New Friends of Coos Bay.

“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: Observation of the main kitchen and unit kitchenettes on 02/06/26, from 11:00 am through 1:30 pm, revealed the following:”

“Based on observation and interview, it was determined the facility failed to ensure staff maintained effective infection control practices to minimize the potential spread of infectious agents during meal service. This had the potential to affect all residents residing in the Dogwood neighborhood. Findings include but are not limited to: Lunch service was observed in the Dogwood neighborhood on 02/06/26, from 11:39 am to 12:45 pm. At approximately 12:15 pm a care staff member was observed to deliver an uncovered plate of food to a resident’s room just off the dining room. Approximately five to seven minutes after the plate of uncovered food was delivered to the resident’s room, a different staff member retrieved the uncovered plate of food and was observed to deliver it to a different resident seated at a dining room table. The uncovered plate of food had been mistakenly delivered to the resident room when it was intended for the resident seated at the table. The resident immediately started eating the potentially contaminated plate of food, before the surveyor could intervene. Other staff members observed this practice and did not prevent the potentially contaminated plate of food from being served to the resident in the dining room. At 1:00 pm, the surveyor reviewed this practice with Staff 1 (Executive Director) and Staff 2 (Dining Services Manager). Both acknowledged the plate of food delivered to the resident’s room should not have been delivered to the resident in the dining room. Both Staff 1 and Staff 2 acknowledged this was an infection control issue requiring immediate staff education. ? Training provided on proper meal services, infection control/prevention with meals service. Meal monitoring done daily for compliance by the management team.”

“Based on observations and interviews, 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 C240 and C295”

“Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to: The facility consisted of a common area in the center of the building with four pods off of the common area. Those pods were named as follows: Alderwood, Birchwood, Cedarwood, and Dogwood. a. Observations during the survey from 08/25/25, to 08/28/25, showed a lack of scheduled and unscheduled activities provided for residents living in the memory care community. An activity calendar was provided, which noted scheduled activities for each day of the week. The activities noted for 08/26/25 included the following: * 9:00 am – Relax/Morning Walk (no location was noted); *10:15 am – BINGO (no location was noted); * 1:30 pm – Art/Music (no location was noted); * Movies and Popcorn (with no time and/or location listed); and * 4:00 pm – Games (no location was noted). During observations in Alderwood on 08/26/25 the above listed activities were not observed to have occurred and/or residents were not observed to have been invited to attend the above activities. Staff 19 (CG) stated the residents in Alderwood were “not very social”. Staff 19 stated the facility had an activities director who came to the pod to invite residents to activities when they occurred. Residents in Alderwood were observed sitting in the living room in recliners watching TV and/or movies throughout the day or sitting at tables in the dining room. Residents who were in their apartments were not approached for activity invitations during observations. The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests, and physical, mental, and psychosocial needs was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/28/25 at 11:00 am. They acknowledged the findings. b. Resident 2’s evaluation and service plan noted s/he was dependent on staff for transfers and escorts in a wheelchair to activities. S/he preferred independent activities, such as painting and puzzles, rather than group activities. S/he enjoyed the sunshine and preferred activities outside and community outings. During the survey from 08/25/25 through 08/28/25, Resident 2 was not observed participating in any outdoor activities, outings in the community, puzzles or painting. The need to ensure the facility provided a daily program of social and recreational activities that were based on individual interests was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 08/26/25 at 2:53 pm. They acknowledged the findings. New Friends of Coos Bay will implement the following:”

“Based on observation, interview, and record review, it was determined the facility failed to determine action or interventions, communicate the interventions to staff on each shift and monitor the interventions for effectiveness for 1 of 1 sampled resident (#3) who experienced a significant change of condition related to a pressure ulcer. Resident 3’s open wound worsened. Findings include, but are not limited to: Resident 3 moved into the MCC in 04/2022 with diagnoses including Alzheimer’s disease. The resident was identified during the acuity interview on 08/25/25 to have a pressure ulcer on his/her buttock. A progress note dated 06/24/25 noted “what appears to be an open area on the right gluteal fold”. Following the identification of the open area, the facility was applying barrier cream per standing orders. The open area was evaluated on 06/27/25 by the resident’s primary care provider (Medical Doctor). The provider identified the wound as a stage II decubitus ulcer (open wound) to the right gluteal fold and gave orders to cleanse wound, continue Secura protective cream and cover with foam dressing daily, reposition every two hours, and cushion or donut pillow to be used while the resident was in the wheelchair. There was no documented evidence the following interventions were communicated to staff or monitored for effectiveness: *Cleanse the wound and cover with foam dressing daily; *Reposition every two hours; and *Use of a cushion or donut pillow while the resident was in the wheelchair. On 07/18/25, Staff 2 (RN) completed an initial assessment noting “buttock wound is open, wound bed has greenish slough and is draining, Edges [sic] are defined, wound is pressure, not stageable due to slough”. Following the RN assessment, there was no documented evidence the facility reviewed the treatment interventions for effectiveness or determined new interventions. On 07/23/25, the resident was seen by his/her primary care provider (Medical Doctor) for follow-up on the decubitus ulcer (open wound). The provider’s assessment noted the decubitus ulcer (open wound) had worsened, progressing from stage II towards stage III, and the presence of significant skin breakdown. Provider placed an urgent referral for wound care and recommended the following interventions: * Use of a 1.5-inch-thick foam pad on the wheelchair to alleviate pressure; * Spend more time in bed or a recliner; and * Limit sitting in his/her wheelchair longer than one hour. There was no documented evidence the above treatment interventions were communicated to staff, implemented or weekly monitoring of the wound. On 07/30/25 the resident was seen at the emergency department (ED) for a wound on his/her right buttock. The wound was diagnosed as a pressure ulcer stage III. The resident was admitted to hospice services on 08/18/25. Antibiotic (metronidazole) treatment for an infection in the wound was initiated on 08/21/25. Review of hospice RN documentation of wound assessment dated 08/25/25 revealed the right gluteal fold wound was a stage IV pressure ulcer (open wound), indicating further worsening of the wound. The facility failed to determine interventions, communicate interventions to staff, implement wound treatments, monitor the interventions for effectiveness, and/or implement new interventions and monitor the wound, resulting in the wound worsening. Observation of wound care performed by a hospice nurse was made on 08/26/25 at 10:55 am. The Nurse Surveyor noted the wound open to right gluteal fold with no odor present. The resident was medicated by the MA or pain before wound care, however the resident expressed pain when the nurse touched the wound by making a moaning sound and moving his/her body away from the nurse. On 08/28/25 at 9:45 am, additional documentation of skin monitoring was requested. On 08/28/25 at 12:00 pm, Staff 2 and Staff 7 (Corporate Nurse/LPN) confirmed there was no additional documentation. The need to ensure the facility determined action or interventions, communicated the interventions to staff on each shift and monitored the interventions for effectiveness was discussed with Staff 1(ED), Staff 2, Staff 3 (RCC), Staff 7, Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer) on 08/28/25 at 12:00 pm. They acknowledged the findings. New Friends of Coos Bay will implement the following :”

“Based on interview and record review, it was determined that the facility failed to complete an RN assessment timely, including the documentation of interventions made as a result of the assessment and provide intermittent direct nursing services for 1 of 1 sampled resident (#3) who experienced a significant change of condition. Resident 3’s open wound worsened. Findings include, but are not limited to: Resident 3 moved into the MCC in 04/2022 with diagnoses including Alzheimer's disease. Resident 3's progress notes, dated 05/25/25 through 08/25/25 were reviewed and revealed the following: On 06/24/25, Staff 18 (MA) documented the identification of an open area on the right gluteal fold, which was communicated to management. On 06/27/25, Resident 3 was seen by his/her primary care provider (Medical Doctor), who documented the presence of a stage II decubitus ulcer (open wound) to the right gluteal fold. The presence of a stage II ulcer indicated a significant change of condition which required an RN assessment. An RN assessment was completed by Staff 2 (RN) on 07/18/25, 24 days following the documentation of the resident’s open area. The facility failed to ensure an RN assessment was completed timely following the identification of a stage II pressure ulcer on 06/27/25 and failed to ensure interventions were documented as a result of the RN assessment on 07/18/25 which noted the stage II pressure ulcer (open wound) had worsened to an unstageable pressure ulcer. In an interview with Staff 2 on 08/28/25 at 12:00 pm, she confirmed 07/18/25 was her first assessment of the area and noted the wound was an unstageable pressure ulcer. The RN assessment lacked documented treatment interventions made as a result of the assessment. Additionally, the facility failed to provide intermittent direct nursing services for Resident 3’s decubitus pressure ulcer (open wound) from 06/24/25 through 08/05/25 when nursing services were not available through hospice, home health, or a third-party referral. The need to ensure documented RN assessment was completed timely and documented interventions made as a result of the assessment was discussed with Staff 1(ED), Staff 2, Staff 3 (RCC), Staff 7 (Corporate Nurse/LPN), Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer) on 08/28/25 at 12:00 pm. They acknowledged the findings. No further information was provided. Refer to C 270. New Friends of Coos Bay will implement the following:”

“Based on observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols for multiple sampled and unsampled residents related to dining services. Findings include, but are not limited to: Multiple meals were observed in the Birchwood pod between 08/26/25 and 08/27/25. a. Staff were observed serving meals and beverages, touching residents, touching their own faces, repositioning wheelchairs, and assisting residents with feeding without changing their gloves or performing hand hygiene between all clean and dirty tasks. b. Direct care staff were observed serving meals and providing feeding assistance to sampled and unsampled residents without donning a protective barrier over potentially contaminated clothing. On 08/26/25 at 4:43 pm, Staff 9 (CG) and Staff 15 (CG) confirmed the only staff member who wore an apron during meal service was the person dishing up the food. The need to ensure the facility maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during meal service was reviewed on 08/28/25 at 11:16 am with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Corporate Nurse/LPN), Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer). They acknowledged the findings. New Friends of Coos Bay will implement the following:”

“Based on interview and record review, it was determined that the facility failed to ensure treatment orders were carried out as prescribed for 1 of 1 sampled resident (# 3) whose treatment orders were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease. Resident 3's current physician's orders, MAR/TAR dated 06/01/25 through 08/25/25, and progress notes dated 05/25/25 through 08/26/25 were reviewed, and the following was identified: Resident 3 was seen by his/her primary care provider on 06/27/25 for a stage II decubitus ulcer to the right gluteal fold and was prescribed the following: * Daily wound cleansing and foam dressing applied, and to continue to use Secura protective skin cream with each dressing change and toileting. Review of the resident’s record during the survey on 08/25/25 through 08/28/25 revealed the above orders for daily wound cleansing and applying foam dressing were not transcribed to the MAR. Interview with Staff 7 (Corporate Nurse/LPN) and Staff 2 (RN) on 08/28/25 at 12:00 pm confirmed the facility did not have supplies to carry out the order as prescribed and Staff 7 confirmed she did not enter the order on the MAR. The need to ensure all treatments were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, Staff 3 (RCC), Staff 7, Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer) on 08/28/25 at 12:00 pm. They acknowledged the findings. No further documentation was provided. New Friends of Coos Bay will implement the following:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure an RN, PT, or OT assessment was completed prior to the use of a supportive device with potentially restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (# 2) who used a supportive device with restraining qualities. Findings include, but are not limited to: Resident 2 had a twin size mattress approximately five inches in thickness on the floor laying parallel to his/her bed. During an interview and observation on 08/26/25 at 2:18 pm, Resident 2 was observed lying in bed with the twin mattress on the floor next to the bed. Resident 2 stated “that thing (pointing to the mattress on the floor), makes me afraid cause I can’t get my footing. I asked them to move it, but they don’t, so I just don’t get up. I want that thing out of here.” During an interview with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 08/26/25 at 2:53 pm, evaluations for Resident 2’s bed alarm and mattress on the floor were requested. Staff 2 stated, “there isn’t an evaluation for the mattress on the floor and if you are looking for an evaluation for the alarms, I can tell you now, you won’t find an evaluation for any residents that have an alarm on their bed or chair.” The need to ensure devices with potentially restraining qualities were assessed by an RN, PT or OT and evaluated on a quarterly basis was discussed with Staff 1, Staff 2, and Staff 3 on 08/26/25 at 2:53 pm. They acknowledged the findings. New Friends of Coos Bay will implement the Following:”

“Based on interview and record review, it was determined the facility failed to conduct fire drills per OFC and to instruct staff in fire and life safety topics on alternate months from fire drills. Findings include, but are not limited to: Facility fire drill and fire and life safety records from 03/2025 to 08/2025 were requested and reviewed with Staff 1 (ED) and Staff 5 (Maintenance) on 08/26/25 at 8:50 am. The facility’s fire drill records lacked the following documentation: * Life safety training for staff on alternate months of the fire drills; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated and/or relocated to the point of safety. The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed with Staff 1 and Staff 5 on 08/26/25 at 8:50 am They acknowledged the findings. New Friends of Coos Bay will implement the Following:”

“Based on observation and interview, it was determined the facility failed to ensure the environment was clean and in good repair. Findings include, but are not limited to: The facility consisted of a common area in the center of the building with four pods off the common area. Those pods were named as follows: Alderwood, Birchwood, Cedarwood, and Dogwood. The interior of the building was observed on 08/25/25 at 1:38 pm through 3:35 pm and again on 08/27/25 at 10:15 am. The following areas needed cleaning and/or repair: Common Area: * Coffee table in front of the couches in the entry had multiple scratches; and * Chairs outside of the RCC office and near the piano were missing varnish and/or had stained seats. Alderwood: * Table in the entry/common area had wood chipped and/or missing; * Trim throughout had black scuff marks and/or was chipped; * Uncovered garbage can in the kitchenette; * Vents in the ceiling outside of A-10 had dust build up; * Dining room chairs had worn seats with cracked vinyl; and * Exit door to the courtyard had chipped paint. Birchwood: * Exit doors to the courtyard had chipped paint; * Sink in B-14 was slow to drain; and * Trim throughout had black scuff marks and/or was chipped. Cedarwood: * Table in the common area was marked/chipped; * Chairs in the common area had worn and/or stained seats; * Trim throughout had black scuff marks and/or was chipped; * Faucet in room 12 was installed with hot and cold reversed; * Dining room chairs had worn seats with cracked vinyl; and * Exit door to the courtyard had chipped paint. Dogwood: * Table in the common area was marked/chipped; * Chairs in the common area had worn and/or stained seats; * Dining room chairs had worn seats with cracked vinyl; and * Exit door to the courtyard had chipped paint. The areas needing cleaning and/or repair were shown to and discussed with Staff 1 (ED) and Staff 5 (Maintenance) on 08/27/25 at 10:15 am. They acknowledged the findings. New Friends of Coos Bay will implement the Following:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure each individual was free from restraints. Findings include, but are not limited to: Refer to C340. Refer to C340 OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for 4 of 4 sampled residents (#s 1, 2, 3, and 4) and multiple unsampled residents who shared bathrooms. Findings include, but are not limited to: Observations of the four pods of the MCC were conducted between 08/25/25 and 08/28/25. Residents 1, 2, 3, 4, and multiple unsampled residents were noted to share a bathroom. The bathrooms had two sliding pocket doors with each door opening to a different resident unit. Both pocket doors had the capability to lock from inside the bathroom; however, each door could be unlocked without a key by turning the locking mechanism from the resident’s room. Therefore, each individual was not ensured privacy when using his/her shared restroom. In an interview with Staff 1 (ED) and Staff 5 (Maintenance) on 08/26/25 at 3:20 pm and 08/27/25 at 10:15 am, it was confirmed bathrooms with pocket doors shared between two units had a locking mechanism that could be opened without a key from each resident’s room. The need to ensure privacy in individual resident units was reviewed on 08/28/25 at 12:00 pm with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), Staff 7 (Corporate Nurse/LPN), Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer). They acknowledged the findings. New Friends of Coos Bay will implement the Following:”

“Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their individual units. Findings include, but are not limited to: The service plans for Residents 1, 2, 3, and 4 were reviewed between 08/25/25 and 08/28/25 and revealed the four sampled residents had not been given keys to their rooms. During an interview on 08/26/25 at 2:53 pm, Staff 1 (ED) reported “most of the residents don’t have a key, they can’t use it. If the family doesn’t want it, then we don’t give one.” The need to ensure all residents were provided keys to their individual units was reviewed on 08/28/25 at 12:00 pm with Staff 1, Staff 2 (RN), Staff 3 (RCC), Staff 7 (Corporate Nurse/LPN), Staff 29 (Corporate LPN), and Staff 30 (Chief People Officer). They acknowledged the findings. New Friends of Coos Bay will implement the following: 1.Executive Director and RCC were retrained on the need to ensure all residents were provided keys to their individual units and documented. All residents and guardians will be offered a key and it will be documented and put into their service plan per rule. All new move-ins will be using the new version of the Assessment , so the key assessment is automatically on the service plan. 3. With each Move in, and careplan done. 4. The Executive Director and RCC will be responsible for monitoring the corrections to be sure they are completed. OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by:”

“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 C242, C295, C420 and C513. Refer to C242, C295, C420 and C513. 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, 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 C270, C280, C303, and C340. Refer to C270, C280, C303, and C340. OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:”

“There are no detail notes for this visit.”

“Based on observation, interview, and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to provide enough staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents. Findings include, but are not limited to: A review of staffing schedules, facility's posted staffing plan, and ABST it was confirmed the facility was not meeting the scheduled and unscheduled needs of the residents. The posted staffing plan showed the care staff levels for the following: Cedarwood, Alderwood, Dogwood and Birchwood pods were to have two caregivers, one MT and one universal worker for day and swing shifts, and two caregivers and one MT on night shifts. A review of the staff schedule confirmed inconsistent staffing levels from 11/02/23 through 11/31/23 that do not match posted staffing plans or ABST for all shifts. A review of the facility's ABST on 03/11/24 indicated staffing levels on day shift should have been the following: in Cedarwood three care staff, Alderwood two and half care staff, Dogwood two care staff and Birchwood one and half care staff. Compliance Specialist (CS) observed the facility was staffed with the following: Cedarwood two caregivers and one floating MT, Alderwood one caregiver, Dogwood one caregiver and one floating MT and Birchwood two caregivers. In an interview on 03/11/24 at 11:40 am, Staff 1 (ED) confirmed the facility was short staffed during 11/02/23-11/31/23 and the day of site visit. The above information was shared with Staff 1 on 09/28/23. S/he acknowledged the findings. It was confirmed the facility failed to provide enough staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents. VPOC: ED reports they are actively hiring care staff for all positions including multiple care staff positions. ED had three interviews today 03/11/24. ED reported they were filling positions immediately and using agency staff to fill positions on the floor. ED reports that administration is actively working the floor as needed to fill in and cover any callouts. Based on observation, interview, and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to provide enough staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents. Findings include, but are not limited to: A review of staffing schedules, facility's posted staffing plan, and ABST it was confirmed the facility was not meeting the scheduled and unscheduled needs of the residents. The posted staffing plan showed the care staff levels for the following: Cedarwood, Alderwood, Dogwood and Birchwood pods were to have two caregivers, one MT and one universal worker for day and swing shifts, and two caregivers and one MT on night shifts. A review of the staff schedule confirmed inconsistent staffing levels from 11/02/23 through 11/31/23 that do not match posted staffing plans or ABST for all shifts. A review of the facility's ABST on 03/11/24 indicated staffing levels on day shift should have been the following: in Cedarwood three care staff, Alderwood two and half care staff, Dogwood two care staff and Birchwood one and half care staff. Compliance Specialist (CS) observed the facility was staffed with the following: Cedarwood two caregivers and one floating MT, Alderwood one caregiver, Dogwood one caregiver and one floating MT and Birchwood two caregivers. In an interview on 03/11/24 at 11:40 am, Staff 1 (ED) confirmed the facility was short staffed during 11/02/23-11/31/23 and the day of site visit. The above information was shared with Staff 1 on 09/28/23. S/he acknowledged the findings. It was confirmed the facility failed to provide enough staff sufficient in numbers to meet the scheduled and unscheduled needs of the residents. VPOC: ED reports they are actively hiring care staff for all positions including multiple care staff positions. ED had three interviews today 03/11/24. ED reported they were filling positions immediately and using agency staff to fill positions on the floor. ED reports that administration is actively working the floor as needed to fill in and cover any callouts.”

“Based on observation, interview, and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool. Findings include, but are not limited to: Onsite facility observation confirmed the following staff were in care pods: Cedarwood two caregivers and one floating MT, Alderwood one caregiver, Dogwood one caregiver and one floating MT and Birchwood two caregivers. A review of the facility's ABST on 03/11/24 indicated staffing levels on day shift should have been the following: In Cedarwood three care staff, Alderwood two and half care staff, Dogwood two care staff and Birchwood one and half care staff. The posted staffing plan showed the care staff levels for the following: Cedarwood, Alderwood, Dogwood and Birchwood pods were to have two caregivers, one MT and one universal worker for day and swing shifts, and two caregivers and one MT on night shifts. The tool did not match the posted staffing plan and was not consistent with staffing schedule dated 03/11/24. The facility was staffing inconsistently to the levels indicated by their ABST. In an interview on 03/11/24 at 11:40 am, Staff 1 (ED) stated the facility was not staffing based on ABST. The above information was shared with Staff 1 on 03/11/24. S/he acknowledged the findings. It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool and was consistently staffing below the levels indicated by the tool. Based on observation, interview, and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool. Findings include, but are not limited to: Onsite facility observation confirmed the following staff were in care pods: Cedarwood two caregivers and one floating MT, Alderwood one caregiver, Dogwood one caregiver and one floating MT and Birchwood two caregivers. A review of the facility's ABST on 03/11/24 indicated staffing levels on day shift should have been the following: In Cedarwood three care staff, Alderwood two and half care staff, Dogwood two care staff and Birchwood one and half care staff. The posted staffing plan showed the care staff levels for the following: Cedarwood, Alderwood, Dogwood and Birchwood pods were to have two caregivers, one MT and one universal worker for day and swing shifts, and two caregivers and one MT on night shifts. The tool did not match the posted staffing plan and was not consistent with staffing schedule dated 03/11/24. The facility was staffing inconsistently to the levels indicated by their ABST. In an interview on 03/11/24 at 11:40 am, Staff 1 (ED) stated the facility was not staffing based on ABST. The above information was shared with Staff 1 on 03/11/24. S/he acknowledged the findings. It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool and was consistently staffing below the levels indicated by the tool.”

“Based on observation, record review and interview, 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 C200, C240 and C260. Based on observation, record review and interview, 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 C200, C240 and C260. Refer to C200, C240, and C260 Refer to C200, C240, and C260 There are no detail notes for this visit.”

“The findings of the kitchen inspection and facility site visit, conducted 12/12/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054 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 and facility site visit, conducted 12/12/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054 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 12/12/23, conducted 02/29/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the first revisit to the kitchen inspection of 12/12/23, conducted 02/29/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure staff treated residents with dignity and respect during dining for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Resident 1 moved to facility on 11/3/2022 with diagnoses that included severe dementia with behavioral disturbance. On 12/12/23 at 11:45 pm, lunch service was observed in Cedarwood unit. Staff 4 (CG), Staff 5 (CG), and Staff 6 (MA) were observed assisting with meal service. Resident 1 was observed to be served their tray of food. The resident then set their plate of food down and returned to the counter and reached across the counter and grabbed a plate that was dished up for another resident. Staff 4 quickly reached for the plate and tried to retrieve it from the resident's hands. Staff 4 and Resident 1 struggled with the plate of food. Staff 5 was telling Resident 1 that was not his/her plate. After a few moments of the resident and staff member tugging at the plate back and forth, the staff member let the resident have the plate. Resident 1 walked away from the service area with the additional plate of food. A few moments later Resident 1 returned to the dining room/meal service area and quickly reached for another resident's dished up plate of food. Staff 4 and Staff 5 both with raised voices tried to deter the resident from taking the additional plate of food stating, "That's not yours, you already have yours." Staff 4 lunged for the plate, trying to reach it before the resident grabbed it but was not able to.  Resident 1 left the dining area and went to his/her room with the additional plate of food. A few moments later the resident came out of his/her room to the dining space where residents were seated and having their meal. Resident 1 again grabbed a pre-plated plate of food from the counter and walked away from the area where s/he sat down with the plate. Staff 4 and Staff 5 were verbalizing frustration about the resident taking off with another resident's food. They had a conversation about how another resident now didn't have a tray for lunch. Resident 1 again came back to the dining area and made his/her way to where residents were seated at their tables. The resident was about to reach for another resident's plate when the seated resident stated, "Go," and Resident 1 turned around. Staff 6 had made his/her way to the table and encountered the resident where s/he tried to redirect the resident to their room. Resident 1 was visibly agitated and frustrated, pushed Staff 6, and attempted to bat/strike at his/her arms. Staff 6 guided the resident away from the dining tables. Staff 4 and 5 were visibly frustrated. This encounter was not a dignified dining experience for Resident 1 and other residents in the dining room. At 1:45 pm Staff 3 (RCC) and Staff 1 (ED) were interviewed. They acknowledged Resident 1 was not treated with dignity or respect during dining. Based on observation, interview, and record review, it was determined the facility failed to ensure staff treated residents with dignity and respect during dining for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Resident 1 moved to facility on 11/3/2022 with diagnoses that included severe dementia with behavioral disturbance. On 12/12/23 at 11:45 pm, lunch service was observed in Cedarwood unit. Staff 4 (CG), Staff 5 (CG), and Staff 6 (MA) were observed assisting with meal service. Resident 1 was observed to be served their tray of food. The resident then set their plate of food down and returned to the counter and reached across the counter and grabbed a plate that was dished up for another resident. Staff 4 quickly reached for the plate and tried to retrieve it from the resident's hands. Staff 4 and Resident 1 struggled with the plate of food. Staff 5 was telling Resident 1 that was not his/her plate. After a few moments of the resident and staff member tugging at the plate back and forth, the staff member let the resident have the plate. Resident 1 walked away from the service area with the additional plate of food. A few moments later Resident 1 returned to the dining room/meal service area and quickly reached for another resident's dished up plate of food. Staff 4 and Staff 5 both with raised voices tried to deter the resident from taking the additional plate of food stating, "That's not yours, you already have yours." Staff 4 lunged for the plate, trying to reach it before the resident grabbed it but was not able to.  Resident 1 left the dining area and went to his/her room with the additional plate of food. A few moments later the resident came out of his/her room to the dining space where residents were seated and having their meal. Resident 1 again grabbed a pre-plated plate of food from the counter and walked away from the area where s/he sat down with the plate. Staff 4 and Staff 5 were verbalizing frustration about the resident taking off with another resident's food. They had a conversation about how another resident now didn't have a tray for lunch. Resident 1 again came back to the dining area and made his/her way to where residents were seated at their tables. The resident was about to reach for another resident's plate when the seated resident stated, "Go," and Resident 1 turned around. Staff 6 had made his/her way to the table and encountered the resident where s/he tried to redirect the resident to their room. Resident 1 was visibly agitated and frustrated, pushed Staff 6, and attempted to bat/strike at his/her arms. Staff 6 guided the resident away from the dining tables. Staff 4 and 5 were visibly frustrated. This encounter was not a dignified dining experience for Resident 1 and other residents in the dining room. At 1:45 pm Staff 3 (RCC) and Staff 1 (ED) were interviewed. They acknowledged Resident 1 was not treated with dignity or respect during dining.”

“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: Observation of the main kitchen and unit kitchenettes on 12/12/22 from 10:30am to 3:30pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Ice machine with visible black substance on the inside; * Ceiling fire sprinklers; * Hood vent above stove/grill; * Metal piping hanging from ceiling above steam table; * Metal rack shelving with dust accumulation; * Reach in refrigerators in care units; * Kitchenettes in units behind, between and under cabinets; * Toasters in all unit kitchenettes with heavy crumb buildup; and * Oven in kitchenettes. b. The following areas were in need of repair: * Multiple areas of kitchen floor with damage, cracks, gaps and other integrity issues rendering the floor not a smooth cleanable surface; * Large area in ceiling over the reach in freezers was open with visible water damage from a broken pipe. Parts of the ceiling had visible black matter; * Area in the ceiling in dry storage room had visible prior water damage that had not been repaired leaving bubbles and cracks in ceiling; * Temperature gauge dials of dish machine were cracked and condensation accumulation made reading of the dials difficult; *Vent in ceiling was not completely flush with ceiling, leaving a large crack where potential pests could enter the kitchen; * Metal wire racks with visible corrosion and/or rust build up; * Microwave in kitchen with visible rust colored areas where protective, smooth wipeable surface of internal oven was gone; * Screen door to back with areas where screen was ripped and torn near bottom of door allowing possible pest entry access when door was open. Surveyor observed door left open during survey process; * Reach in freezer in units with heaving frost/ice build up; and * Two reach in refrigerators were not holding correct temperature. c. Dining room tableware was preset, and utensils were not covered to prevent potential contamination. d. Caregiving staff did not have an aprons during meal service to protect from potential contamination of clothes during care provisions. e. Multiple bulk bins of food had scoops stored inside the food product posing potential contamination of food product. f. Handwashing sink did not contain sign for staff to wash hands as directed in rule. g. Two reach-in refrigerators located on units had temperatures above the required 41 degrees Fahrenheit. Cedarwood fridge thermometer was at 60 degrees. Milk from that fridge was found at 52 degrees. Temperature logs were reviewed and documented several times the temperature was above the required 41 degrees. There were also several missing temperatures not recorded. The reach in refrigerator in Birchwood unit was found at 50 degrees. Milk from that fridge temperature was at 52 degrees. Facility staff were notified to remove/discard items in those fridges as it was unclear how long those items were above 41 degrees and could be unsafe. Staff 2 (Dietary Manager) toured kitchen with surveyor and acknowledged the areas identified. At approximately 1:00 pm, the surveyor and Staff 1 (Executive Director) reviewed areas of concern with kitchen and unit kitchenettes. Staff 1 acknowledged the above areas needed to be cleaned and repaired and practices that needed addressed. 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: Observation of the main kitchen and unit kitchenettes on 12/12/22 from 10:30am to 3:30pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Ice machine with visible black substance on the inside; * Ceiling fire sprinklers; * Hood vent above stove/grill; * Metal piping hanging from ceiling above steam table; * Metal rack shelving with dust accumulation; * Reach in refrigerators in care units; * Kitchenettes in units behind, between and under cabinets; * Toasters in all unit kitchenettes with heavy crumb buildup; and * Oven in kitchenettes. b. The following areas were in need of repair: * Multiple areas of kitchen floor with damage, cracks, gaps and other integrity issues rendering the floor not a smooth cleanable surface; * Large area in ceiling over the reach in freezers was open with visible water damage from a broken pipe. Parts of the ceiling had visible black matter; * Area in the ceiling in dry storage room had visible prior water damage that had not been repaired leaving bubbles and cracks in ceiling; * Temperature gauge dials of dish machine were cracked and condensation accumulation made reading of the dials difficult; *Vent in ceiling was not completely flush with ceiling, leaving a large crack where potential pests could enter the kitchen; * Metal wire racks with visible corrosion and/or rust build up; * Microwave in kitchen with visible rust colored areas where protective, smooth wipeable surface of internal oven was gone; * Screen door to back with areas where screen was ripped and torn near bottom of door allowing possible pest entry access when door was open. Surveyor observed door left open during survey process; * Reach in freezer in units with heaving frost/ice build up; and * Two reach in refrigerators were not holding correct temperature. c. Dining room tableware was preset, and utensils were not covered to prevent potential contamination. d. Caregiving staff did not have an aprons during meal service to protect from potential contamination of clothes during care provisions. e. Multiple bulk bins of food had scoops stored inside the food product posing potential contamination of food product. f. Handwashing sink did not contain sign for staff to wash hands as directed in rule. g. Two reach-in refrigerators located on units had temperatures above the required 41 degrees Fahrenheit. Cedarwood fridge thermometer was at 60 degrees. Milk from that fridge was found at 52 degrees. Temperature logs were reviewed and documented several times the temperature was above the required 41 degrees. There were also several missing temperatures not recorded. The reach in refrigerator in Birchwood unit was found at 50 degrees. Milk from that fridge temperature was at 52 degrees. Facility staff were notified to remove/discard items in those fridges as it was unclear how long those items were above 41 degrees and could be unsafe. Staff 2 (Dietary Manager) toured kitchen with surveyor and acknowledged the areas identified. At approximately 1:00 pm, the surveyor and Staff 1 (Executive Director) reviewed areas of concern with kitchen and unit kitchenettes. Staff 1 acknowledged the above areas needed to be cleaned and repaired and practices that needed addressed.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's needs, provided clear direction for staff, and were consistently implemented by staff for 1 of 1 sampled resident (#1), whose service plan was reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 11/2022 with diagnoses including dementia with behavioral disturbances. Observations of the resident, interviews with staff, and review of the resident's 12/04/23 service plan were completed. On 12/12/23 at 11:45 am, Resident 1 was observed to exhibit behaviors of taking other residents' food/plates during mealtime. The staff were observed to attempt to grab away the plates the resident reached for. At one time, Staff 4 and the resident were noted to tug back and forth on a plate of food until the staff member eventually relinquished the plate to the resident. The interactions were observed to escalate and frustrate the resident and the staff. The resident was observed to continually pick up a plate of food that was not designated for him/her throughout the meal service. Visual frustration by the staff assisting and the resident was observed. During attempts of redirection, Resident 1 escalated to the point of shoving and attempting to strike Staff 6 while Staff 6 was trying to lead the resident back to his/her room to prevent the resident from grabbing at another resident's plate. On 12/12/23 at approximately 12:45 pm, Staff 4 (CG) was interviewed and confirmed the observed behavior by Resident 1 at the recent meal was a common daily behavior exhibited by the resident. Staff 4 stated, "It happens every day at every meal." Staff 4 acknowledged being frustrated with having to try to manage Resident 1's behavior while serving other residents. S/he stated, "It just feels impossible. We just try and get the food out to the other resident's as fast as possible." Staff 4 acknowledged they did not feel the current interventions were effective and that the other residents' meal experience was negatively affected by Resident 1's mealtime behavior. The resident's service plan was reviewed and was not reflective, lacked resident-specific direction for staff, and/or was not consistently implemented by staff relating to meals and behaviors. The service plan did not address behaviors around attempting to take food from other residents or from staff during dining service. There were no identified interventions to help guide staff on how to intervene or redirect the mealtime behavior. The service plan indicated the resident could become "grumpy" with staff, with verbal bossiness and physical behaviors around completing ADL care tasks. Some goals indicated the resident was "easily directed with communication asking if [s/he] needs to use the restroom or offering to color or offering snacks." It also suggested to "change the subject by asking about [his/her] family history book or asking about [his/her] son." The service plan also indicated s/he was easily redirected with ice cream. During the meal observation on 12/12/23 none of the interventions listed in the service plan were attempted with the resident. At 1:45 pm the above observations were reviewed with Staff 1 (ED) and Staff 3 (RCC). Staff 3 indicated she was unaware of any issues the resident had around mealtimes and taking or attempting to take other residents' plates. Staff 3 acknowledged these items were not addressed in the service plan and that interventions were needed to prevent behavioral escalation by Resident 1. The need to ensure Resident 1's service plan was reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (RCC) at 2:00 pm. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's needs, provided clear direction for staff, and were consistently implemented by staff for 1 of 1 sampled resident (#1), whose service plan was reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 11/2022 with diagnoses including dementia with behavioral disturbances. Observations of the resident, interviews with staff, and review of the resident's 12/04/23 service plan were completed. On 12/12/23 at 11:45 am, Resident 1 was observed to exhibit behaviors of taking other residents' food/plates during mealtime. The staff were observed to attempt to grab away the plates the resident reached for. At one time, Staff 4 and the resident were noted to tug back and forth on a plate of food until the staff member eventually relinquished the plate to the resident. The interactions were observed to escalate and frustrate the resident and the staff. The resident was observed to continually pick up a plate of food that was not designated for him/her throughout the meal service. Visual frustration by the staff assisting and the resident was observed. During attempts of redirection, Resident 1 escalated to the point of shoving and attempting to strike Staff 6 while Staff 6 was trying to lead the resident back to his/her room to prevent the resident from grabbing at another resident's plate. On 12/12/23 at approximately 12:45 pm, Staff 4 (CG) was interviewed and confirmed the observed behavior by Resident 1 at the recent meal was a common daily behavior exhibited by the resident. Staff 4 stated, "It happens every day at every meal." Staff 4 acknowledged being frustrated with having to try to manage Resident 1's behavior while serving other residents. S/he stated, "It just feels impossible. We just try and get the food out to the other resident's as fast as possible." Staff 4 acknowledged they did not feel the current interventions were effective and that the other residents' meal experience was negatively affected by Resident 1's mealtime behavior. The resident's service plan was reviewed and was not reflective, lacked resident-specific direction for staff, and/or was not consistently implemented by staff relating to meals and behaviors. The service plan did not address behaviors around attempting to take food from other residents or from staff during dining service. There were no identified interventions to help guide staff on how to intervene or redirect the mealtime behavior. The service plan indicated the resident could become "grumpy" with staff, with verbal bossiness and physical behaviors around completing ADL care tasks. Some goals indicated the resident was "easily directed with communication asking if [s/he] needs to use the restroom or offering to color or offering snacks." It also suggested to "change the subject by asking about [his/her] family history book or asking about [his/her] son." The service plan also indicated s/he was easily redirected with ice cream. During the meal observation on 12/12/23 none of the interventions listed in the service plan were attempted with the resident. At 1:45 pm the above observations were reviewed with Staff 1 (ED) and Staff 3 (RCC). Staff 3 indicated she was unaware of any issues the resident had around mealtimes and taking or attempting to take other residents' plates. Staff 3 acknowledged these items were not addressed in the service plan and that interventions were needed to prevent behavioral escalation by Resident 1. The need to ensure Resident 1's service plan was reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (RCC) at 2:00 pm. They acknowledged the findings.”

“The findings of the on-site investigation, conducted 07/30/2023 through 08/01/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT: Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse The findings of the on-site investigation, conducted 07/30/2023 through 08/01/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT: Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse”

“The findings of the on-site investigation, conducted 07/30/2023 through 08/01/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT: Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse The findings of the on-site investigation, conducted 07/30/2023 through 08/01/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT: Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse”

“The findings of the on-site investigation, conducted 07/30/2023 through 08/01/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT: Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse The findings of the on-site investigation, conducted 07/30/2023 through 08/01/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT: Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse”