Pacific Living Centers of Redmond.

“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 OAR 333-150-000. Findings include, but are not limited to: On 04/15/26, between 11:45 am and 2:00 pm, the facility kitchen was observed to need corrections in the following areas:”

“Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. Refer to C240 Continued. 3C. Weekly 4A. Executive Director, Assistant Executive Director, or Maintenance Director. 4B. Executive Director, Assistant Executive Director 4C.Executive Director, Assistant Executive Director”

“Based on observation and interview, 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: On 12/03/25 at 4:30 pm, the facility kitchen was observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dirt and/or black matter was observed on or underneath the following: * Oven interior; * Floor perimeter; * Floor of dry storage closet; and * Exterior of several drawers and cabinets. b. The following areas needed repair: * The half-doors on both sides of the kitchen had chipped and/or worn paint on the upper ledges. c. Countertops had a large accumulation of miscellaneous items which included but were not limited to: staff drinks, fast food bags, charging cords, soiled dishes and flatware, baskets of assorted items, binders, scissors and cleaning supplies. d. The standing mixer, bowl, and mixing paddle were uncovered creating potential for cross contamination. The need to ensure the kitchen was clean, in good repair, and that Food Sanitation Rules were followed was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) during a tour of the kitchen on 12/03/25 at 5:35 pm. The findings were acknowledged. 1A. Oven interior, Floor, Closet, exterior drawers were all deep cleaned. 1B. half doors on both sides of the kitchen were repaired and repainted. 1C. Staff items and none kitchen items were removed from the kitchen. 1D. All counters were decluctered, kitchen appliances stored when not in use. 2A. NOC shift to deep clean all exterior, interior cabinets and floors weekly on Tuesdays. Executive Director will audit every Wednesday. 2B. Side doors added to Maintenance log monthy for any repairs. 2C. Staff have been reeducated about cross contamination. All items will be kept in employee break room. 2D. Executive Director will do spot checks for counter clutter. All appliances not in use will br stored in a specific storage area. Continued on page 3.”

“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. See C240”

“The findings of the Change of Ownership survey, conducted 04/15/24 through 04/16/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations. 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the Change of Ownership survey, conducted 04/15/24 through 04/16/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations. 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC:       Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day The findings of the re-visit to the re-licensure survey of 04/16/24, conducted on 07/12/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004. The findings of the re-visit to the re-licensure survey of 04/16/24, conducted on 07/12/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.”

“Based on observation, interview, and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#2) whose medications, MARs, and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 2 was admitted to the facility in 05/2023 with diagnoses including anxiety and congestion. Resident 2 had orders for: * Lorazepam 0.25 mg as needed for anxiety; and * pseudoephedrine 60 mg, three times daily for nasal congestion. Review of Resident 2's Controlled Substance Disposition Logs, 03/01/24 to 04/15/24 MARs, and pills, revealed multiple occasions when the disposition logs did not match the MARs. The medication count matched the dispensation logs. The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Regional Director of Operations) on 04/16/24. She acknowledged the discrepancies. Based on observation, interview, and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#2) whose medications, MARs, and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 2 was admitted to the facility in 05/2023 with diagnoses including anxiety and congestion. Resident 2 had orders for: * Lorazepam 0.25 mg as needed for anxiety; and * pseudoephedrine 60 mg, three times daily for nasal congestion. Review of Resident 2's Controlled Substance Disposition Logs, 03/01/24 to 04/15/24 MARs, and pills, revealed multiple occasions when the disposition logs did not match the MARs. The medication count matched the dispensation logs. The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Regional Director of Operations) on 04/16/24. She acknowledged the discrepancies. Executive Director and Assistant Executive Director will do a daily MAR to cart to Narcotic book audit on all residents. By auditing daily and addressing any concerns with staff. Daily for the next 30 days. Executive director, Assistant Executive Director and Regional Director of Operations Executive Director and Assistant Executive Director will do a daily MAR to cart to Narcotic book audit on all residents. By auditing daily and addressing any concerns with staff. Daily for the next 30 days. Executive director, Assistant Executive Director and Regional Director of Operations There are no detail notes for this visit.”

“Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 05/2023 with diagnoses which included anxiety. Resident 2's 03/01/24 to 04/15/24 MARs and current orders were reviewed. Resident 2 had orders for: * Hydroxyzine HCL 25 mg twice daily as needed for anxiety; and * Lorazepam 0.25 mg as needed for panic attack, use Hydroxyzine first. There were multiple occasions when the Lorazepam was given before administering the Hydroxyzine, as ordered. The need to ensure orders were followed was reviewed with Staff 1 (Regional Director of Operations). She acknowledged the findings. Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 05/2023 with diagnoses which included anxiety. Resident 2's 03/01/24 to 04/15/24 MARs and current orders were reviewed. Resident 2 had orders for: * Hydroxyzine HCL 25 mg twice daily as needed for anxiety; and * Lorazepam 0.25 mg as needed for panic attack, use Hydroxyzine first. There were multiple occasions when the Lorazepam was given before administering the Hydroxyzine, as ordered. The need to ensure orders were followed was reviewed with Staff 1 (Regional Director of Operations). She acknowledged the findings. All PRN have been audited to ensure sequencing is in place. Med tech training done on 4/19/24. Executive director will review PRN's given weekly and address any concerns with staff. Regional Director of Operations will review. Executive Director, Assistant Executive Director and Regional Director of Operations. All PRN have been audited to ensure sequencing is in place. Med tech training done on 4/19/24. Executive director will review PRN's given weekly and address any concerns with staff. Regional Director of Operations will review. Executive Director, Assistant Executive Director and Regional Director of Operations. There are no detail notes for this visit.”

“Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 302 and C 303. Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 302 and C 303. Refer to C302 and C303. Refer to C302 and C303. There are no detail notes for this visit.”

“Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height. Findings include, but are not limited to: The facility was toured on 04/15/24. Sections of fencing surrounding the perimeter of the outdoor recreation area did not meet the six foot height requirement. The surveyor measured several sections of the fence. Measurements included areas as low as 65 inches, or five feet five inches, in height. The facility had cameras to monitor the courtyard. The door alerted staff when residents exited the facility into the courtyard. The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height was discussed with Staff 1 (Regional Director of Operations) on 04/15/24. She acknowledged the findings. Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height. Findings include, but are not limited to: The facility was toured on 04/15/24. Sections of fencing surrounding the perimeter of the outdoor recreation area did not meet the six foot height requirement. The surveyor measured several sections of the fence. Measurements included areas as low as 65 inches, or five feet five inches, in height. The facility had cameras to monitor the courtyard. The door alerted staff when residents exited the facility into the courtyard. The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height was discussed with Staff 1 (Regional Director of Operations) on 04/15/24. She acknowledged the findings. Quotes are being obtained. Door alarm on back door when residents go outside/inside let's staff know resident is going out/in and there are cameras in the back yard to monitor residents. We have a company making a model of what an extension would look like to reach height requirement. Until extension or repair is made to current fencing. Executive Director, Assistant Executive Director and Regional Director of Operations. Quotes are being obtained. Door alarm on back door when residents go outside/inside let's staff know resident is going out/in and there are cameras in the back yard to monitor residents. We have a company making a model of what an extension would look like to reach height requirement. Until extension or repair is made to current fencing. Executive Director, Assistant Executive Director and Regional Director of Operations. There are no detail notes for this visit.”

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