Carriage Place.

“Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 7, 9, and 12) completed all required pre-service dementia training and 2 of 2 staff (#s 9 and 13) demonstrated competency in all assigned duties within 30 days of hire. Findings include, but are not limited to: The facility’s training records were reviewed on 04/14/26 and 04/15/26 with Staff 1 (Administrator). The following was identified:”

“Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to C270. Refer to C270”

“Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to: Observations during the survey, from 04/13/26 to 04/15/26, showed there was a lack of scheduled and unscheduled activities provided for residents living in the memory care community. An activity calendar was posted in the hallway which noted scheduled activities for each day of the week. The activities noted for 04/15/26 included the following: * 9:00 am – Coffee and the News; and * 10:00 am – Walk. Observations made on 04/15/26 confirmed the 9:00 am and 10:00 am scheduled activities did not take place. The television remained on in the common area throughout the survey, with five to six residents watching it at any given time. Other residents were observed wandering the hallways. Residents who were in their apartments were not approached for activity invitations during observations. An interview with Staff 10 (CG/MA) on 04/15/26 at 10:18 am confirmed there would be no activities that day, as the staff member who had been filling in would be working as a caregiver. On 04/15/26 at 11:35 am, Staff 1 (Administrator) confirmed the employee who had been in charge of Activities was currently on leave. The need to ensure the facility provided a daily program of social and recreational activities that were based on individual and group interests, and physical, mental, and psychosocial needs was discussed with Staff 1 and Staff 3 (Office Manager) on 04/15/26 at 11:35 am. They acknowledged the findings. Review individual LEC plans and ensure care plans reflect resident preference as to whether or not they would like to participate in activities. Will ensure staff know everyone is responsible for resident activities. Check to make sure activities are being done per the activities calendar. Activities will be checked on daily. Admin, LEC, OM”

“Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were monitored until resolution for 2 of 2 sampled residents (#s 1 and 2) who experienced short-term changes of condition. Findings include, but are not limited to: 1.Resident 1 moved into the memory care community in 02/2026 with diagnoses including severe Alzheimer's dementia. The resident’s 03/05/26 service plan and 02/03/26 through 04/11/26 progress notes were reviewed. The resident experienced multiple short-term changes without progress noted at least weekly until resolved in the following areas: * 02/03/26 – New move-in; * 02/03/26 – Bruise on the left arm; * 02/13/26 and 02/14/26 – Resident to Resident altercation; * 02/19/26 – Blister on both feet; * 03/22/26 – Skin concern on bilateral buttocks; and * 03/27/26 – Resident to Resident altercation. An interview with Staff 1 (Administrator), Staff 2 (RCC), and Staff 3 (Office Manager), on 04/15/26 at 10:30 am, confirmed there was no additional documentation for the changes of condition. The need to ensure changes of condition were monitored at least weekly until resolution was discussed with Staff 1 and Staff 2 on 04/15/26 at 10:30 am. The findings were acknowledged. 2. Resident 2 moved into the memory care community in 06/2022 with diagnoses including dementia and hypertension. The resident’s 02/06/26 to 04/13/26 clinical record was reviewed. The resident experienced the following short-term changes of condition without weekly progress noted until the condition resolved: * 02/09/26 and 03/02/26 – Swelling of the right pinky; and * 03/08/26 – Bruise to the left upper arm. An interview with Staff 2 (RCC) on 04/14/26 at 11:00 am confirmed the above-mentioned changes of condition were not monitored, with weekly progress noted until the condition resolved. Staff 2 stated their system automatically set monitoring for three days, and if they did not manually extend it, the monitoring automatically discontinued. The need to ensure changes of condition were monitored, with weekly progress noted until resolution, was discussed with Staff 1 (Administrator) and Staff 3 (Office Manager) on 04/15/26 at 11:35 am. They acknowledged the findings. Alerts will be monitored daily to make sure the issue is resolved before dropping off. Task sheet to be completed daily for verification that alerts are checked daily and will be monitored, removed, or extended. The alerts will be checked daily RCC, Nurse, Admin”

“Based on observation, interview, and record review, it was determined the facility failed to ensure the interior was free from unpleasant odors. Findings include, but are not limited to: The interiors of the memory care were toured on 04/14/26 at 8:25 am. The following was identified: Pervasive odors were present throughout the hallway around rooms 120 to 128 and did not dissipate during the survey. In an interview with Staff 1 (Administrator) on 04/14/26 at 9:05 am, she stated that Resident 2 resided in the hallway and frequently urinated in multiple areas throughout his/her room. Review of Resident 2’s service plan confirmed the presence of this behavior. The need to ensure the facility was free from unpleasant odors was discussed with Staff 1 and Staff 3 (Office Manager) on 04/15/26 at 11:35 am. They acknowledged the findings. Purchasing of urine enzyme eliminator Carpets will be cleaned. Area to be checked for pervasive odors Carpet cleaning to be completed weekly and when visibly soiled Housekeeping, OM, Admin”

“Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to C242 and C513. Refer to C242 and C513”

“Based on observation, interview, and record review, it was determined the facility failed to ensure a setting that promoted individuals’ rights of privacy, dignity, and respect. Findings include, but are not limited to: Refer to C200. See C200.”

“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, C231, C420, C422, C510, and C513. Refer to C200, C231, C420, C422, C510, and C513.”

“Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (# 2) received service in a manner that protected dignity and supported a homelike environment. Findings include, but are not limited to: On 06/24/25 at 8:40 am, the resident’s bathroom sink was observed and was found to be non-functional. On 06/24/25 at 8:57 am, Staff 2 (RCC) reported the kitchen sink had been disabled due to a previous flooding incident caused by the resident. However, Staff 2 thought the bathroom sink should be working. On 06/24/25 at 9:05 am, the surveyor and Staff 2 checked the bathroom sink together and confirmed it was not operational. Multiple staff interviews indicated it had been between four to six months since the bathroom sink had not been functioning and was no longer in use. When asked how the resident’s personal hygiene needs, including brushing his/her teeth and washing his/her face, were being met, staff reported the resident was escorted to the public restroom in the morning and afternoon to complete personal hygiene tasks. The need to ensure the resident received care with dignity and in a manner that supported a homelike environment during personal hygiene was discussed with Staff 1 (Administrator), Staff 2, and Staff 3 (Office Manager) on 06/25/25. The staff acknowledged the findings.”

“Based on interview and record review, it was determined the facility failed to report incidents of abuse to the local Seniors and People with Disabilities (SPD) office and/or failed to promptly investigate injuries of unknown cause and report to the local SPD office if abuse could not be ruled out for 2 of 2 residents (#s 1 and 3) whose incident reports were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure staff were provided with fire and life safety training every other month and to document all required fire drill elements per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety documentation from 01/2025 through 06/2025 was reviewed on 06/24/25. The following was identified:”

“Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to: Fire and life safety documentation from 01/2025 through 06/2025 was reviewed on 06/24/25. In an interview on 06/24/25 at 1:10 pm, Staff 1 (Administrator) was unable to provide documentation that residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the facility within 24 hours of admission or re-instructed annually. The need to provide fire and life safety instruction to residents within 24 hours of admission and to provide re-instruction at least annually was discussed with Staff 1 on 06/24/25 at 1:10 pm and with Staff 1, Staff 2 (RCC), Staff 4 (Oversight Nurse/RN), and Staff 5 (Resident Care Nurse/LPN) on 06/25/25 at 11:45 am. They acknowledged the findings.”

“Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair, grounds were kept orderly, and garbage was stored in covered refuse containers. Findings include, but are not limited to: The outside of the facility was toured on 06/23/25. The following deficiencies were identified: * Courtyard pathways had drop-offs up to 3” from the concrete to the planting beds, which caused a potential tripping hazard for residents; * Dead branches were in the planting bed on the street-side of the facility; and * The lid of a dumpster located in the parking lot was open. The need to maintain pathways in good repair, to keep the grounds orderly, and to keep garbage containers covered was discussed with Staff 1 (Administrator) on 06/24/25 at 1:10 pm and with Staff 1, Staff 2 (RCC), Staff 4 (Oversight Nurse/RN), and Staff 5 (Resident Care Nurse/LPN) on 06/25/25 at 11:45 am. The findings were acknowledged.”

“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, and the facility was kept free of unpleasant odors. Findings include, but are not limited to: The interior of the facility was toured on 06/23/25 at 2:15 pm and 06/24/25 at 10:55 am. The following was identified: * The carpet was stained in multiple areas throughout the facility; * Multiple doors, door frames, baseboards, and walls were scratched, scraped, and/or gouged; * Numerous kick plates on resident unit doors had black and/or white scrapes; * Multiple windowsills had an accumulation of dust; and * There was a pervasive odor of urine in Room 120 throughout the survey, from 06/23/25 through 06/25/25. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 06/24/25 at 1:30 pm. The need to ensure all interior materials and surfaces were kept clean and in good repair, and to keep the facility free of unpleasant odors, was discussed with Staff 1, Staff 2 (RCC), Staff 4 (Oversight Nurse/RN), and Staff 5 (Resident Care Nurse/LPN) on 06/25/25 at 11:45 am. They acknowledged the findings.”

“based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview, and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s service plans were reviewed and showed some information about residents’ interests. However, the facility had not fully evaluated the residents’: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and/or * Activities that could be used as behavioral interventions, if necessary. There was no specific/individualized activity plan in place that detailed what activities would be offered, when and how often they would occur, how they would be implemented, or how staff would assist residents with individualized activities. The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Coordinator) and Staff 3 (Office Manager) on 06/25/25. The staff acknowledged the findings.”