Footsteps at Clackamas Woods.

“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 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 on 07/29/25 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 and Division 57 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day The findings of the on-site investigation, conducted on 07/29/25 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 and Division 57 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day”

“Based on observation, 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 C200, C295, C360, C362, C420, C513, C530, and C545. Refer to C200, C295, C420, C513, C530 and C545 for plan of correction 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 their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to evaluate residents for activities and develop an individualized activity plan based on the evaluation for 1 of 3 sampled residents (# 3) whose records were reviewed. Findings include, but are not limited to: Residents 3's most recent evaluation and service plan was reviewed. a. Review of Resident 3's service plan dated 07/12/24 and initial evaluation dated 03/13/24 offered some information about the resident's interests; however, the facility had not fully evaluated the resident's: * Current skills; * Emotional and social needs and patterns; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. b. There was no individualized activity plan developed based on the evaluation that reflected the resident's activity preferences and needs for Residents 3. The need to ensure the facility evaluated each resident for activities and developed an individualized activity plan based on the evaluation was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (Memory Care Coordinator) on 10/17/24 at 2:25 pm. They acknowledged the findings. 1) Based on interview and record review, facility failed to evaluate residents for activities and individulized activity plans for residents #1 and #3. a. Resident #3 was not fully evaluated for current skill, emotional & social needs, adaptations necessary, identification of activities for behavioral interventions. Care plan was immediately updated. b. There was no individualized activity plan developed based on the evaluation that reflected the needs for Residents #1 and #3. The care plan was reviewed to ensure compliance. 2) All resident activities plans have been reviewed and found to be in compliance of the OAR. The Memory Care administrator will ensure at the time of move in that a comprehensive activities plan is in place that is specific to the new resident. This will also be reviewed during quarterly evaluations. Each month 3 random residents will be reviewed for compliance on going. 3) Individualize activity plans will be reviewed upon move in, during quarterly evaluations, or when there has been a change in condition. Further, 3 random individualized activities plans will be reviewed each month. 4) Memory Care Administor, MCC, RSCs, Administrator or designee OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that promoted privacy, respect, and dignity in a homelike environment for 1 of 3 sampled residents (#2) and multiple unsampled residents. Findings include, but are not limited to: a. Observations on 10/14/24 at 12:05 pm identified the following: * Two unsampled residents shared a room which separated the room in half by a common wall. Each resident lacked a privacy screen to allow for privacy when the other roommate entered into the room or the bathroom. Additionally, the shared bathroom the two roommates used lacked a lock on the bathroom door. In an interview on 10/15/24 at 2:00 pm with Staff 1 (ED) when asked how the residents in apartment 1 (Fir unit) were provided privacy for care and services, Staff 1 reported there was no privacy screen/curtain available. The need to ensure residents' right to be afforded privacy was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (Resident Services Coordinator) on 10/17/24. They acknowledged the findings. b. Resident 2 was admitted to the facility in 06/2023 with diagnoses including vascular dementia. During the acuity interview on 10/14/24 at 9:42 am, Resident 2 and an unsampled resident were identified as requiring assistance with eating. Meal observations were conducted on 10/14/24 and 10/15/24. Caregivers were observed providing full assistance with eating for Resident 2 and an unsampled resident. Staff were standing over the residents instead of sitting next to them. On 10/15/24 at 12:31 pm, Staff 13 (CG) was asked why s/he stood while providing assistance eating. Staff 13 reported s/he tried not to sit too much, or s/he got sleepy. The need to ensure residents' right to be afforded privacy and treated with dignity and respect was discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (Resident Services Coordinator) on 10/17/24 at 2:17 pm. They acknowledged the findings. 1) Based on observation and interview, it was determined that the facility failed to: a. ensure privacy to residents as evidenced by the lack of a privacy screen in shared rooms and lack of a lock on a shared room bathroom doors. A lock was added to the bathroom door immediately by the Plant Ops Director and all remaining shared bathrooms were evaluated and found to be in compliance. Privacy curtains to be installed into shared rooms to ensure privacy when roommate enters into the room or bathroom. b. Ensure resident dignity and respect while providing full assistance with eating by standing over them instead of sitting next to them. Staff was counseled as to the importance of protecting the resident's dignity by sitting at eye level with resident while assisting during mealtimes. 2) a. A lock was added to the bathroom door immediately by the Plant Ops Director and all remaining shared bathrooms were evaluated and found to be in compliance. b. Staff was counseled as to the importance of protecting the resident's dignity by sitting at eye level with resident. 3) a. All rooms to be walked monthly to check for compliance. b. A manager will make an unscheduled walk through during mealtimes weekly to observe meal times and service. 4) a. Plant Ops Director, Memory Care Administrator, MCC, RSC, Health Services Administrator or designee b. Memory Care Administrator, MCC, RSC, Health Services Administrator or designee OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 1 of 1 sampled resident (#2) during incontinence care and multiple sampled and unsampled residents during meal service. Findings include, but are not limited to:”

“based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to: a. On 10/14/24 during the entrance conference, survey requested a facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs. Staff 2 (Memory Care Administrator) stated the facility used the Department’s acuity-based staffing tool (ABST) to determine staffing levels. The ABST was reviewed during the survey. The facility ABST was not accurately being used to determine the correct staffing minutes for sampled Residents 2 and 3 who required 1:1 meal assistance and/or increased ADL care needs due to behaviors. Refer to C 362 b. During the acuity interview on 10/14/24 the following was identified: The facility was home to 24 residents, in two distinct and segregated units. i. Fir Unit * Twelve residents; * One resident required a two-person assist transfer; * One resident required a two-person assist transfer using a sit-to-stand lift; * One resident was identified as exit seeking; and * Two residents were identified as fall risks. ii. Grove Unit * Twelve residents; * Two residents required a two-person assist with transfers; * Two residents required cueing/redirection during meals and/or one-on-one assistance with feeding; and * One resident was identified as exit seeking. c. The staffing plan posted by the facility was as follows: Day shift: 6:00 am to 2:00 pm Fir Unit - 0.5 Med Tech, 1 Caregiver Grove Unit – 0.5 Med Tech, 2 Caregivers Swing Shift: 2:00 pm to 10:00 pm Fir Unit - 0.5 Med Tech, 1 Caregiver Grove Unit – 0.5 Med Tech, 2 Caregivers Overnight (NOC) Shift: 10:00 pm to 6:00 am Fir Unit - 0.5 Med Tech, 1 Caregiver Grove Unit – 0.5 Med Tech, 1 Caregiver d. During interviews conducted 10/14/24 through 10/17/24, family and staff stated the following: *During an interview on 10/14/24, Staff 13 (CG) stated there was always a float caregiver between Fir and Grove units on day shift and swing shift. This was confirmed with Staff 2 (Memory Care Administrator) on 10/14/24. She acknowledged each unit has one caregiver on all shifts and one caregiver was assigned as a float between the Fir unit and Grove unit on day shift and swing shift. * During an interview with a resident’s family member on 10/16/24 at 10:33 am, s/he stated, “Sometimes I’d like to see more workers there, for the residents and for the workers. If something came up, and I know it is a locked unit, but what would happen if one patient required a one-to-one situation or a fall. If they [the caregivers] are the only one. I’m sure they have people who can come from another unit quickly. Can [the staff] get it done?” e. Observations conducted on the Fir and Grove units throughout survey showed the following: * On 10/14/24 and 10/15/24, observations made in Fir unit found residents left alone on the unit during breakfast and lunch. * On 10/14/24 at 2:40 pm, a resident’s family member was observed to walk into the common area, looked around and then returned to a resident’s room. S/he stated, “I’ll have to wait until I see someone.” f. Fire and life safety and evacuation requirements were reviewed throughout the survey and revealed the following: During an interview on 10/15/24, Staff 1 (ED) indicated facility procedure during an evacuation was to use staff from the separately licensed assisted living facility as part of the evacuation plan. During an interview with Staff 6 (Plant Operations Manager) on 10/16/24 at 10:00 am, he identified that in the event of a fire the following would occur: * In the Fir unit, three doors (the main exit, to the courtyard and north exit) unlocked automatically; * In the Grove unit, three doors (the main exit, to the courtyard and south exit) unlocked automatically; * Regardless of which unit the fire was in, two exit gates from the shared courtyard unlocked automatically; and * If there was a fire on NOC shift, one staff member was expected to locate the source of the fire and one staff member was expected to watch one of the three doors that unlocked. They were then expected to call for back up assistance. Staff 6 acknowledged “It's not feasible to be able to watch all of the doors so [direct care staff] will call neighbors in the other memory care building first, the night porter…and the MT from [assisted living].” The facility failed to ensure a sufficient number of caregivers were available to meet the 24-hour scheduled and unscheduled needs of each resident and fire evacuation standards of the multiple residents who required the assistance of two care staff for transfers and had high levels of care needs. An amended staffing plan to address the insufficient staffing was requested from Staff 2 at 4:31 pm on 10/14/24 and was received by the survey team at 4:12 pm on 10/15/24. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents for all shifts was discussed on 10/17/24 with Staff 1 (ED), Staff 2, and Staff 3 (Memory Care Coordinator). They acknowledged the findings. 1) Based on observation and interview, it was determined that the facility did not have adequate staffing to: a. meet scheduled and unscheduled needs of residents and to meet fire evacuation standards. A new staffing plan was requested at time of survey that was produced and received by the survey team prior to exit adding additional staff to all 3 shifts. 2) Staff were added to all 3 shifts to meet scheduled and unscheduled needs. 3) Daily audits of the ABST will be done to ensure that staffing is adequate for the care needs of the residents. 4) Memory Care Administrator, MCC, RSCs, Administrator or designee OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resi”

“Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to have an accurate number of minutes for 2 of 3 sampled residents (#s 2 and 3) whose ABST was reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records from 04/2024 through 10/2024 were reviewed with Staff 6 (Director of Plant Operations) on 10/15/24. Review of the documentation provided revealed: a. Fire drill records lacked consistent documentation of one or more of the following required elements: * Location of simulated fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Evidence alternate routes were used during fire drills. b. Staff interviewed on 10/17/24 were not knowledgeable of the designated point of safety. c. Fire drills were conducted on 04/30/24 and 06/28/24 and no additional fire drills had been completed in either of the two memory care buildings. The requirements for providing and documenting fire drills were discussed with Staff 1 (ED), Staff 2 (Memory Care Administrator) and Staff 3 (Memory Care Coordinator) on 10/17/24 at 3:05 pm. They acknowledged the findings. 1) Based on interview and record review, it was determined that the facility failed to meet requirements of Fire and Life Safety due to: a. Fire drills lacked consistant documentation. Spoke with Fire and Life Safety representative (Plant Ops Director) and discussed the documentation elements required to be in compliance. b. Staff were not knowledgeable of the designated point of safety. A fire drill was conducted on 10/31/24. Additional training and protocols added to care staff binder. c. Fire drills were conducted on 4/30/24 and 6/28/24 and no additional fire drills were conducted. A fire drill was completed on 10/31/24 and will be continued according to the requirements of the OAR. 2) a. Additional fire and life safety training was done with the Plant Ops director regarding required documentation for fire drills. b. Additional training and protocols given to staff and protocols were added to the care staff binder. c. Additional training with Plant Ops Director regarding the frequency that drills need to be completed. 3) a & c.Every month the Memory Care Administrator and Executive Director will review the fire, life and safety binder, ensuring the unannounced drill occurred and the documentation meets the expectations of the OAR. b. All new hires will be trained on fire, life and safety training including designated points of safety. In addition all current staff will receive ongoing training monthly during routine fire drills and all staff meetings 4) Memory Care Administor, MCC, RSCs, Administrator or designee OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: A tour of the facility on 10/15/24 through 10/16/24 was completed and the following was identified: Fir Unit: * The carpet in the common area had multiple stains; * A chair in the common area had multiple stains on the armrest; * Multiple chairside tables had dings and white stains; * Lightbulb burned out in light fixture on wall near room 9; * The wall near the entry into the kitchenette had peeling paint; * The laundry room had dirt and dust accumulation on wire shelving and fire alarm; and * Laundry room wall had gaps around pipes that were not sealed. Grove Unit: * The carpet in the common area and near the front door had multiple stains; * A chair in the common area had a stain on the chairback; and * Chairside table had dings and was sticky to touch. The environment was toured with Staff 2 (Memory Care Administrator) and Staff 6 (Director of Plant Operations) on 10/16/24 at 2:10 pm. The need to ensure all interior and exterior materials and surfaces were kept clean and in good repair was discussed. They acknowledged the findings. 1) Based on observation and interview, facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Finding include, but are not limited to: a. Fir: Carpet with multiple stains has been shampooed, common room chairs with stains on armrest will be cleaned, chairside tables with dings and white stains were repaired and cleaned, burned out light bulb near room 9 was repaired, wall near entry into kitchenette had peeling paint has been repainted, laundry room with dirt and dust build up and gaps around pipes in laundry room have been cleaned. b. Grove: Carpet with multiple stains has been shampooed,chair in common area with stain on the chairback has been cleaned, and chairside tables had dings and was sticky to touch has been repaired and cleaned. In addition, weekly walk throughs of common areas will be done by Memory Care Administrator and/or MCC and any findings will be addressed with Plant Ops Director to address maintenance needs. 2) Memory Care Administrator or MC coordinator will facilitate weekly walk throughs to ensure all enviromental needs are met and submit requests for any repairs needed. 3) Common area will be evaluated weekly. 4) Memory Care Administrator, MCC, RSCs, Plant Ops Director, or Designee. 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 a one-way flow of soiled laundry to preclude potential contamination, a flushing rim clinical sink with a handheld rinsing was used and ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to: Facility laundry rooms were toured on 10/15/24 and revealed the following: * Each laundry room had two rooms side by side that were connected by an interior door. Both rooms could also be entered into from the hallway. One room housed the hopper with an enzyme pre-spotter cleaner and was used as a chemical disinfectant for soiled items. The room adjacent to the hopper room had residential washing machines with a laundry detergent and was not identified as a chemical disinfectant. Multiple care staff were interviewed on 10/14/24 regarding the laundry process for soiled items and revealed the following: * Interviews with Staff 15 (CG) and Staff 16 (CG) confirmed the soiled items were taken directly into the washing machine and the laundry detergent was used. Staff 16 indicated s/he washed the soiled items “two or three times” in the washing machine. Staff 16 was asked what the room next to the laundry room was used for, that housed the hopper, and s/he indicated “I think it is the storage room for more garbage.” Neither Staff 15 or Staff 16 indicated the hopper and/or chemical disinfectant was used for soiled laundry items. * Staff 13 (CG) indicated s/he typically brought the soiled item “straight to the washing machine. I make sure one is open so I can just take it straight into the machine." S/he later clarified, "...if it is really soiled with [bowel movement] I’ll put it in the hopper first." S/he confirmed the hopper and chemical disinfectant was used for soiled items that contained feces only. On 10/16/24 at 2:15 pm, Staff 2 (Memory Care Administrator) confirmed staff were to enter the laundry room with soiled linens and soiled clothing through the door with the hopper, use the enzyme pre-spotter with a disinfectant and soak for 15 minutes prior to moving the soiled items into the washing machine to be washed. The need to ensure a safe and sanitary process for handling soiled laundry was discussed with Staff 1 (ED), Staff 2 and Staff 3 (Memory Care Coordinator) on 10/17/24 at 3:05 pm. They acknowledged the findings. 1) Based on observation and interview, it was determined that staff were unable to adequately report the process for using the hopper to ensure a safe and sanitary process for handling soiled laundry. Staff received additional training as to proper hopper usage, the one-way flow of soiled laundry and adequate sanitization and disinfecting measures and proper hopper usage protocols were posted in each hopper room. 2) Staff received additional training as to proper hopper usage, the one-way flow of soiled laundry and adequate sanitization and disinfecting measures and proper hopper usage protocols posted in each hopper room. 3) Staff will be individually observed and checked off to assure knowledge and compliance of proper hopper usage. 4) Memory Care Administor, MCC, RSCs, Administrator or designee OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common areas were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to: A tour of the facility on 10/14/24 revealed the following: a. In the Grove unit, the hot water temperature, taken by the surveyor with a digital thermometer, was between 136.8 and 140.2 degrees Fahrenheit. * During an interview with Staff 6 (Director of Plant Operations) on 10/14/24 at 2:19 pm, the surveyor reviewed water temperature findings. The need to ensure residents were supervised when using the water in the Grove unit was discussed with the staff who were currently working in the building. At 3:14 pm, Staff 6 confirmed the temping valve had been replaced, and the hot water temperature was less than 120 degrees Fahrenheit. At 5:15 pm the water temperatures in residents’ bathroom sinks were re-tested by the surveyor and Staff 2 (Memory Care Administrator) and was between 106.8 and 107 degrees Fahrenheit. b. In the Fir unit, various residents’ bathroom sinks’ hot water was between 101 and 107.4 degrees Fahrenheit. On 10/14/24 at 2:19 pm the hot water temperature findings were shared with Staff 6. On 10/15/24 the hot water temperatures in residents’ bathroom sinks were re-tested and found to be the following: * Grove unit was between 110 and 111.9 degrees Fahrenheit; and * Fir unit was between 115.2 and 116.3 degrees Fahrenheit. The need to ensure hot water temperatures were monitored and maintained within a range of 110 - 120 degrees Fahrenheit was discussed with Staff 1 (ED), Staff 2 and Staff 3 (Memory Care Coordinator) on 10/17/24 at 3:05 pm. They acknowledged the findings. 1) Based on observation and interview facility failed to ensure hot water temperatures in resident rooms and common areas. Range is to be between 110-120 fahrenheit. a. Grove unit was registering at 140 fahrenheit. Valve was replaced and water adjusted accordingly. Water was retested on 10/15/24 and registering 110-111.9 b. Fir unit resident rooms were tested and were registering between 101-107.4 fahrenheit. Water was adjust and retest on 10/15/24 and registering between 115.2-116.3 fahrenheit. 2) Temperatures adjusted in both Fir and Grove house. 3) Continue monthly water temperature audit. 4) Memory Care Administor, MCC, RSCs, Plant Ops Director, Administrator or designee OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure resident’s rights of respect and dignity for 1 of 1 sampled resident (#2) and an unsampled resident who required assistance with eating. Findings include, but are not limited to: Refer to C200. Refer to C200 C for plan of correction OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure the setting was physically accessible for multiple sampled and unsampled residents whose access to a locked interior courtyard was restricted. Findings include, but are not limited to: Refer to Z168. Refer to Z168 for plan of correction OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to ensure resident’s rights of privacy in his or her own unit for two unsampled residents who shared a room. Findings include, but are not limited to: Refer to C 200. Refer to C200 A and B for plan of correction OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by:”

“Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Findings include, but are not limited to: During a tour on 10/14/24 of the secure courtyard shared between the Fir and Grove units, it was observed the doors entering and returning from the courtyard were locked. This prevented residents from accessing the secure courtyard without staff assistance, both going outside and returning indoors. The courtyard doors continued to remain locked on 10/15/24. On 10/14/24 at 1:18 pm in the Grove unit, an observation was made of an unsampled resident attempting to exit into the courtyard but the doors were locked. No staff assisted him/her in opening the door. On 10/14/24 at 3:13 pm in the Fir unit, Resident 1 was observed pushing on the door to the locked courtyard. S/he stated, “That’s locked.” Staff 2 (Memory Care Administrator) responded she would assist Resident 1 in a moment. Interviews with multiple caregivers on 10/14/24 indicated the doors in and out of the courtyard from both Fir and Grove units were locked and they opened the doors for the residents when they wanted to go outside. The need to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 2 on 10/15/24 at 3:25 pm. She acknowledged the findings. 1) Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways allowing residents to enter and return without staff assistance. The doors were unlocked immediately and staff were reminded that doors to the courtyard need to remain unlocked during daytime hours. However, it was noted then that the courtyard door in G house was not remaining unlocked due to a faulty mechanism. Plant Ops director ordered and will be replacing the mechanism to ensure compliance. 2) The courtyard doors will remain unlocked during daylight hours with the exception of inclement weather or a lockdown situation. Policies will be created to address both scenarios. 3) Doors will be checked daily to assure compliance. 4) Memory Care Administor, MCC, RSCs, Administrator or designee OAR 411-057-0160(g) Outside Area (g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). This Rule is not met as evidenced by:”

“The findings of the kitchen inspection, conducted 08/24/23, are documented in this report. The survey was conducted to determine compliance with 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 08/24/23, are documented in this report. The survey was conducted to determine compliance with 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 08/24/23 kitchen inspection, conducted 10/27/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the first revisit to the 08/24/23 kitchen inspection, conducted 10/27/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.”

“Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 08/24/23 at 11:20 am, the main kitchen was observed and the following was noted: a. In the dry storage area: *Scoops were stored in containers of powdered sugar, gluten-free pancake mix and brown sugar; *The outside of the containers and lids containing powdered sugar and gluten-free pancake mix had accumulation of food debris; and *The rolling cart held four trays of cookies which were uncovered. b. Main kitchen prep area: *Scoops were stored in the large bins of flour, oatmeal and granulated sugar. c. In the walk in refrigerator: *The rolling cart held two trays of waffles which were uncovered. d. The kitchen was in midst of remodeling and the back area of the kitchen was open to the outside, creating a potential for rodent/pest infestation and cross contamination to uncovered food items. e. Three garbage cans in food prep areas were uncovered when not in use. The findings were observed and discussed with with Staff 1 (Dining Services Director) and Staff 2 (Executive Director) on 08/24/23. The findings were acknowledged. Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 08/24/23 at 11:20 am, the main kitchen was observed and the following was noted: a. In the dry storage area: *Scoops were stored in containers of powdered sugar, gluten-free pancake mix and brown sugar; *The outside of the containers and lids containing powdered sugar and gluten-free pancake mix had accumulation of food debris; and *The rolling cart held four trays of cookies which were uncovered. b. Main kitchen prep area: *Scoops were stored in the large bins of flour, oatmeal and granulated sugar. c. In the walk in refrigerator: *The rolling cart held two trays of waffles which were uncovered. d. The kitchen was in midst of remodeling and the back area of the kitchen was open to the outside, creating a potential for rodent/pest infestation and cross contamination to uncovered food items. e. Three garbage cans in food prep areas were uncovered when not in use. The findings were observed and discussed with with Staff 1 (Dining Services Director) and Staff 2 (Executive Director) on 08/24/23. The findings were acknowledged. 1a. Dry storage area: - Holders for the scoops have been purchased for scoops to be placed in when not in use. - All accumulation of debris has been removed and staff will be checking it daily. - Cookies that were left uncovered were removed and disposed of. Cookies will be covered while cooling and removed to a covered container as soon as cooling has completed. b. Main kitchen prep area: Holders for the scoops have been purchased for scoops to be placed in when not in use. c. Walk in refrigerator: Waffles that were stored uncovered were removed and disposed of. d. Remodel completed same day as survey visit and open area was closed up. e. New garbage can lids were ordered for all uncovered garbage cans. All of these will be monitored daily by staff and weekly by dining managers to assure compliance. 1a. Dry storage area: - Holders for the scoops have been purchased for scoops to be placed in when not in use. - All accumulation of debris has been removed and staff will be checking it daily. - Cookies that were left uncovered were removed and disposed of. Cookies will be covered while cooling and removed to a covered container as soon as cooling has completed. b. Main kitchen prep area: Holders for the scoops have been purchased for scoops to be placed in when not in use. c. Walk in refrigerator: Waffles that were stored uncovered were removed and disposed of. d. Remodel completed same day as survey visit and open area was closed up. e. New garbage can lids were ordered for all uncovered garbage cans. All of these will be monitored daily by staff and weekly by dining managers to assure compliance. There are no detail notes for this visit.”

“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 C240. 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 C240. Please refer to C tag corrections above. Please refer to C tag corrections above. There are no detail notes for this visit.”