administration Records for August 2022 revealed R1 received an additional dosage of medication. Record review on 02/06/23 of facility's internal investigation and self report to Adult Productive Services on 08/11/22 support S1's statement. On 02/06/23, S1 acknowledged the findings. Plan of Correction: After an internal investigation of medication errors, the med tech at fault was provided education on proper medication administration procedures.

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 02/02/2023.  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 observation and interview, it was determined the facility failed to ensure residents received services in a manner that protected their privacy and dignity for 10 of 13 unsampled residents. Findings include, but are not limited to: 1. A group of seven unsampled residents were interviewed on 02/07/23 at 10:45 am. Six residents reported staff did not wait for the resident to respond prior to staff entering their room. 2. Observations of lunch tray delivery to unsampled residents' apartments were made on 02/07/23 at 12:42 pm. In four of six deliveries, the caregiver said "knock, knock," opened the resident's door and entered the room. The resident did not have the opportunity to invite the caregiver into his/her apartment. The need to ensure residents received services in a manner that protected privacy and dignity was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (RCC) on 02/08/23 at 1:24 pm. They acknowledged the findings.

C 200 1.  All staff will receive additional training in procedures for entering resident's apartments.  In addition new staff will receive appropriate training in procedures for entering a resident's apartment. 2.  Training with current staff has been completed at shift changes, 2/13, 2/14, and 2/15/2023.  This included all staff on the schedule.  Completed 2/15/2023.   A detailed training with all staff occured at the All Staff Meeting, 2/22/23 New staff will receive training at "new hire orientation".  All staff will receive ongoing reminders and training as necessary, and will be included at the monthly, all staff meeting. 3.  This area will be evaluated daily, with training and correction ongoing each day, if needed. 4.  Corrections are to be completed and monitered by RCC, HSD, and ED.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were monitored consistent with their evaluated needs and service plan for 1 of  3 sampled residents (#5) whose records were reviewed. Findings include, but are not limited to: Resident 5 was admitted to the facility in 2021 with diagnoses including arteriosclerotic heart disease. The 12/19/22 evaluation and 12/28/22 service plan were reviewed and noted the resident was a bed bound, hospice patient who was at risk for weight loss. The service plan noted the facility would monitor the resident's weight as tolerated. The facility obtained the resident's weights as follows: * 08/10/22 - 155 pounds; and * 09/10/22 - 156 pounds pounds. There was no documented evidence the facility made attempts to  monitor the resident's weight after 09/10/22. In interview on 02/07/23, Staff 3 (RN) reported the resident had been resistant to being transferred out of bed for several months and frequently refused to drink the nutritional supplements offered by the facility. She acknowledged the most recent service plan lacked any new interventions to address the risk for weight loss or instructions for monitoring the resident. The facility's failure to monitor the resident consistent with his/her evaluated needs and service plan was discussed with Staff 1 (ED) and Staff 3 on 02/08/23. They acknowledged the findings.

C 270 1.  Staff will measure the upper arm (bicep) circumference, bilaterally once every 2 weeks.  If a difference of more than 2 cm is found, staff will notify RN immediately. Staff will meet with 209 to learn food preferences.  DSM and a PCA will meet with 209 when filling out a daily menu, and go over the alternative choices on the menu, and will also find out what personal choices he may have that are not listed.   Staff will notify the kitchen daily of 209's meal and food choices. 2.  RN will implement the process of upper arm measurement when it is recognized that getting accurate weights is no longer an option.  Arm measurements will become a part of the service plan, and the task will be reviewed quarterly.  209's meal options and choices will be reviewed with him daily as part of his updated care plan. 3.  Arm circumference will be measured bi-weekly. Food choices service plan will be evaluated quarterly at minimum. 4.  RN will be responsible for changes to the service plan and will moniter.  ED will ensure that all is implemented and monitered as stated.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training was completed prior to providing services to residents, for 2 of 3 newly hired staff (#s 12 and 13). Findings include, but are not limited to: Facility's training records were reviewed with Staff 2 (Business Office Manager) on 02/08/23. Staff 12 (CG) hired on 07/18/22 and Staff 13 (CG) hired on 08/01/22, lacked documented evidence of completing the following: Pre-service dementia training including: * Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms; * 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; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and * Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia. The need for staff to complete the required pre-service dementia training before working with residents was reviewed with Staff 1 (ED) and Staff 3 (RN) on 02/08/23. They acknowledged the findings.

C 370 1.  All staff must complete and print certificate for required training in Pre-Service Dimentia and Pre-Service Infection prevention, prior to training on the floor.  Staff hired 8/1/22, was terminated on 2/13/23.  Staff hired on 7/18/22, will complete Pre-Service Dementia training by 3/01/23, and will not be scheduled until after the training is complete.   2.  OM and RN will work together to ensure as part of orientation, Pre-Service Dementia, and Pre-Service Infection Prevention is completed and certificates are printed and filed.  RN and RCC will not schedule an employee until all training is complete and corresponding certificates are filed. 3.  An evaluation will be conducted Quarterly and verification will be made that all training is current. 4.  In cooperation, OM, RCC, HSD, ED will complete and monitor.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 9, 12 and 13) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Training records were reviewed with Staff 2 (Business Office Manager) on 02/08/23 and identified the following: 1. Staff 9 (MT) hired on 11/15/22, lacked documentation of demonstrated competency in: * First Aid/Abdominal Thrust. 2. Staff 12 (CG) hired on 07/18/22, lacked documented evidence of demonstrated competency in : * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; and * Conditions that require assessment, treatment, observation and reporting. 3. Staff 13 (CG) hired on 08/21/22, lacked documentation of demonstrated competency in: * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; and * Conditions that require assessment, treatment, observation and reporting. The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (ED) and Staff 3 (RN) on 02/08/23. They acknowledged the findings.

C 372 1.  All staff must complete online CPR training and show competency in First Aid/Abdominal Thrust, prior to being scheduled.  This process will be completed on Day 1, or Day 2 of orentation.  Certificates must be printed prior to bing scheduled on the floor.  Certificates will be filed.   Staff 9 (MT), hired on 11/15/22,  demonstrated compentency for Abdominal Thrust, on 2/10/23.   Staff 12 (CG) hired on 7/18/22, has completed PCA and MT compentency and is documented.  (2/17/23).   Staff 13 (CG)  hired on 8/1/22 was seperated from employment on2/13/23.  This employeee had competed the competency training but in an oversight did not sign the training addendum. 2.  OM and RN will work together to ensure that as part of orientation, Pre-Service Dementia, and Pre-Service Infection Prevention, and all required training is completed and certificates are printed and filed.  RN and RCC will not schedule an employee until all training is complete and corresponding certificates are filed.    3.  Evaluation will be ongoing, with all staff and newly hired staff. 4.  ED will ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and recorded every other month, included required components on fire drill records, and provided fire and life safety instruction to staff on alternating months. Findings include, but are not limited to: On 02/07/23, fire drill and fire and life safety training records for the previous six months were reviewed, and the following was identified: * Fire drills were not consistently completed every other month during the six-month time frame reviewed; * Fire drill records lacked the following components: - Escape route used; - Problems encountered, comments relating to residents who resisted or failed to participate in the drills; - Number of occupants evacuated; and - Evidence alternate routes were used during fire drills. * Fire and life safety instruction was not consistently provided to staff on alternate months. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (ED), Staff 3 (RN), Staff 4 (RCC) and Staff 5 (Maintenance Director) on 02/08/23. The findings were acknowledged.

C 420 1.  Fire drills will be conducted monthly.  Documention using the CBC Fire and Life Safety Review form will be used.  The escape routes used,  problems that were encountered with the building or residents, number of occupants evacuated, and evidence of alternate routes used, correcting the rules violation, will be utilized and documented.  In addition to the CBC form,  documention will be entered into and filed using the TELS documention form.  Forms will be uploaded for computer filing by the Maintenance Director (MD).  Fire and Safety instruction will be provided monthly to staff in Monthly staff meetings with proper documentaion. 2.  All Drills will be properly and routinely conducted, as required, to ensure that all staff are properly receiving the necessary instruction and training. 3.  All Fire, Life and Safty will be evaluated on a monthly interval, at a minimum. 4.  MD will ensure all compliance with regulations are met, with the oversight and monitoring of the ED.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces, pathways and individual resident patios were maintained in good repair. Findings include, but are not limited to: Observations of the facility pathways and seating areas on 02/06/23 showed the following: * Multiple drop-offs of 2-4 inches were noted along pathway edges and resident personal patios at the back of the facility; * Two sections of the concrete pathway had lifted creating an uneven surface; and * One side of the concrete ramp located at the resident smoking area had dropped, which created a separation and lip approximately two inches in height. The need to ensure pathways around the facility, and around the residents' individual patios did not have potential tripping hazards was reviewed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 02/07/23. They acknowledged the findings.

C 610 1.   2-4" drop offs will be eliminated. 2.  Rock and soil will be delivered to the facility.  The areas needing attention will be filled with the rock and/or soil as needed to level the areas along the pathways and aound the resident patios.  Reseeding of grass will be completed as necessary. 3.  These areas will be monitered weekly through our First Impressions inspections by the MD. CRD, and ED. 4.  The MD will ensure that these areas are brought into compliance.  The corrections will be completed pending weather conditions, but will be completed by 04/09/23.  The ED will have final responsibility for completion. C610 1.  Uneven concrete pathways in two locations, and an  uneven ramp on the pathway, near the designated resident smoking area.  Thes areas will be made even with no ledges or dropoffs.  Excessive spaces between concrete slabs, results of shrinking and expanding since construction, will be eliminated. 2.  A cement mix will be used to eliminate the ledges and dropoffs.  The mix will also be used to fill in spaces between concrete slabs.  This mix is a professional cement mixture that will ensure an asthetic appearance and provide a long lasting solution and will eliminate the trip hazard. 3.  MD will repair the hazard. 4.  ED will monitor for future hazards, and ensure the corrections are completed.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to: Observations of the facility on 02/06/23 through 02/07/23 showed the following areas in need of cleaning or repair: * Multiple dining room chairs had stains of varying sizes on the fabric chair backs; * Arm chairs in the upstairs common area and in the main lobby had stains and splatters on the arms and seats of varying sizes as well as tears and exposed stuffing; * The cupboards, drawers and walls in the activity room had spills, stains and splatters. * The drink station in the dining room had large stains and spills inside the cupboards and drawers had splatters and debris on the inner surfaces; * The main facility laundry and the resident laundry room on the second floor had cracked linoleum that was separating around the drains and/or at the seams of the floor; * Scrapes, dings and deep gouges were noted on doors, door frames or nearby walls at Rooms 103, 104, 105, 108, 201, 202, 208, 210, 220, 222 and 225; * Significant black/red/white stains of varying sizes from a few inches to several feet were noted in the activity room, outside the elevator, in the area in front of the kitchen entrance, outside the dietary managers office, outside the housekeeping door, in front of exterior doors, in hallways throughout the first and second floor in common areas and in front of multiple resident rooms, inside the dining room and inside Rooms 105, 201, 206 and 220; * Room 216 had a hole in the wall behind the recliner, chipped/scraped bathroom door frame and a brown substance observed on the top and underside of the toilet seat; * Room 220 had a large section of door frame/molding missing on the interior portion, large dings/chips and missing pieces of plaster to the interior of the front door and along walls in the room; * Counter top surface lifting up and pulling away from the sink area in the whirlpool room and chips/dings/scrapes noted to the wood surface at the outside of the whirlpool tub; * Two wood benches in the resident outdoor area had cracked slats or detached metal supports; * Siding above the dining room over hang was crumpled, lifting and pulling away from the building; * A mesh box encasing multiple dryer vents on the outside of the building near the activity room entrance, was covered in a thick layer of lint on all sides; and * Multiple dirty cushions, rags, a broken table and old filters were observed on the patio and in the borders outside the activity room and dining room. The areas in need of cleaning and repair were shown to and discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 02/07/23. They acknowledged the findings.

C 613 1.  All items listed needing cleaning and repairs will be addressed by the MD, with utiolization of housekeepers and outside vendors to complete the task. 2.  *Dining room chairs with stains will be cleaned. *  Arm chairs with splatters will be cleaned.  Arm chairs with tears and exposed stuffing will be removed. *The cupboards, drawers, and walls in the activity room have been cleaned. 2/10/23 * TThe inside area of the drink station in the dining room has been cleaned, prepped, and repainted. * The cracks and seams in the main laundry room flooring will be repaired per industry standard. * Scrapes, dings and deep gouges in doors, in door frames, and nearby walls, will be repaired and painted for all listed locations. *Carpets will continue to be cleaned with the carpet extrator, with attempts to remove all stains.  Many stains are permanent and we plan torequest an extension as we move forward with replacing the carpet with a flooring upgrade to the facility.  A plan will be developed to replace the carpets in apts. 105,201,206,220.  This will be part of the requested extension. *MD will repair the hole in the wall in apt. 216, as well as the damaged door frame.  The toilet has been cleaned. 2/9/23 *Apt. 220 will be an ongoing daily repair project for repairing all damages caused by the residents' use of a motorized chair in the apt.  Damage occurs daily, and will be repaired as they occur. *The countertop in the whirlpool room will be repaired and all chips/dings/scrapes in the wood around the whirlpool will be repaired. *The two wood benches in the courtyard area have been removed.  2/8/23 *Siding above the dining room doors will be repaired.  Bids have been taken and will be repaired weather permitting, asap. but an extension will be requested to ensur completion. *The mesh dryer vent box, above the activities room window has been cleaned and will continue to be monitored and cleaned per the TELs maintenance schedule or as needed. *All dirty cushions, rags, the broken table, h-vac filters, in both areas around the patio have been removed.  2/17/23 3. All areas needing correction will be monitored on a daily basis utilizing the First Impressions program of Prestige.  First Impressions walk throughs occur daily with the CRD, MD, and ED.  The TEL's system for maintemance of the facility , will also be utilized, and the time schedules pre different mantenance tasks will be used and followed.  These times vary based onthe task, (daily, weekly, bi-weekly, monthly). 4.  The CRD, MD, and ED will all be responsible for ensuring that all corrections are made and maintained. Note:  The ED will be speaking with Prestigecare management about the necessary upgrade for flooring, furniture, and general refurbishment of the facility.  Thus, an extension will be requested for the mentioned items that would be corrected by a facility refurbish and upgrade. C 999 C 260  This technical item has been corrected.  The resident's care plan was updated to correctly indentify the proper times for using a gate belt with this resident.  The wording in the care plan was changed and is now reflective of the proper procedure for the resident. 2/10/23 C280  An assessment was made to determing the ability of resident 205's ability to safely operate her motorized chair.  A note was sent to her doctor and her family, requesting that a different style of motorized chair be provided.  The RN and ED will be following through with thes request with concerns for the resident's safety and the safety of others. C 295  A strict reminder was given to all staff at the all staff meeting on 3/23/23, concerning the proper wearing of face coverings.  Staff are being verbally reminded at shift change, and throughout their shift to keep their mask up and properly in place.  All administrative staff are reminded daily in Stand up meeting, and are expected to set an example for all staff and residents, and are to remind staff on an ongoing basis for proper mask wearing.

The findings of the re-licensure survey, conducted  02/06/23  through  02/08/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 02/08/23, conducted 08/07/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 07/07/22, the main kitchen was observed to need cleaning and repair in the following areas: a. The dish washing station was noted with: * The dish machine, electrical box, walls, floor, shelving, ceiling grate, and pipes under the dish machine and sinks had an accumulation of black matter, debris and food matter; * Dish racks were stored directly on the floor; and * The dish machine utilized a low temperature rinse cycle with chlorine to sanitize dishes. There were no sanitizer strips available to ensure the correct chemical levels. The surveyor toured the dish washing station with Staff 1 (Executive Director). She acknowledged the need for cleaning and arranged for sanitizer strips to be acquired. b. The following was observed in the main areas of the kitchen: * Floors throughout the kitchen had thick black matter build-up and food debris in corners, under equipment, and around edges/inside of floor drains; * Spills, smears, splatters, and debris were noted on: -Carts, -Drawers interior and exterior; -Cupboards interior and exterior; -Walls; -Freezer and refrigerator doors, handles, and venting fans; -Ceilings throughout the kitchen; -Counters; -Shelves; -Stove, grill,and range; -Steam table; -Plate warmer; -Food bins; -Stand mixers; -Microwave interior; and -Underneath appliances; * Food was stored on the floor of the refrigerator and the freezer; * Multiple food items in the refrigerator had dates in excess of seven days; * Cupboards, shelves, and counter tops were damaged creating un-cleanable surfaces; * The vents and ceiling grates had a layer of dust and dirt; * A large industrial fan had a layer of dust on the cage; * Garbage cans in food prep and storage areas lacked lids; * Dented can of food noted in they dry storage area; and * Stove hood vents had a layer of grease and dust; Caregiving staff assisting with meal service and delivery on 07/07/22 were not using aprons and dietary staff were observed during meal preparation on 07/07/22 to not change gloves or practice hand hygiene between tasks. Infection control practices and the areas in the kitchen needing cleaning and repair were observed and reviewed with Staff 1 on 07/07/22. She acknowledged the findings.

The kitchen is scheduled to be deep cleaned. The Hood has already been cleaned and is now set on a regular schedule. Ordered stickers to ensure of proper dates and making sure all food is stored and removed properly. PSI has been here to fix the hood and is not cleared. Maintenance director and DSM have come up with an ordering system to ensure all chemicals and testing supplies are in the facility. ED went over with maintenance director on the areas that needed cleaned and repaired. All vents are scheduled to be taken down after kitchen hours and cleaned. ED and DSM have met with all staff on proper use of aprons in the kitchen. DSM, ED meet weekly to ensure things are getting repaired and cleaned properly. DSM is to report when repairs are needed promptly via Electronic Maintenance systems. DSM is creating charts for all staff for follow.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: On 10/04/22, the dish machine was observed in operation. The dish machine utilized a low temperature rinse cycle with chlorine to sanitize dishes. The sanitizer was tested with the available strips and the chemical level was noted out of the required range. There was no documented evidence of monitoring of the sanitizing solution or accurate monitoring of the dish machines temperature. The surveyor reviewed the need to ensure correct sanitizer solution and temperature monitoring with Staff 1 (Executive Director) and Staff 2 (Dietary Manager). They acknowledged the findings. The following was observed in the main areas of the kitchen: * Floors throughout the kitchen had black matter build-up and food debris in corners, under equipment, on cove base, and around edges/inside of floor drains; * Spills, smears, splatters, and debris were noted on: -Carts, -Walls; -Back of grill and side of range; -Food bins; -Stand mixer; -Microwave interior; and -Underneath appliances; * Food was stored on the floor of the refrigerator and the freezer; and * Dented can of food noted in they dry storage area. The areas in the kitchen needing cleaning and repair were observed and reviewed with Staff 1 and Staff 2 on 10/04/22. They acknowledged the findings.

Tag C240 Will be corrected by cleaning all areas of the kitchen including but not limited to the floor edges and molding, the back walls, and vents. All Kitchen Equipment is on a schedule to be cleaned whether it' s used or not. Vents are on a new cleaning schedule and to be followed up by DSM. DSM has implented new temp and chemical logs and has full access to print all logs when needed and is to keep all records up to date. All Dented cans have been removed and will never be placed in the working area. DSM ED meet weekly to go over all forms to make sure they are in compliance.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

POC  C 455 submitting POC today and will ensure all POC's in the future are timely.

The findings of the kitchen inspection, conducted 07/07/22, 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 revisit to the kitchen inspection of 07/07/22, conducted 10/04/22, 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 second revisit to the kitchen inspection of 07/07/22, conducted 12/13/22, 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.