Village at Valley View.

“Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C290. Refer to C290”

“Based on interview and record review, it was determined the facility failed to ensure staff were informed of new interventions recommended by outside providers and the service plan was adjusted, if necessary, for 1 of 1 sampled resident (# 1) who received home health services. Findings include, but are not limited to: Resident 2 moved into the MCC in 07/2025 with diagnoses including mild dementia and congestive heart failure. During the acuity interview on 04/06/26 at 1:45 pm, Resident 2 was identified to have a pressure ulcer and a foley catheter and as receiving home health services. The resident's clinical record, from 01/06/26 through 04/06/26, was reviewed, and staff were interviewed. The following was identified: Resident 2 was receiving home health services due to having a pressure wound and foley catheter. The following transcriptions of the outside provider’s recommendations were identified in the residents’ progress notes: * 01/08/26: New wound care orders, drink Ensure three to four times daily, and offload at all times; * 01/20/26 and 01/30/26: Encourage the resident to lay in bed to relieve pressure to wounds; * 01/29/26: Absolutely no shearing forces or sliding of any sort, lift and transfer resident; * 02/06/26: Encourage the resident to elevate lower extremities when able; * 02/18/26: Monitor temperature to ensure it comes down, keep wound covered, when left open in brief with incontinence, it increases risk of infection; and *02/20/26: Keep dressing intact and not get wet, provide bed baths to maintain the dressing dry. Documentation revealed staff reviewed the above recommendations; however, there was no documented evidence direct care staff were informed of the recommendations or that the service plan was adjusted. In an interview on 04/08/26 at 9:08 am, Staff 3 (LPN) confirmed the interventions recommended by the outside provider were not communicated to staff, and the service plan was not updated. The need to ensure staff were informed of new interventions and the service plan was adjusted as necessary after receiving outside provider services were provided recommendations was discussed with Staff 1 (Administrator) on 04/09/26 at 1:45 pm. He acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and recorded every other month at different times of the day, evening, and night shifts, and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: On 04/08/26 at 10:00 am, fire drill records from 10/2025 through 03/2026 were reviewed with Staff 5 (Facilities Services Director). He confirmed the facility had not conducted a fire drill during evening or night shifts. On 04/08/26 at 1:00 pm, Staff 6 (Business Office Manager) confirmed there was no documentation of fire and life safety instruction to staff on alternate months of fire drills. The need to ensure fire drills were conducted and recorded every other month at different times of the day, evening, and night shifts, and fire and life safety instruction was provided to staff on alternate months was reviewed with Staff 1 (Administrator), Staff 2 (Regional RN), Staff 3 (LPN), Staff 4 (Resident Care Manager), Staff 5, Staff 6, and Staff 9 (Lead MT) on 04/08/26 at 3:15 pm. They acknowledged the findings. 1.Fire Drills are held every other month and Fire Safety Training at All Staff meeting on the alternate months. Alternating shifts implemented for fire drills. Fire Safety done 3/15/2026. Fire Drill Scheduled for NOC shift on 5/14/2026. Updated forms in use. Designated safety point is the front parking lot. or the side parking lot depending on fire location. Orientation checklist has fire safety and fire locations performed by the Maintenance director for all new staff. 2. The system is corrected to follow the above plan for fire drills and twice yearly emergency drills. 3. At least monthly review of Fire and Life safety Drills. 4. Maintenance director is responisble to ensure fire and emergency drills are completed on alternative months. Administrator to assure oversight.”

“Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C420. Refer to C420”

“Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:”

“Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to C240. Myself, Josh Hamik the Executive Director and Tony the Executive Chef will be monitoring these areas weekly, monthly and as needed to make sure we stay on top of these items listed below. Tony has created checklists, updated checklists to include daily, weekly and monhtly duties for his staff. a. Janitor sink and wall has been scrubbed and cleaned and will be maintained daily after usage b. All floor drains have been cleaned and will be added to the weekly cleaning list c. All appliances will be kept covered after being cleaned and finished being used d. Microwave has been cleaned and is added to the dialy cleaning list e. Can opener was removed from table and thoroughly cleaned and reattached. The actual opener piece is cleaned daily and added to the cleaning list f. Dry storage shelves have all been wiped down and added to daily cleaning list g. Both mixers have been cleaned completely and added to the daily cleaning list h. Flour and Sugar bins were both emptied and cleaned inside and out. Both added to the weekly cleaning list i. All shelves were wiped down, both in the walk in and in the kitchen. Those have been added to the daily cleaning list. j. All trash cans were cleaned inside and out and added to the weekly cleaning list k. Used a pressure washer to clean the walls in the dish area and are on the daily cleaning list to be attended to daily l. All light fixtures, sprinkler heads and the ceiling were cleaned and will be added to the weekly cleaning list m. All vents in the ceiling were removed and cleaned and will be added to the weekly cleaning list n. Food carts have been cleaned and added to the daily cleaning list o. Pressure washer was used to clean the pipes under the hand washing sink and will be added to the weekly cleaning list p. Electrical cords that are over the prep table were wiped down and sanitized and will be added to the weekly cleaning list q. The dry storage shelves are planned to be repainted to meet compliance r. Carestaff have been retrained to ensure that all containers in the cottages are to remain closed when not in use and date after opening s. The areas under the sinks in all cottages are currently under repair and will be finished before date of compliance t. Kitchen staff have been retrained to date all products that have been opened and cleaned u. Kitchen staff have been retrained to keep raw meat products on or in a designated container on the bottom shelf of the meat rack v. All cutting boards have been replaced with new ones w. Hair nets and beard nets have been purchased and will be worn daily These corrective actions will be monitored by the Executive Chef OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure lever-type door handles were provided on all doors used by residents. Findings include, but are not limited to: The environment was toured on 02/11/25 at 1:45 pm. Multiple unsampled resident rooms, in the Daisy and Lily cottages, were observed to have a sliding barn door to access the bathroom located within the room. The doors did not have a lever-type handle. During a review of the environment on 02/12/25 at 4:15 pm, Staff 1 (Administrator) and Staff 7 (Facility Services Director) acknowledged that not all doors used by residents had a lever-type door handle. The need to ensure lever-type door handles were provided on all doors used by residents was reviewed with Staff 1 and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 252, C 260, C 262, C 270, C 280, C 282, C 290, C 300, C 302, C 303, C 305, C 310, C 330, and C340. See C252, C260, C262, C270, C280, C282, C290, C300, C302, C303, C305, C310, C330, C340”

“Based on observation, interview, and record review, it was determined the licensee failed to provide administrative oversight to ensure the quality of care and services rendered in the facility. Findings include, but are not limited to: During the re-licensure survey, conducted 02/10/25 through 02/14/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations. Refer to deficiencies in the report.”

“Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to: During the survey, conducted 02/10/25 through 02/14/25, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective. In an interview on 02/12/25 at 3:00 pm, Staff 1 (Administrator) and Staff 2 (Executive Nurse) confirmed that ongoing quality improvement programs were not being conducted. The need to ensure the facility developed and conducted ongoing quality improvement programs was reviewed with Staff 1 and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings. Refer to the deficiencies in the report.”

“Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required wound care. Findings include, but are not limited to: Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. The resident’s clinical chart including the service plan available to caregiving staff dated 04/30/24, Interim Service Plans (ISPs), dated 11/01/24 through 02/14/25, Observation notes, dated 11/10/24 through 02/14/25, and signed physician orders were reviewed. Observations of the resident and interviews with the staff were completed. On 02/11/25 at 10:00 am, an observation of the resident during ADL care was completed. Resident 3 was observed to have an intact blood blister on his/her left calf that was unbandaged. On 02/11/25 at 11:15 am, Staff 3 (Wellness Director/LPN) confirmed the facility had no documentation of the presence of the blood blister, including instructions to staff for monitoring or care of the blood blister. A telehealth assessment of the intact blood blister was completed by Staff 2 (Executive Nurse) on 02/11/25 at 3:15 pm. Staff were instructed to monitor the blood blister. On 02/12/25 at 4:15 pm, Staff 2 documented in Observation notes that the resident’s blister remained intact, and she covered the blister with loose fitting gauze and gauze wrap. There was no documented evidence provided to survey of instructions to staff for care or monitoring of the newly wrapped blister. On 02/12/25 at 12:35 pm, Staff 2 stated the intact blood blister alone did not constitute a significant change of condition; however, if it were to open then it would be followed as a wound by the RN. On 02/13/25 at 10:11 am, Resident 3 was visualized with a soiled bandage on his/her left lower leg. This surveyor asked Staff 16 (MT) what happened to the resident, and she stated she needed to change the bandage. There was no documented evidence of instructions to the MT on how to perform a dressing change for the skin injury. The MT unwrapped the bandage from the resident’s leg with skin and/or residue pulled from the open area as the bandage was removed. This constituted a change in the skin injury from a blister to an open wound which required a nursing assessment. There was no audible or physical indication the resident was in pain during the removal of the bandage. The MT continued to treat the newly opened area by spraying the wound with wound cleanser. She prepared to dress the wound with a bandage, but the surveyor stopped the process and requested a nurse be called to assess the open area first. At 10:36 am, Staff 2 entered the resident’s room and told Staff 16 that MTs could only perform First Aid and not wound care without directions from a nurse. Staff 2 proceeded to complete a skin assessment, and she dressed the resident’s wound. The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents when an unlicensed staff member exercised her own independent judgment in how to care for an open wound without instructions from a licensed professional. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required wound care. Findings include, but are not limited to: Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. The resident’s clinical chart including the service plan available to caregiving staff dated 04/30/24, Interim Service Plans (ISPs), dated 11/01/24 through 02/14/25, Observation notes, dated 11/10/24 through 02/14/25, and signed physician orders were reviewed. Observations of the resident and interviews with the staff were completed. On 02/11/25 at 10:00 am, an observation of the resident during ADL care was completed. Resident 3 was observed to have an intact blood blister on his/her left calf that was unbandaged. On 02/11/25 at 11:15 am, Staff 3 (Wellness Director/LPN) confirmed the facility had no documentation of the presence of the blood blister, including instructions to staff for monitoring or care of the blood blister. A telehealth assessment of the intact blood blister was completed by Staff 2 (Executive Nurse) on 02/11/25 at 3:15 pm. Staff were instructed to monitor the blood blister. On 02/12/25 at 4:15 pm, Staff 2 documented in Observation notes that the resident’s blister remained intact, and she covered the blister with loose fitting gauze and gauze wrap. There was no documented evidence provided to survey of instructions to staff for care or monitoring of the newly wrapped blister. On 02/12/25 at 12:35 pm, Staff 2 stated the intact blood blister alone did not constitute a significant change of condition; however, if it were to open then it would be followed as a wound by the RN. On 02/13/25 at 10:11 am, Resident 3 was visualized with a soiled bandage on his/her left lower leg. This surveyor asked Staff 16 (MT) what happened to the resident, and she stated she needed to change the bandage. There was no documented evidence of instructions to the MT on how to perform a dressing change for the skin injury. The MT unwrapped the bandage from the resident’s leg with skin and/or residue pulled from the open area as the bandage was removed. This constituted a change in the skin injury from a blister to an open wound which required a nursing assessment. There was no audible or physical indication the resident was in pain during the removal of the bandage. The MT continued to treat the newly opened area by spraying the wound with wound cleanser. She prepared to dress the wound with a bandage, but the surveyor stopped the process and requested a nurse be called to assess the open area first. At 10:36 am, Staff 2 entered the resident’s room and told Staff 16 that MTs could only perform First Aid and not wound care without directions from a nurse. Staff 2 proceeded to complete a skin assessment, and she dressed the resident’s wound. The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents when an unlicensed staff member exercised her own independent judgment in how to care for an open wound without instructions from a licensed professional. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure residents' rights to be treated with dignity and respect and to be free from physical restraints for 1 of 1 sampled resident (#3) who had a full-length bed rail and received feeding assistance and for an unsampled resident who required feeding assistance. Findings include, but are not limited to:”

“Based on observation, interview and record review, it was determined the facility failed to notify the local Senior and People with Disabilities (SPD) office when an incident of abuse, or suspected abuse, occurred and failed to report physical injuries of unknown cause to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, and failed to ensure investigations included all required components including Administrator review, for 4 of 4 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure initial evaluations addressed all required elements, and were updated and changed as appropriate within the first 30 days for 1 of 1 newly admitted resident (#2), and quarterly evaluations were the foundation used to develop residents' quarterly service plans, including documentation relevant to the residents' needs and current condition for 2 of 3 sampled residents (#s 1 and 3) whose evaluations were reviewed. Findings include, but are not limited to:”

“Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure changes and entries made to the service plan must be dated and initialed, service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and service plans were implemented for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 3 and 4’s most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. During an interview on 02/14/25 at 10:10 am, Staff 5 (RCC) confirmed the facility lacked documented evidence of a Service Planning Team for all residents. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings. 1.All service plans will be reviewed and updated for accuracy by the alleged compliance date. Re-implementation of use of the company Service conference form has occurred and RCC and Administrator have been trained on it's use by VP of Health Services the week of March 10th. Using this form allows for documentation of the occurrence of the Service conference and documents involved parties including, but not limited to the resident as able, family representative, caseworker, direct care staff, and other entities. 2. The company approved Service Plan form is be used to assure that the service plan is completed and that the conference is documented. A record book of service conferences is to be maintained. Caseworkers will be sent monthly notifications of service conferences for them to attend as able. 3. Monthly evaluation to assure that service conferences and the associated service plans are done timely and within the standard time frame. A review of attendees will be checked. A report will be run prior to the upcoming month to schedule service conferences prior to the expiration of the current service plan. 4. RCC, RN, Administrator and VP of Health Services.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated, referred to the RN for assessment and the service plan was updated as needed for 2 of 2 sampled residents (#s 1 and 3); and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 2 sampled residents (#s 1 and 3) who experienced significant changes of condition. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#5) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task. During the acuity interview on 02/10/25, Resident 5 was identified to be administered insulin injections by non-licensed staff. Resident 5’s MAR, reviewed from 01/01/25 through 02/12/25, revealed the resident received Admelog (insulin to treat diabetes) once daily and Lantus (insulin to treat diabetes) once daily. The insulin had been given by Staff 13 (Lead MT) and Staff 16 (MT) on multiple occasions. Review of delegation records and the MAR, showed the following: a. There was no documented evidence that the reauthorization for Staff 13, dated 02/06/25, and Staff 16, dated 01/09/25, occurred prior to the end of the prior reauthorization period. b. There was no documentation by the RN verifying that all requirements from the initial delegation were met. c. There was no documented evidence of a nursing assessment and condition of the resident in their environment of care to determine that the condition remained stable and predictable, and delegation remained a safe care delivery option. d. There was no documented evidence that the RN had verified Staff 13 and Staff 16’s documentation and observed Staff 13 and Staff 16 perform the nursing procedure. e. There was no documentation of the length of authorization period. The requirements for delegation were reviewed with Staff 2 (Executive Nurse) on 02/13/25 and 02/14/25. She acknowledged the findings. The need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure staff were informed of new interventions, and the service plan was adjusted, if necessary, and reporting protocols were in place for 2 of 3 sampled residents (#s 1 and 3) who received outside services. Findings include, but are not limited to:”

“Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 2 of 3 sampled residents (#s 3 and 4) whose ADL care was observed, and for multiple unsampled residents who received meal service and assistance. Findings include, but are not limited to: 1a. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia. The resident was dependent on staff for all ADL care including incontinence care, grooming, and hygiene. At 10:15 am on 02/11/25, Staff 19 (CG) and Staff 27 (CG) were observed providing incontinence care for Resident 4 in his/her bed. Staff 19 and Staff 27 were observed donning gloves and then assisting the resident in rolling in order to remove his/her soiled incontinence pad and soiled brief. Staff 27 placed the soiled incontinence pad onto the floor without first placing it in a bag. Staff 19 and 27 proceeded to assist the resident in donning a clean brief and placing a clean incontinence pad on the bed without removing their soiled gloves or performing hand hygiene. After providing incontinence care, staff were observed discussing oral hygiene for the resident, and Staff 27 began to reach for an oral mouth swab while still wearing soiled gloves. This surveyor stopped the process and requested staff perform hand hygiene and don clean gloves prior to continuing to provide ADL assistance. b. Observations of meal service were conducted from 02/10/25 through 02/13/25 and the following was identified: * Caregiving staff were observed serving food and feeding residents without wearing a protective covering over potentially contaminated clothing; and * No hand hygiene for residents occurred, despite multiple unsampled residents observed to be eating with their hands. The need to maintain effective infection prevention and control protocols was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. At 10:00 am on 02/11/25, Staff 16 (MT) and Staff 18 (CG) were observed providing ADL assistance for Resident 3. During the observation, both staff donned gloves and assisted the resident in transferring to the toilet. Staff 16 removed the resident’s soiled brief and incontinence pad. Staff 16 proceeded to put lotion on the resident’s arms and legs. No glove change or hand hygiene was performed between tasks. Staff 18 provided perineal care and assisted the resident in donning a clean brief and pants. Staff 18 then assisted the resident to the sink and started to set-up the resident’s toothbrush. No glove change or hand hygiene was performed between tasks. This surveyor stopped the process and requested the staff perform hand hygiene and don clean gloves prior to continuing ADL assistance. The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to: During the re-licensure survey, conducted 02/10/25 through 02/14/25, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C 160 – Reasonable Precautions; * C 282 – RN Delegation and Teaching; * C 302 – Tracking Control Substances; * C 303 - Medication and Treatment Orders; * C 305 - Resident Right to Refuse; * C 310 - Medication Administration; and * C 330 – Psychotropic Medications. The need to ensure a safe medication and treatment system was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings. 1.Complete MAR audit to be completed by nursing by alleged compliance date. When completed, new 90 day orders will be sent to providers. 2. 90 Day orders are done quarterly by the RN and sent to providers. All new orders, changes, or DC orders are managed by qualified staff. Manual imputation of orders are limited to nursing and only for urgent orders. Otherwise orders are entered by the pharmacy and approved in the EHR through the pharmacy link section by trained Med techs with 3 check process in place. 3. Quarterly MAR audit while preparing 90 physician orders. Daily review of "Dashboard" in ECP to identify MAR discrepancies for quality assurance. Monthly Med Room Audits are completed by RN. 4. RN and Administrator See Tag C160, C282, C302, C303, C305, C310, C330”

“Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 3 of 3 sampled residents (#s 2, 3, and 4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed; and failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose orders were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order, for 3 of 3 sampled residents (#s 1, 2, and 3) with documented refusals. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept and/or resident-specific parameters and instructions were included for PRN medications for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 1 and 3) who were prescribed and administered PRN medications to treat behaviors. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT; failed to document other less restrictive alternatives evaluated prior to the use of the device; and failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (#3) who had full length side rails. Findings include, but are not limited to: Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer’s disease. Resident 3 was observed to have a hospital bed with a single full side rail that ran the length of the left side of the bed, and the right side of the bed was positioned against the wall. The full side rail was visualized to be in the elevated position on 02/11/25 at 10:00 am with the resident calling for help with his/her left leg draped over the side rail. There was no documented evidence the following required elements were completed related to the full bed rail: * Assessment by facility RN, PT, or OT; * The facility documented other less restrictive alternatives evaluated prior to the use of the device; and * The facility had instructed caregivers on the correct use and precautions related to the use of the device. The full side rail was replaced with a half side rail on 02/12/25. On 02/13/25, Staff 2 (Executive Nurse) confirmed she had completed the resident's "Lenity Oregon Device Assessment” related to the half side rail that replaced the full bed rail. The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives were evaluated prior to the use of the device and caregivers were instructed on the correct use and precautions related to the device was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings.”

“based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to the following: During the entrance conference on 02/10/25 at approximately 2:30 pm with Staff 1 (Administrator), Staff 3 (Wellness Director/LPN) and Staff 27 (CG), the following was identified: * The MCC consisted of three distinct cottages – Lily, Rose, and Daisy. Sixteen residents were living in Lily, 14 residents were living in Rose, and 13 residents were living in Daisy; * Two residents required two-person assist for transfers at all times – one resident resided in Lily and one resident resided in Daisy; * One resident, who resided in Rose, required occasional two-person assist for transfers; and * Eighteen residents were reported to require high levels of caregiving assistance due to requiring hospice services, cognitive decline, history of falls/fall risk, feeding assistance, history of behaviors, and history of resident-to-resident altercations. Observations of cares provided to residents and interviews with staff throughout the survey revealed five residents who required two-person transfer assistance. Daisy cottage had one resident who required two-person transfer assistance, Lily cottage had two residents, and Rose cottage had one resident who required two-person assistance at all times and one who required occasional two-person assistance. The facility's posted staffing plans, the staffing schedule from 01/25/25 through 01/31/25, and the corresponding timeslips were reviewed. The facility's posted staffing plan indicated three caregivers and one medication technician were scheduled to work the 10:00 pm to 6:00 am shift daily. This equated to one caregiver in each cottage and a MT to assist with caregiving duties as needed. On 02/12/25 at 2:57 pm, Staff 1 and Staff 2 (Executive Nurse) acknowledged the facility had not completed fire drills every other month with evacuation or relocation of residents, including the residents who required two-person transfer assistance. Additionally, when asked how the current overnight staffing plans accounted for the two-person transfers, Staff 2 acknowledged she would adjust the overnight staffing immediately. The facility lacked a sufficient number of overnight staff to meet the scheduled and unscheduled needs and fire evacuation standards of the multiple residents who required the assist of two care staff for transfers, had high levels of care needs, had behaviors (including resident-to-resident altercations) and resided in three distinct cottages. On 02/13/25 at 3:13 pm, the facility provided an updated schedule and staffing plan which included five caregivers and one MT for the 10:00 pm to 6:00 am shift. This updated schedule accounted for the scheduled and unscheduled needs of the residents and the fire safety evacuation standards. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents and fire evacuation standards on the overnight shift was discussed with Staff 1 and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time that the staff were providing to each resident as outlined in each individual service plan for 3 of 4 sampled residents (#s 1, 3, and 4) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in, no less than quarterly at the same time of service plan update, and/or with a significant change of condition for 3 of 4 sampled residents (#s 2, 3, and 4) and an unsampled resident, and failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. Findings include, but are not limited to: The facility was a licensed MCC with three distinct cottages.”

“Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired direct care staff (#s 25 and 30) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 6 (Business Office Manager) on 02/11/25. Staff 25 (CG), hired 01/01/25, and Staff 30 (CG), hired on 12/05/24, lacked documented evidence they had completed First Aid and abdominal thrust training within 30 days of hire. The need to ensure direct care staff completed the required First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 6 on 02/11/25 and with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code and to provide fire and life safety instruction on alternate months. Findings include, but are not limited to: Six months of fire drill and fire and life safety training records were requested on 02/10/25. The following was identified: a. There was no documented evidence the facility had conducted a fire drill every other month between 08/2024 and 02/2025. b. One fire drill had been conducted during the reviewed time period. This fire drill, on 12/19/24, did not include activating the fire alarm system. Documentation of the fire drill failed to address the following: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. c. During interviews completed 02/11/25 through 02/13/25, staff were unable to identify the designated point of safety in case of a fire. d. There was no documented evidence the facility was providing fire and life safety training to staff on alternating months from fire drills. The need to ensure fire drills were conducted in accordance with the Oregon Fire Code and fire and life safety instruction was provided to staff on alternate months was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) at 12:15 pm on 02/14/25. They acknowledged the findings. 1.Fire Drills are held every other month and Fire Safety Training at All Staff meeting on the alternate months. Alternating shifts implemented for fire drills. Fire Safety done 2/27/2025. Fire Drill (actual) held on 3/14/2025 on day shift. Updated forms in use. Designated safety point is the front parking lot. or the side parking lot depending on fire location. Orientation checklist has fire safety and fire locations performed by the Maintenance director for all new staff. 2. The system is corrected to follow the above plan for fire drills and twice yearly emergency drills. 3. At least monthly review of Fire and Life safety Drills. 4. Maintenance director is responisble to ensure fire and emergency drills are completed on alternative months. Administrator to assure oversight.”

“Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission; and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending per the Oregon Fire Code (OFC) unless the resident’s mental capability did not allow for following such instruction. Findings include, but are not limited to: Fire and life safety records were reviewed on 02/11/25. During an interview on 02/11/25 at 2:38 pm, Staff 1 (Administrator) reported that residents had not been receiving fire and life safety training on admission, nor had the facility been re-instructing residents at least annually. The need to instruct and re-instruct residents on fire and life safety training per the OFC requirements was discussed with Staff 1 and Staff 2 (Executive Nurse) at 12:15 pm on 02/14/25. They acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to have an emergency preparedness plan that included analysis and response to emergency hazards in event of a prolonged power failure, and failed to conduct a drill of the emergency preparedness plan at least twice a year. Findings include, but are not limited to: In an interview on 02/11/25 at 11:20 am, Staff 7 (Facility Services Director) stated the facility frequently experienced “rolling blackouts”, including six times the previous summer. During interviews on 02/11/25 and 02/12/25, care staff expressed concern that the facility did not have an emergency plan in event of a power outage. They stated a power outage, lasting approximately ten hours, occurred at the facility on 02/04/25, and staff did not know how to complete tasks such as documenting medication administration. During an interview on 02/12/25 at 3:00 pm, Staff 1 (Administrator), Staff 2 (Executive Nurse) and Staff 7 confirmed the facility experienced a power outage on 02/04/25 and the facility did not implement a system for documenting medications administered while the power was out. They stated that the facility had not been conducting drills of the emergency preparedness plan at least twice per year. The survey team requested the facility’s emergency preparedness plan in the event of a power outage or other emergency. This was reviewed on 02/13/25 at 10:50 am and the following was identified: * Multiple areas of the plan were blank, including areas describing how the facility would gather provisions such as water, food or medical supplies for the resident’s needs in case of an emergency; and * Names and phone numbers of who should be contacted in case of an emergency belonged to staff who were no longer employed by the facility. The need to ensure the facility developed an emergency preparedness plan that included analysis and response to emergency hazards in event of an emergency such as a prolonged power failure, and to conduct a drill of the emergency preparedness plan at least twice a year, was reviewed with Staff 1 and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the right to freedom from restraints. Findings include, but are not limited to: Refer to C 200 and C 340. Refer to C200 and C340”

“Based on observation and interview, the facility failed to ensure each individual resident had privacy in his/her unit. Findings include, but are not limited to: The environment was toured on 02/11/25 at 1:45 pm. Multiple unsampled resident rooms, shared between two residents, were observed to have a sliding barn door to access the bathroom located within the room. There was no way to lock the door to ensure privacy while using the bathroom. The environment was toured with Staff 1 (Administrator) and Staff 7 (Facility Services Director) on 02/12/25 at 4:15 pm. They acknowledged that the barn doors on shared resident room bathrooms did not have a way to lock to ensure privacy. The need to ensure each individual resident had privacy in his/her unit was reviewed with Staff 1 and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple sampled and unsampled residents. Findings include, but are not limited to: Multiple observations were made in Daisy, Rose, and Lily Cottages during the survey of staff using their key to open sampled and unsampled resident unit doors. During an interview during the survey, Staff 1 (Administrator) confirmed the residents did not have keys to their units. Review of Resident 1, 2, 3, and 4’s service plans did not indicate if the residents had a key to their unit or if they were evaluated to have one. Resident 1’s service plan, dated 10/31/24, reflected that the “resident is able to keep track of their own room key” and that staff “are to assist further if requested.” On 02/12/25 at 10:37 am, Staff 27 (CG) confirmed the resident did not have a key to their unit. The need to ensure the individual resident and only appropriate staff had a key to access their unit was discussed with Staff 1 and Staff 2 (Executive Nurse) during the survey. On 02/14/25, Staff 1 verified the keys were being made and that all residents would have a key to their unit as soon as the facility had the keys.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure initial evaluations addressed all required elements including the pronouns and gender identity for 1 of 1 sampled resident (#2) who’s evaluation was reviewed. Findings include, but are not limited to: Refer to C 252. See C 252”

“Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to: C 150, C 156, C 160, C 200, C 231, C 295, C 360, C 362, C 363, C 372, C 420, C 422, C 435, and C 513. Refer to C 150, C156, C160, C200, C231, C295, C360, C362, C363, C372, C420, C422, C435, C513”

“Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 25, 28, and 30) completed pre-service orientation and dementia training prior to beginning their job responsibilities, 5 of 5 newly hired staff (#s 12, 25, 28, 30, and 33) had documented evidence of demonstrated competency in all required areas within 30 days of hire, 2 of 2 long term staff (#s 15 and 26) completed a total of 16 hours of annual in-service training, and 1 of 3 long term, non-direct care staff (#9) completed required annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed with Staff 6 (Business Office Manager) on 02/11/25 and 02/12/25. The following was identified: a. There was no documented evidence Staff 25 (CG), hired 01/01/25, Staff 28 (CG), hired 01/01/25, and Staff 30 (CG), hired 12/05/24, completed all required pre-service orientation topics and pre-service dementia training prior to beginning job duties in the following topics: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Environmental factors that are important to a resident’s well-being; * Family support and the role the family many have in the care of the resident; * How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * Use of supportive devices with restraining qualities in memory care communities. b. Staff 12 (MT), hired 01/22/25, Staff 25, Staff 28, Staff 30, and Staff 33 (CG), hired 01/20/25, lacked documented evidence they had completed all of the required training and demonstrated competency in all job duties within 30 days of hire, or prior to working with residents independently, 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 that require assessment, treatment, observation and reporting; and * Other duties as applicable. In an interview on 02/12/25, Staff 5 (RCC) acknowledged Staff 12 did not have documentation of demonstrated competency in medication pass prior to working independently as a MT. Staff 5 agreed to ensure Staff 12 demonstrated competence prior to independently passing medications. c. There was no documented evidence Staff 15 (MT), hired 01/09/23, and Staff 26 (CG), hired 01/19/20, completed 16 hours of annual in-service training, including at least six hours of dementia care topics. d. Staff 9 (Activity Aide), hired 01/23/23, lacked documented evidence of completion of annual infectious disease training. The need to ensure all staff completed pre-service orientation and dementia training, demonstrated competence in job duties within 30 days, had 16 hours of annual in-service training, and completed required infectious disease training annually, was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), Staff 5, and Staff 6 on 02/11/25, 02/12/25, and 02/14/25. They acknowledged the findings. 1.Complete training audit under review to assure that all staff are trained per policy and OAR. All staff to be completed by the alleged compliance date. Mandatory trainings will be done on-site and in-person by VP of Health Services (RN) the week of March 21 and 24th including a dementia specific training on Dementia. All competencies have been completed 3/14/2025. In specifc, Staff 25, 28,30, 15, 26, and 9 will have all missing training components completed by 3/24/2025. 2. Process: Hire, Onboarding with Orientation form and required pre-service trainings (Oregon Care Partners: Pre-Service Dementia, Infection control, Providing Inclusive Care, HCHB IBL) including CPR, First Aid,and Food Handlers, shadowing on the floor, demonstrated competencies, finish 30 day trainings. BOM monitors staffing to assure compliance and trainings are completed. Annual Training is completed with a variety of methods including training at All-Staff (documented appropriate with trainer, time, and topic), assigned Relias Courses, and company provided training with certificates documenting topic, hours, and trainer. 3.The Business Office Manager or designee maintains the tracking spreadsheet to assure accuracy of training and within all required timeframes per policy and OAR. The BOM notifies managers if there are staff who are not in compliance. 4. BOM with Administrator oversight. See also C372”

“Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4's service plans were reviewed. The service plans were found to be lacking information and staff instructions related to an individualized nutrition and hydration plan. The need to develop an individualized nutrition and hydration plan for each resident and include it in the service plan was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25. They acknowledged the findings.”

“based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4’s records were reviewed and observations were made during the survey. The current activity evaluations did not address one or more of the following required components: * Past and current interests; * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations needed to participate; and * Identification of activities for behavioral interventions. The current activity plans were not individualized to each resident based on their activity evaluation and not included on the resident's activity service or care plan. In an interview with Staff 9 (Activity Aide) on 02/12/25 at 3:19 pm, she confirmed that the residents did not have an activity evaluation. The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25. They acknowledged the findings.”

“based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of their rooms. Findings include, but are not limited to: During the survey from 02/10/25 through 02/14/25, multiple sampled and unsampled residents were observed to be locked out of their room. During interviews on 02/10/25 through 02/12/25, care staff stated that “most” resident rooms were kept locked at all times. On 02/11/25 at 12:03 pm in Daisy cottage, an unsampled resident was observed attempting to enter his/her room and found it to be locked. The resident went to the dining room and asked a CG to “unlock my door so I can get my coat.” The CG replied, “not now, after lunch.” The resident appeared to become agitated and began yelling. During an interview at 12:35 pm, the CG stated the resident was not let back in to his/her room because the resident had “already been let back into [his/her] room three times” and the CG needed to finish serving lunch to the other residents. The need to ensure residents were not locked outside of their rooms was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) at 12:15 pm on 02/14/25. They acknowledged the findings.”

“The findings of the kitchen inspection, conducted 03/20/24, 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. The findings of the kitchen inspection, conducted 03/20/24, 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.”