Oak Lane Residential Care Facility.

“Based on interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impacted the resident and others in the community were evaluated and included on the service or care plan for 2 of 2 sampled residents (#s 1 and 5) in the MCC whose records were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to report an injury of unknown cause to the local SPD unless an immediate investigation reasonably concluded and documented the injury was not the result of abuse for 1 of 2 sampled residents (#1) in the MCC who had injuries of unknown cause. Findings include, but are not limited to: Resident 1 moved into the MCC in 08/2024 with diagnoses including dementia and a history of falls. The resident’s progress notes and incident reports/investigations dated 12/02/24 to 02/24/25 were reviewed, and the following was identified: The resident experienced an unwitnessed injury fall on 01/27/25. A facility investigation was completed; however, it failed to rule out abuse. During an interview at 2:40 pm on 02/25/25, Staff 5 (Care Coordinator MCC) confirmed the investigation of the incident had not ruled out abuse. Survey requested the facility report the injury fall to the local SPD office, and confirmation was received at 10:25 am on 02/26/25. The need to ensure injuries of unknown cause were reported to the local SPD office unless a facility investigation reasonably concluded and documented the injury was not the result of abuse was discussed with Staff 1 (Regional Director), Staff 2 (ED), and Staff 9 (Regional RN) on 02/26/25. They acknowledged the findings, and no further information was provided. #1 Resident 1 had an unwitnessed injury fall and it was reported to the local SPD office on 02/26/25. The Resident Care Coordinator (RCC) Social Services (SSD), Liscensed Nures (LN) and Executive Director (ED) will complete training on incident reporting and investigation, including proper evaluation and ruling out abuse and neglect All staff will complete Relias training on elder abuse and reporting. #2 The RCC's, SSd, LN and Ed will review incedent reports throughout the weekand will conduct through investigations to rule out abuse and neglect. ED will report to the local APS office as needed if abuse and neglect can not be rulled out. #3 ED will monitor incidents Monday thru Friday to ensure that abuse and neglect concerns have been properly investigated and addressed. #4The ED and LN will be responsible to see that corrections are complete and monitored. OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by:”

“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 service plans were reflective of residents’ needs and preferences and provided clear direction regarding the delivery of services for 2 of 2 sampled residents (#s 1 and 5) in the MCC whose records were reviewed. Findings include, but are not limited to:”

“Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to carry out medication orders as prescribed for 1 of 2 sampled residents (#1) in the MCC whose records were reviewed. Findings include, but are not limited to: Resident 1 moved into the MCC in 08/2024 with diagnoses including dementia, hypertension, hypothyroidism, and Type 2 diabetes. The resident’s 02/01/25 to 02/24/25 MAR and “Administration” notes and current physician orders were reviewed. The following was identified: The resident had the following orders: Staff documented the medications were not administered due to the medications not being available as follows: * Aspirin, on 12 occasions; * Levothyroxine, on 12 occasions; and * Metformin, on 25 occasions. Staff 9 (Regional RN) stated at 10:20 am on 02/26/25 that the resident’s pharmacy had sent the refill requests to the wrong provider, and MCC staff had not made the nurse aware of the medications not being filled. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (Regional Director), Staff 2 (ED), and Staff 9 on 02/26/25. They acknowledged the findings, and no further information was provided. #1-Resident 1's medications were updated and carried out as prescribed by the physician. RCC's will complete a facility audit of missed and unavailable medications to ensure all residents have their medications available. #2RCC's will receive additional training on ordering medications. Med-aids will complete training on missed medications, unavailble medications, and medication ordering conducted by LN. #3 The clinical team will meet daily to ensure all medications are in the facility #4 The LN and ED will monitor missed medications reports daily and provide support to RDD's and med-aids OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:”

“Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated no less than quarterly for 46 of 54 residents. Findings include, but are not limited to: During the acuity interview at 1:30 pm on 02/24/25, Staff 1 (Regional Director) confirmed the facility census was at 54 residents. The facility’s ABST data and posted staffing plan were reviewed at 1:30 pm on 02/26/25. The ABST data for 46 of 54 residents did not show documented evidence of being updated at least quarterly. During an interview on 02/26/25 at 2:30 pm, Staff 4 (Social Services Director) stated the facility process for updating the ABST included to update it at the same time the service plan was being updated and/or with significant changes of condition. No additional documentation was provided to show the ABST for the above residents had been updated at least quarterly. The need to ensure residents’ ABST was updated no less than quarterly was discussed with Staff 1 (Regional Director), Staff 2 (ED), Staff 3 (Health Services Director/LPN) and Staff 9 (Regional RN) on 02/27/25. They acknowledged the findings. #1The ED and SSD will conduct a facility-wide audit of all residents assesments for accuracy. #2 Post-audit, the SSD will update the Acuity Based Tool after each care conference. #3 Each residents assesment will be updated every 90 days. #4 The ED will ensure the above processes are completed weekly. OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were safely stored in a locked storage and exterior pathways were maintained in good repair. Findings include, but are not limited to: During a tour of the facility on 02/24/25 at 2:00 pm, the following was identified: * Cleaning chemicals and disinfectants were found unlocked in cabinets under the sink and counter in the kitchenette of the memory care unit. The kitchenette area was easily accessible to residents; * The exterior pathways and accesses to the facility had multiple cracked and uneven concrete areas. There were multiple drop-offs of one to two inches along pathway edges. A concrete path between buildings had a drop-off of up to four inches measured from the pathway’s edge to the asphalt. The drop-offs created a potential tripping and fall hazard for residents; and * There was an accumulation of yard debris and miscellaneous refuse around the exterior of the building. The need to ensure chemicals were kept in a locked storage and exterior pathways were maintained in good repair was shown to and discussed with Staff 1 (Regional Director) and Staff 2 (ED) on 02/26/25. They acknowledged the findings. #1 The ED will conduct weekly audits to ensure all chemicals and disinfectants are stored properly. The Ed and RDO will obtain estimates to replace all cracked and uneven areas. #2 Maintence will conduct daily walks to ensure no accumulation yard debris or trash. Staff will receive additional training on proper chemicals and disinfectant storage. The facility will remove concrete pathway and install grass or rock. #3The ED will perform weekly inspections to ensure the facility's exterior is free of debris. #4 The ED and head of maintence will be responsible for seeing all corrections are completed. OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: ?Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were safely stored in locked storage and exterior pathways were maintained in good repair. Findings include, but are not limited to: The facility continues to be out of compliance in the area of general building exterior; however, they have requested and were approved for an extension to their allegation of compliance date of 09/28/25. OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to: Observations of the facility on 02/24/25 through 02/26/25 showed the following areas were in need of cleaning and/or repair: * Carpet throughout the facility including resident rooms, had dark stains of varying sizes and showed significant signs of wear and tear; * Doors and door frames throughout the facility, including resident rooms on the west and east sides, were gouged, scraped, and damaged; * The doors to the laundry rooms had been removed; * Dining room chairs and tables were scraped, dinged, and chipped; * The memory care unit common-use bathroom had discolored and missing caulking around the toilet base and shower area; and * There was a consistently pervasive odor of urine throughout the memory care unit. The need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (Regional Director) and Staff 2 (ED) on 02/26/25. They acknowledged the findings. #1The facility will replace all carpeting throughout, Laundry and dining room doors will be replaced. Floors in the MC bathroom and discolored caulking around toilets and showers will be replaced. The facility will repair or restain doors. The facility will increase air circulation to manage the odors. #2. The Head of maintence and ED will walk the facilty regularly to do regular maintence to maintain facility in accordence with regulations. #3The ED will conduct walk throughs 3X a week to ensure facility maintains state regulations #4 The ED and RDO will be responsible to see that the corrections are completed. OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to: The facility continues to be out of compliance in the area of environment; however, they requested and were approved for an extension to their allegation of compliance date of 09/28/25. OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with a functional alarm for security purposes and to alert staff when residents exited the facility and failed to provide a call system that connected resident units to the care staff or staff pagers on the memory care unit and that a manually operated emergency call system was provided in each toilet and bathing facility used by residents and visitors. Findings include, but are not limited to: A tour of the facility on 02/24/25 identified the following: * Exit doors, including the doors to the secured courtyard of the memory care unit, lacked an operational alarming device or other acceptable system to alert staff when residents exited the building; * There were no manually operated emergency call systems in any of the common-use bathrooms used by residents and visitors; and * There was no call system in place to connect resident units to the care staff or staff pagers in the memory care unit. Observations made of the memory care unit during the survey and interviews with staff indicated residents were routinely checked on every one to two hours by staff due to the lack of a call system. During a walkthrough of the facility on 02/26/25 at 1:15 pm, Staff 1 (Regional Director) and Staff 2 (ED) verified that the exit door alarms were inoperable and acknowledged that there were no call systems in the memory care and common-use bathrooms used by residents and visitors. Staff 1 reported that the facility had already contacted a call system company and that they would be at the facility the following week for installation. The need to ensure exit doors were equipped with a functional alarm for security purposes and to alert staff when residents exited the facility, and that the memory care had a call system, including providing a manually operated emergency call system in all the common-use bathrooms used by residents and visitors was reiterated to Staff 1 and Staff 2 on 02/27/25. F ? ? #1 A new call light sytem will be installed in MC and add bathroom call lights throughout the facility. The facility will also add door alarms to the current call light system. #2 The facility will obtain bids to have new call system installed in MC as well as bathroom call lights #3 The RCC and ED will verify system is working properly twice a week. #4 The ED and RDO will be responsible to follow through with assuring the corrections are completed and meet the state requirements OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with a functional alarm for security purposes and to alert staff when residents exited the facility and failed to provide a call system that connected resident units to the care staff or staff pagers on the memory care unit and that a manually operated emergency call system was provided in each toilet and bathing facility used by residents and visitors. Findings include but are not limited to: The facility continues to be out of compliance in the areas of call systems and exit door alarms, however, they requested and were approved for an extension to their allegation of compliance date of 09/28/25. OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident 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 C231, C295, C363, C510, C513, C555. Refer to corrective actions outlined in C0295, C0231, C0363, C0510, C0513, and C0555. 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 follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C510, C513, and C555. 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 ensure health services were consistently provided in accordance with the licensing rules of the facility. Findings include, but are not limited to: Refer to C260, C303. Refer to corrective actions outlined in C0260, and C0303. 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:”

“Based on interview and record review, it was determined the facility failed to ensure an individualized nutritional plan for each resident was developed and included in residents' service plans for 2 of 2 sampled residents (#s 1 and 5) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to: Service plans for Residents 1 and 5 were reviewed during survey. Each of the service plans included some food preferences but lacked individualized hydration information and staff instructions related to meeting resident-specific nutrition and hydration needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Regional Director), Staff 2 (ED), Staff 3 (Health Services Director/LPN), and Staff 9 (Regional RN) on 02/27/25. They acknowledged the findings #1-Residents #1 and #5 service plans were updated to reflect individualized nutrition/hydration information and staff instructions related to meeting resident-specific nutrition and hydration needs. RCC will audit each residents diet for accuracy and ensure each each resident has a nutrition/hydration plan for MC. #2 Facility will purchase cups for MC residents: staff will fill each shift and as needed. RCC and ED will verify that staff is filling residents cups with fresh water throughout each shift. #4 The RCC and ED will follow up and ensure this correction is complete and monitored for continued frequency. OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:”

“The findings of the kitchen inspection, conducted 06/03/24, 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 and OARs 411 Division 57 for Memory Care Communities. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. The findings of the kitchen inspection, conducted 06/03/24, 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 and OARs 411 Division 57 for Memory Care Communities. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. The findings of the revisit to the kitchen inspection of 06/03/24, conducted 09/09/24, 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 and OARs 411 Division 57 for Memory Care Communities. The findings of the revisit to the kitchen inspection of 06/03/24, conducted 09/09/24, 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 and OARs 411 Division 57 for Memory Care Communities.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The kitchen was toured with Staff 2 (Kitchen Manager) on 06/03/24. Observations of the facility's kitchen, food storage areas, food preparation, and food service on 06/03/24 revealed: * Splatters, spills, stains, and debris noted on: - Hand washing sink; - Can opener blade and casing; - Wire rack storage shelves in walk-in refrigerator, walk in freezer, and throughout the kitchen; - Open shelving throughout the kitchen; - Walls throughout the kitchen; - Floors in walk-in refrigerator, walk-in freezer, throughout the kitchen,  cove base, and drains; - The dishwashing area walls, floors, and equipment; - Both sides of the range, grill, and oven; - Standing mixer; - Carts; - Free standing air conditioner; - Interior of drawers in main kitchen and Memory Care dining room; and - Cabinet fronts in the Memory Care dining room. * Walls, shelving, flooring, and cove base through the kitchen was damaged, creating un-cleanable surfaces. * The plastic cutting board attached to the steam table were deeply scored and stained black. * There was an approximately 2 foot wooden cutting board attached to the steam table. * Dish racks were stored directly on the floor. * A soiled cloth was observed stored over the clean flatware bin. * There were undated and unlabeled foods in the walk in refrigerator and reach in refrigerator in the Memory Care dining room. * Packaged foods were not dated when opened. * There were expired food items in the walk in refrigerator. The kitchen was reviewed with Staff 1 (Executive Director) and Staff 2 on 06/03/24. They acknowledged the findings. Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The kitchen was toured with Staff 2 (Kitchen Manager) on 06/03/24. Observations of the facility's kitchen, food storage areas, food preparation, and food service on 06/03/24 revealed: * Splatters, spills, stains, and debris noted on: - Hand washing sink; - Can opener blade and casing; - Wire rack storage shelves in walk-in refrigerator, walk in freezer, and throughout the kitchen; - Open shelving throughout the kitchen; - Walls throughout the kitchen; - Floors in walk-in refrigerator, walk-in freezer, throughout the kitchen,  cove base, and drains; - The dishwashing area walls, floors, and equipment; - Both sides of the range, grill, and oven; - Standing mixer; - Carts; - Free standing air conditioner; - Interior of drawers in main kitchen and Memory Care dining room; and - Cabinet fronts in the Memory Care dining room. * Walls, shelving, flooring, and cove base through the kitchen was damaged, creating un-cleanable surfaces. * The plastic cutting board attached to the steam table were deeply scored and stained black. * There was an approximately 2 foot wooden cutting board attached to the steam table. * Dish racks were stored directly on the floor. * A soiled cloth was observed stored over the clean flatware bin. * There were undated and unlabeled foods in the walk in refrigerator and reach in refrigerator in the Memory Care dining room. * Packaged foods were not dated when opened. * There were expired food items in the walk in refrigerator. The kitchen was reviewed with Staff 1 (Executive Director) and Staff 2 on 06/03/24. They acknowledged the findings. -Splatter, spills, stains and debris- Clean handwashing sink twice a shift and as needed to cut down on debris. Dining Director to over see and audit that it is done by 8/2/2024 -Hand washing sink will only be used for hand washing. Can opener blade and casing to be cleaned after each use as well as checked every shift. Dining Director to over see and audit that it is continuing to be done by 8/2/2024 -Wire racks to be cleaned twice a week and as needed. Staff to insure that racks are in good working condition. Dining Director responsible for audit and to make sure everything needing replaced is done so before 8/2/2024 -Open shelving in the kitchen will only contain dishware, that will be stored properly, staff to insure that racks are in good working order. Dining Director to audit daily. will be in compliance by 8/2/2024 -Deep cleaning of all walls and surfaces to be done once a month and as needed. Maintenance to clean and repair uncleanable surfaces and walls. Deep clean of walk in freezer and refrigerator. And maintain a daily, weekly and monthly cleaning schedule. Dining Director to audit and maintain cleaning schedule by 8/2/2024 -Non slip grip to be replaced in freezer. Floors to be cleaned daily. And deep cleaned once a month and as needed. Cleaning schedule and audit to be done daily by Dining Director and Executive Director And will be in compliance by 8/2/2024 -All carts and equipment will be checked and cleaned daily. To be over seen by Dining Director. compliance by 8/2/2024 -Free standing air conditioner will be moved away from ice machine and cleaned weekly as needed. Will be monitored and tracked on cleaning schedule and be in compliance by 8/2/2024 -All damaged areas of floors, walls, shelving and cove bases to be repaired to be a cleanable surface. Maintenance Director to complete by 8/2/2024 -Plastic Cutting board to be replaced. Ordering new cutting board and will maintain and switch out when needed. Dining Director and Maintenance will replace and monitor. Compliance by 8/2/2024 -Wood rack on steam table to be replaced with a cleanable surface. Ordering and replacing wood cutting board with appropriate material. Compliance by 8/2/2024 -Dish racks to be stored in dish pit off of floor. Will be followed by Dining Director doing cleaning Audits and daily walk throughs. Compliance by 8/2/2024 -In-service with staff of where to place soiled rags, sign off sheet to be put in place to show that staff had the training. Daily audits and walk throughs done by Dining Director and Executive Director. Compliance by 8/2/2024 -Proper dating of opened items will be checked daily by kitchen staff and audited bu Dining Director. Compliance by 8/2/2024 -Food will be checked for expiration dates and thrown out before they are expired. Audited byb Dining Director. Compliance by 8/2/2024 Training on policy and procedures for kitchen operations to be provided by Executive Director. Executive Director and Dinning Director Will be responsible to see that the corrections are completed/ monitored no later then 8/2/2024 and on. -Splatter, spills, stains and debris- Clean handwashing sink twice a shift and as needed to cut down on debris. Dining Director to over see and audit that it is done by 8/2/2024 -Hand washing sink will only be used for hand washing. Can opener blade and casing to be cleaned after each use as well as checked every shift. Dining Director to over see and audit that it is continuing to be done by 8/2/2024 -Wire racks to be cleaned twice a week and as needed. Staff to insure that racks are in good working condition. Dining Director responsible for audit and to make sure everything needing replaced is done so before 8/2/2024 -Open shelving in the kitchen will only contain dishware, that will be stored properly, staff to insure that racks are in good working order. Dining Director to audit daily. will be in compliance by 8/2/2024 -Deep cleaning of all walls and surfaces to be done once a month and as needed. Maintenance to clean and repair uncleanable surfaces and walls. Deep clean of walk in freezer and refrigerator. And maintain a daily, weekly and monthly cleaning schedule. Dining Director to audit and maintain cleaning schedule by 8/2/2024 -Non slip grip to be replaced in freezer. Floors to be cleaned da”

“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 C 240. 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 C 240. -Splatter, spills, stains and debris- Clean handwashing sink twice a shift and as needed to cut down on debris. Dining Director to over see and audit that it is done by 8/2/2024 -Hand washing sink will only be used for hand washing. Can opener blade and casing to be cleaned after each use as well as checked every shift. Dining Director to over see and audit that it is continuing to be done by 8/2/2024 -Wire racks to be cleaned twice a week and as needed. Staff to insure that racks are in good working condition. Dining Director responsible for audit and to make sure everything needing replaced is done so before 8/2/2024 -Open shelving in the kitchen will only contain dishware, that will be stored properly, staff to insure that racks are in good working order. Dining Director to audit daily. will be in compliance by 8/2/2024 -Deep cleaning of all walls and surfaces to be done once a month and as needed. Maintenance to clean and repair uncleanable surfaces and walls. Deep clean of walk in freezer and refrigerator. And maintain a daily, weekly and monthly cleaning schedule. Dining Director to audit and maintain cleaning schedule by 8/2/2024 -Non slip grip to be replaced if freezer. Floors to be cleaned daily. And deep cleaned once a month and as needed. Cleaning schedule and audit to be done daily by Dining Director and Executive Director And will be in compliance by 8/2/2024 -All carts and equipment will be checked and cleaned daily. To be over seen by Dining Director. compliance by 8/2/2024 -Free standing air conditioner will be moved away from ice machine and cleaned weekly as needed. Will be monitored and tracked on cleaning schedule and be in compliance by 8/2/2024 -All damaged areas of floors, walls, shelving and cove bases to be repaired to be a cleanable surface. Maintenance Director to complete by 8/2/2024 Plastic Cutting board to be replaced. Ordering ne cutting board and will maintain and switch out when needed. Dining Director and Maintenance will replace and monitor. Compliance by 8/2/2024 -Wood rack on steam table to be replaced with a cleanable surface. Ordering and replacing wood cutting board with appropriate material. Compliance by 8/2/2024 -Dish racks to be stored in dish pit off of floor. Will be followed by Dining Director doing cleaning Audits and daily walk throughs. Compliance by 8/2/2024 -Inservice with staff of where to place soiled rags. Sign off sheet to be put in place to show staff received training. Daily audits and walk throughs done by Dining Director and Executive Director. Compliance by 8/2/2024 Proper dating of opened items will be checked daily by kitchen staff and audited bu Dining Director. Compliance by 8/2/2024 -Food will be checked for expiration dates and thrown out before they are expired. Audited by Dining Director. Compliance by 8/2/2024 Inservice on policy and procedures for kitchen operations to be provided by Executive Director with sign off sheets to show that staff received the training. Executive Director and Dinning Director Will be responsible to see that the corrections are completed/ monitored no later then 8/2/2024 and on -Splatter, spills, stains and debris- Clean handwashing sink twice a shift and as needed to cut down on debris. Dining Director to over see and audit that it is done by 8/2/2024 -Hand washing sink will only be used for hand washing. Can opener blade and casing to be cleaned after each use as well as checked every shift. Dining Director to over see and audit that it is continuing to be done by 8/2/2024 -Wire racks to be cleaned twice a week and as needed. Staff to insure that racks are in good working condition. Dining Director responsible for audit and to make sure everything needing replaced is done so before 8/2/2024 -Open shelving in the kitchen will only contain dishware, that will be stored properly, staff to insure that racks are in good working order. Dining Director to audit daily. will be in compliance by 8/2/2024 -Deep cleaning of all walls and surfaces to be done once a month and as needed. Maintenance to clean and repair uncleanable surfaces and walls. Deep clean of walk in freezer and refrigerator. And maintain a daily, weekly and monthly cleaning schedule. Dining Director to audit and maintain cleaning schedule by 8/2/2024 -Non slip grip to be replaced if freezer. Floors to be cleaned daily. And deep cleaned once a month and as needed. Cleaning schedule and audit to be done daily by Dining Director and Executive Director And will be in compliance by 8/2/2024 -All carts and equipment will be checked and cleaned daily. To be over seen by Dining Director. compliance by 8/2/2024 -Free standing air conditioner will be moved away from ice machine and cleaned weekly as needed. Will be monitored and tracked on cleaning schedule and be in compliance by 8/2/2024 -All damaged areas of floors, walls, shelving and cove bases to be repaired to be a cleanable surface. Maintenance Director to complete by 8/2/2024 Plastic Cutting board to be replaced. Ordering ne cutting board and will maintain and switch out when needed. Dining Director and Maintenance will replace and monitor. Compliance by 8/2/2024 -Wood rack on steam table to be replaced with a cleanable surface. Ordering and replacing wood cutting board with appropriate material. Compliance by 8/2/2024 -Dish racks to be stored in dish pit off of floor. Will be followed by Dining Director doing cleaning Audits and daily walk throughs. Compliance by 8/2/2024 -Inservice with staff of where to place soiled rags. Sign off sheet to be put in place to show staff received training. Daily audits and walk throughs done by Dining Director and Executive Director. Compliance by 8/2/2024 Proper dating of opened items will be checked daily by kitchen staff and audited bu Dining Director. Compliance by 8/2/2024 -Food will be checked for expiration dates and thrown out before they are expired. Audited by Dining Director. Compliance by 8/2/2024 Inservice on policy and procedures for kitchen operations to be provided by Executive Director with sign off sheets to show that staff received the training. Executive Director and Dinning Director Will be responsible to see that the corrections are completed/ monitored no later then 8/2/2024 and on There are no detail notes for this visit.”