Regent Court.

“Based on observation and interview, it was determined the facility failed to ensure exterior pathways were maintained in good repair. Findings include, but are not limited to: The exterior pathways in the center courtyards contained drop-offs along pathway edges. These drop-offs created a potential tripping and fall hazards for residents. On 10/07/25, the need to ensure exterior pathways were maintained in good repair was shown to and discussed with Staff 1(ED) and Staff 9 (Environmental Services Director). They acknowledged the findings.”

“Based on observation, interview, and record review, it was determined that the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of 1 of 1 sampled resident (#5) who required a modified texture diet, and multiple unsampled residents who required modified texture diets. This placed the residents at risk for potential choking episodes and aspiration and constituted a threat to the residents’ health and safety. Findings include, but are not limited to:”

“Based on observation and interview, it was determined the facility failed to ensure all interior and exterior surfaces and all equipment necessary for the health, safety, and comfort of the residents was kept clean and in good repair. Findings include, but are not limited to: Observations of the facility on 10/06/25 revealed the following: * Multiple doors had scrapes and missing paint on doors and door frames; * Multiple walls throughout the facility had scrapes and missing paint; and * Multiple pathway lights in the courtyard were broken. On 10/07/25, the need to ensure the facility’s interior and exterior were kept clean and in good repair was discussed with and shown to Staff 1 (ED) and Staff 9 (Environmental Services Director). They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure units had entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. Findings include, but are not limited to: Observations made during the survey from 10/06/25 through 10/09/25 identified most resident units had a flathead locking mechanism which were not lockable by the individual. In an interview with Staff 1 (ED) on 10/07/25, it was reported none of the residents in the facility were given a key to their individual rooms. On 10/07/25, the need to ensure residents had a key to access their unit was discussed with Staff 1. She acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to apply individually-based limitations (IBLs) when residents were not provided with a key to their room. Findings include, but are not limited to: During the survey, the MCC was home to 44 residents. During an interview on 10/08/25 at 1:25 pm, Staff 1 (ED) confirmed no residents currently had keys to their own apartments. She also confirmed no residents currently had IBLs in place, regarding not having possession of a key to their personal living units. On 10/09/25 the need to apply an IBL for any resident who was not provided a key to their own apartment, was discussed with Staff 1 (ED), staff 2 (RN/Health and Wellness Director) and staff 7 (Nurse Consultant). They acknowledged the findings.”

“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 C160, C510, C513, H1518, and H1580.”

“Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight, stability, design, and was maintained to prevent resident injury or aid in elopement. Findings include, but are not limited to: During an environmental walk-through of the facility grounds, including the memory care courtyards, on 10/06/25, the following was identified: * Eight lightweight folding tables were observed in the MCC courtyard; and * A lightweight folding chair was observed in the MCC courtyard. The outdoor furniture noted above was not of sufficient weight, stability, design, or maintained to prevent resident injury or aid in elopement. On 10/06/25, the need to ensure outdoor furniture was of sufficient weight, stability, design, and was maintained to prevent resident injury or aid in elopement was discussed during an environment tour with Staff 1 (ED). She acknowledged the findings.”

“Based on interview and record review, conducted during a site visit on 01/31/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: Resident 2 no longer resided in the facility. During an interview on 01/31/24, Staff 4 (MT) indicated the following, · Transferring residents who require two-person assist with one staff member has happened a lot due to the lack of staff to provide those services. · A caregiver this morning told me they had assisted a two-person transfer alone without asking for a second person today. The residents care plan stated the resident was a two-person assist. A review of Resident 3 service plan, dated 01/24/24, indicated Resident 3 required two-person Hoyer lift assist to and from the wheelchair, shower and bed. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. On 01/31/24, the findings were reviewed with and acknowledged by Staff 1 (Executive Director). Verbal plan of correction: The facility has revised the Agency Orientation sign off which now includes verbiage stating that the staff have read and will be held liable for completing cares per the service plans provided for our residents. Our RCC team will also have returning workers sign off that they have read and are following our residents care plans. The staff in question has been DNR'd (Do Not Return.) Lastly, the ED will complete an in-service at our next all staff on the importance of reporting incidents such as this immediately. Based on interview and record review, conducted during a site visit on 01/31/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: Resident 2 no longer resided in the facility. During an interview on 01/31/24, Staff 4 (MT) indicated the following, · Transferring residents who require two-person assist with one staff member has happened a lot due to the lack of staff to provide those services. · A caregiver this morning told me they had assisted a two-person transfer alone without asking for a second person today. The residents care plan stated the resident was a two-person assist. A review of Resident 3 service plan, dated 01/24/24, indicated Resident 3 required two-person Hoyer lift assist to and from the wheelchair, shower and bed. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. On 01/31/24, the findings were reviewed with and acknowledged by Staff 1 (Executive Director). Verbal plan of correction: The facility has revised the Agency Orientation sign off which now includes verbiage stating that the staff have read and will be held liable for completing cares per the service plans provided for our residents. Our RCC team will also have returning workers sign off that they have read and are following our residents care plans. The staff in question has been DNR'd (Do Not Return.) Lastly, the ED will complete an in-service at our next all staff on the importance of reporting incidents such as this immediately.”

“The findings of the kitchen inspection, conducted 01/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the kitchen inspection, conducted 01/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the revisit to the kitchen inspection of 01/04/24, conducted on 03/13/24, 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 revisit to the kitchen inspection of 01/04/24, conducted on 03/13/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.”

“Based on observation and interview, it was determined the facility failed to 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 facility kitchen was reviewed on 01/04/24 from 11:15 am through 2:00 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Refrigerators in unit kitchenettes; * Floors, walls, cabinets and drawers in unit kitchenettes; * Handles of reach in coolers and freezers in main kitchen area; * Light fixtures in hallway storing freezers; * Floors in hallway storing freezers; * Fan and lights above steam table in North unit; * Juice machine; * Radio, timer and phone; and * Industrial mixer. b. The following areas were in need of repair: * Large open area in wall in hallway where freezers where stored; * Reach in refrigerator in south unit not holding correct temperature for cold food storage; * Caulking behind ware washing area with black mold like substance; * Walls in dry storage with peeling/chipped paint and damage from canned goods; and * Racks in reach in coolers with rust. c. Dishwashing racks observed stored on the floor. d. Refrigerator in south unit found at 50 degrees Fahrenheit. Milk products, yogurts and other protein rich items stored for service to residents. Milk was temped and was at 47.5 degrees F higher than the required 41 degrees for safe food storage. Facility did not have a process for monitoring temperatures of unit fridges to ensure kept at appropriate temperature levels for safe food storage. e. Entire box of red potatoes found in dry storage wilting and growing roots with fuzzy white substance. Staff 2 acknowledged those items were bad and should have been thrown away. f. Ready shakes were found stored in multiple reach in fridges without dates to indicate when to use them by. g. Reach in refrigerator on South unit observed without a thermometer to indicate what temperature food was stored at. A carton of eggs was observed stored in there with a use by date of 12/21/23. At approximately 1:15 pm, the surveyor reviewed above areas with Staff 2 (Kitchen Manager) and Staff 1 (Administrator in training), who acknowledged the identified areas. 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 facility kitchen was reviewed on 01/04/24 from 11:15 am through 2:00 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Refrigerators in unit kitchenettes; * Floors, walls, cabinets and drawers in unit kitchenettes; * Handles of reach in coolers and freezers in main kitchen area; * Light fixtures in hallway storing freezers; * Floors in hallway storing freezers; * Fan and lights above steam table in North unit; * Juice machine; * Radio, timer and phone; and * Industrial mixer. b. The following areas were in need of repair: * Large open area in wall in hallway where freezers where stored; * Reach in refrigerator in south unit not holding correct temperature for cold food storage; * Caulking behind ware washing area with black mold like substance; * Walls in dry storage with peeling/chipped paint and damage from canned goods; and * Racks in reach in coolers with rust. c. Dishwashing racks observed stored on the floor. d. Refrigerator in south unit found at 50 degrees Fahrenheit. Milk products, yogurts and other protein rich items stored for service to residents. Milk was temped and was at 47.5 degrees F higher than the required 41 degrees for safe food storage. Facility did not have a process for monitoring temperatures of unit fridges to ensure kept at appropriate temperature levels for safe food storage. e. Entire box of red potatoes found in dry storage wilting and growing roots with fuzzy white substance. Staff 2 acknowledged those items were bad and should have been thrown away. f. Ready shakes were found stored in multiple reach in fridges without dates to indicate when to use them by. g. Reach in refrigerator on South unit observed without a thermometer to indicate what temperature food was stored at. A carton of eggs was observed stored in there with a use by date of 12/21/23. At approximately 1:15 pm, the surveyor reviewed above areas with Staff 2 (Kitchen Manager) and Staff 1 (Administrator in training), who acknowledged the identified areas.”

“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 not limited to: Refer to C 240. 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 not limited to: Refer to C 240. See above plan to reach compliance. See above plan to reach compliance. There are no detail notes for this visit.”