The Pines at the Landing.

“Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen areas and memory care kitchenettes were reviewed on 01/06/26 from 10:15 am through 1:15 pm and the following was identified:”

“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. see C 240 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 interview and record review, it was determined the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, and promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (#2) with a reportable incident. Findings include, but are not limited to: Resident 2 moved into the facility in 05/2025 with diagnoses including dementia, chronic myeloid leukemia, generalized muscle weakness, and osteoarthritis. Resident 2’s clinical record was reviewed during the survey. The following was identified: Staff documented in an Observation Note dated 08/25/25, that bruising was discovered on the resident’s left side torso. Staff 4 (RN) documented on 08/25/25 that staff discovered the bruising on 08/20/25 - five days earlier. Staff 4’s investigation determined the bruising was likely caused by the way staff were lifting the resident during transfers and the service plan was updated for staff to utilize a different method for transferring the resident. Staff documented in an Event Report, dated 08/25/25, that when staff asked the resident what had happened, the resident stated, “The big big [sic] dark girl hurt me when getting me up in the morning and I don’t want her helping me anymore.” Resident 2’s statement that someone hurt him/her constituted an incident of suspected abuse which required the facility to immediately notify the local Department office and promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect the resident and prevent the reoccurrence of abuse. In an interview on 10/07/25, Staff 1 (MCC Administrator) stated she did not report the incident because she believed the investigation determined the cause of the injury and therefore, ruled out abuse. She acknowledged the investigation was not completed until five days after the bruising was discovered. The facility failed to immediately notify the local office and promptly investigate the incident. The need to immediately notify the local Department office of all reported incidents of suspected abuse and promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence, was reviewed with Staff 1 on 10/07/25. She acknowledged the deficiencies. The facility was instructed to report the incident to the local Department office. Confirmation the incident was reported was received on 10/11/25.”

“Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 5) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 4 moved into the facility in 07/2025 with diagnoses including dementia and diabetes mellitus. The resident’s move-in evaluation was reviewed and lacked the following required elements: * Customary routines including eating and bathing; * Leisure activities; * Cultural preferences and traditions; * Physical health status including: List of current diagnoses, list of medications and PRN use, and visits to health practitioners, emergency room, hospital, or nursing facilities in the past year; * Mental health issues including: Presence of depression, thought disorders or behavioral or mood problems, history of treatment, and effective non-drug interventions; * Cognition including: Orientation and decision making abilities; * Personality including how the person copes with change or challenging situations; * Activities of daily living including: personal hygiene and eating; * Non-pharmaceutical pain interventions; * List of treatments including: Type, frequency and level of assistance needed; * Indicators of nursing needs including potential for delegated tasks; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Elopement risk or history; and * Environmental factors that impact the resident's behavior including, but not limited to: Noise, lighting, room temperature. The need to ensure all required elements were addressed in move-in evaluations was discussed with Staff 1 (MCC Administrator) and Staff 2 (Campus Administrator) on 10/08/25 at 1:12 pm. They acknowledged the findings.”

“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 4 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, for 2 of 3 sampled residents (#s 2 and 3) with outside service providers. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were given only after documented non-pharmacological interventions had been attempted and were ineffective, for 1 of 1 sampled resident (# 1) who had an order for PRN psychotropic medication. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2025 with diagnoses including cognitive impairment and hypertension. Resident 1’s 09/01/25 through 10/06/25 MARs and observation notes were reviewed and showed the following: Resident 1 had an order for Ativan 0.5 mg every four hours as needed for anxiety or agitation, demonstrated by yelling, crying and pacing in his/her room or building. Prior to giving engage in calm conversation, offer snack, and position for comfort. The PRN Ativan was administered on six occasions in September and on three occasions, there was no documentation of non-drug interventions being attempted with ineffective results prior to administering the medication. On 10/08/25 at 10:45 am, Staff 3 (Wellness Director/RN) acknowledged the lack of documentation of non-drug interventions being attempted prior to administering the Ativan and stated she would provide re-education to staff. The need to ensure non-pharmacological interventions and their ineffectiveness were documented prior to administering the as-needed psychotropic medication was discussed with Staff 1 (MCC Administrator) and Staff 2 (Campus Administrator) on 10/08/25 at 2:30 pm. They acknowledged the findings. No further information was provided.”

“Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time for the care elements that staff were providing to residents as outlined in each individual service plan for 3 of 4 sampled residents (#s 1, 3 and 4) whose ABSTs were reviewed. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure residents were instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: Fire and life safety records were requested during the survey. The following deficiencies were identified: There was no documentation that fire and life safety training was provided to residents within 24 hours of move in and/or that they were re-instructed at least annually. The need to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed at least annually, was discussed with Staff 1 (MC Administrator) and Staff 2 on 10/08/25 at 2:30 pm. They acknowledged the findings. No further information was provided.”

“Based on observation and interview, it was determined the facility failed to ensure all interior 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 were kept clean and in good repair. Findings include, but are not limited to:”

“Based on interview and record review, it was determined the facility failed to ensure the initial evaluation included the resident’s pronouns and gender identity for 1 of 1 sampled resident (#4) whose initial evaluation was reviewed. Findings include, but are not limited to: Refer to C 252.”

“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 231, C 422, and C 513. Please see plan of correction for the following mentioned tags C231, C422, C513. 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 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 252, C 260, C 290, C 303, C 330 and C 362. Please see plan of correction for the following mentioned tags C252, C260, C290, C303, C330, C362. 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 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, interview, and record review, it was determined the facility failed to ensure each resident’s activity evaluation was updated and reflective of the resident’s current status and an individualized activity plan was developed for each resident based on their activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to: During the survey, many residents were observed needing assistance and encouragement from staff to initiate, attend and participate in activities. The facility offered group activities, which some residents attended. Other residents did not attend the activities and, instead, stayed in their rooms or walked around the facility. Some residents were no longer able to ambulate independently. All the residents were diagnosed with some type of dementia. Resident 1, 2, 3 and 4’s clinical records were reviewed during the survey. The facility used a form called “Getting to Know You” to evaluate and document each resident’s activity information and documented an activity plan for each resident in the resident’s service plan. The following was identified: *Resident 4 moved from the assisted living (AL) part of the facility to the memory care unit. The facility did not update the resident’s activity evaluation, completed when the resident resided in the AL, to reflect the changes to the resident’s activity interests, physical abilities, limitations, and support needs. *Resident 1, 2, 3 and 4’s individualized activity plans lacked instructions for providing activities based on each resident’s activity evaluation. In an interview on 10/08/25, Staff 1 (MC Administrator) and Staff 7 (Life Enrichment Coordinator) acknowledged the lack of individualized activity plans for the residents in the memory care unit. Staff 7 stated she had not been provided information about the rule requirements when she started in her position for the MCC. The need to ensure each resident’s activity evaluation was complete, reflective and updated as needed, and that the information gathered was used to develop an individualized activity plan for each resident, was reviewed with Staff 1 and Staff 2 (Campus Administrator) on 10/08/25. They acknowledged the findings.”

“Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen areas and memory care kitchenettes were reviewed on 01/14/25 from 10:15 am through 2:15 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Reach in coolers/freezers; * Walk in cooler fan cages; * Industrial can opener housing; * Industrial mixer and table; * Food delivery cart; * Stainless steel wall adjacent to and behind stove, fryer and grill top; * Interior of left oven; * Knobs, handles of appliances and equipment; * Caulking around the perimeter of handwashing sinks; * Interior of ice machine; * Unit reach in fridges and freezers; and * Unit microwaves. c. Container of raw chicken was noted in the deli reach-in cooler to be dated 01/04, this was to be used or discarded as of 01/10/25 per rule. It was noted 4 days past this requirement on survey. d. Multiple food items found stored open to potential contamination in walk-in freezer. e. Dry bulk food items were observed with scoops stored in the bins placing the food items at risk of contamination from the scoops. f. Facility found with unpasteurized shell eggs in walk in cooler. Staff 2 (Dining Services Director) confirmed residents were served cook to order eggs including runny (not fully cooked) yolks or whites if residents chose. Staff 2 indicated that facility usually purchased pasteurized shell eggs but their vendor was out. Staff 2 did not know facility would not be able to serve the above egg choices if shell eggs were not pasteurized and would need to serve fully cooked eggs (non runny yolks/whites) until pasteurized were obtained. Staff 2 immediately in serviced the staff to the requirement. g. Multiple single service disposable food service plates or food containers were noted to be stored open to potential contamination of food contact surfaces. h. Reach in cooler in Aspen unit was observed to be at 46 degrees Fahrenheit. Multiple condiments for residents as well as protein shakes for residents were stored in this fridge. Staff 3 (Memory care Administrator) was interviewed at 1:45 pm and asked to provide temperature monitoring records/procedures to ensure resident food was stored at or bellow 41 degrees as required. Staff 3 indicated the system they were using to monitor temperatures had stopped working in October and the facility was unaware this had occurred. Staff 3 acknowledged facility was unaware how long the refrigerator was not operating correctly. Staff 3 immediately turned down the thermostat of that refrigerator, discarded any open and/or potentially hazardous food items and implemented a hand written temperature monitoring log to ensure staff were monitoring food storage temperatures and alerting her and/or staff 2 and maintenance to any issues. i. Staff were observed washing lunch dishes. Staff did not perform hand hygiene prior to touching clean and sanitized dishes. Staff were observed to wash off dirty dishes and handle clean dishes without washing hands of sanitizing hands potentially contaminating clean dishes. Staff were also observed to rinse out sanitized cups with tap water and then put cups away for use therefor potentially contaminating the sanitized cups with tap water. At 1:45 pm, staff 3 was asked to provide a process/procedure for care staff to follow when cleaning and sanitizing dishware. Staff 3 acknowledged there was not a formal process in place. Staff 3 was informed of the above observations and acknowledged this was not a sanitary process in line with food code regulations for sanitation of dishes/equipment. j. Multiple staff drink cups were observed on the memory care unit kitchenettes. None of the employee drinks contained in the kitchen area were in line with food code requirements posing risk of potential contamination. Staff 2 toured with surveyor and acknowledged the above findings. At approximately 2:00 pm, surveyor reviewed above areas with staff 1 (Executive Director) and Staff 3 and they acknowledged the identified areas in need of correction. Kitchen will be maintained in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. 1. a) Dining staff have assigned cleaning areas to complete daily, weekly and monthly. The dining services director/designee will ensure daily completion of tasks. b) Dates on foods raw or otherwise in deli and cooler will be checked daily and if 7 days or older will be discarded. c) All food items in walk in freezer will be stored in closed containers. d) Scoops for dry bulk food items will be stored in proper receptacles outside of food storage bin. e) Unpasteurized eggs will be served full cooked only. f) All single service disposable food service containers will be stored upside down to prevent contamination of food contact surfaces. 2. Weekly audits of all kitchen areas will be completed by the administrator or designee using the Oregon kitchen audit tool. Any areas not in compliance will be reviewed by the DSD and administrator. Corrective action will be taken to ensure continued compliance. 3. Weekly audits will be completed. Ice machine was completed by Roseburg Refrigeration - during the process instruction on how to maintain cleanliness was given to the DSD for routine maintenance purposes. 4. Administrator and Dining Service Director will be responsible to see that the correcitons are completed and are being monitored on an on going weekly basis.”

“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. OAR 411-057-0140 Refer to C240. 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 interview and record review, conducted during a site visit on 04/30/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's March 2024 MAR and progress notes, signed 90 day orders, and suspected abuse or unexplained injury reporting form dated 03/08/24, indicated the following: · 90 day orders show Quetiapine 25 MG Tab (Serequel) to be given 0.5 Tablet (12.5 MG) by mouth every morning. Ok to crush and mix with food for mood, · 90 day orders show Quetiapine 25 MG Tab (Serequel) to be given 1 Tablet by mouth every evening. Ok to crush and mix with food for mood, · Suspected abuse or unexplained injury reporting form dated 03/08/24 indicated  "On 3/8/24 it was discovered that resident had been getting a ½ tab of [his/her] Seroquel rather than a whole tab as ordered.  No adverse reactions occurred." In an interview, Staff 2 (MC ED) stated s/he was not aware of the details of the incident. The findings were reviewed with and acknowledged by Staff 2 on 04/30/24. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: Facility had a 4-hour MT training for all staff administering medications, starting at the end of March 2024. Any new med techs are now starting out with that class, going over the medication training navigator. ED and Nurse have been sitting down with each med tech one on one for additional training. They are doing daily clinical where they are looking at MAR and orders to audit for any missed meds or meds that were not passed. If a med tech is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located. Additional education has been provided to staff regarding re-ordering medications when there is a 10-day supply left. Based on interview and record review, conducted during a site visit on 04/30/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 3). Findings include, but are not limited to: A review of Resident 3's March 2024 MAR and progress notes, physician orders, and Event Report dated 03/22/24, indicated the following: · Orders show Secura Protective 10% cream (zinc oxide) Topically apply to affected areas when resident is changed to help improve healing over time. Note this is scheduled to correspond to changes, as a preventative to excoriation/urine burn · Event report dated 03/22/24 indicated  "Resident did not receive their Secura cream-not on hand" · MAR indicated Secura Protective 10% cream was not administered at 4:06pm or at 9:34pm due to none on hand on 03/22/24 In an interview, Staff 2 (MC ED) stated s/he was made aware of the incidents, and they were reported to APS. The findings were reviewed with and acknowledged by Staff 2 on 04/30/24. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: Facility had a 4-hour MT training for all staff administering medications, starting at the end of March 2024. Any new med techs are now starting out with that class, going over the medication training navigator. ED and Nurse have been sitting down with each med tech one on one for additional training. They are doing daily clinical where they are looking at MAR and orders to audit for any missed meds or meds that were not passed. If a med tech is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located. Additional education has been provided to staff regarding re-ordering medications when there is a 10-day supply left. Based on interview and record review, conducted during a site visit on 04/30/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: A review of Resident 2's April 2024 MAR and progress notes, and Event Report dated 04/02/24, indicated the following: · MAR shows Lisinopril 40 MG Tab (Zestril) 1 Tablet by mouth every day hold if systolic is less than 110, · MAR shows Quetiapine 25 MG Tab (Seroquel) 1 Tablet by mouth 2 times daily · Event report dated 04/02/24 indicated Resident 2  " missed PM (4/1/24) dose of medications Lisinopril 40 MG tab and Quetiapine 25 MG tab " In an interview, Staff 2 (MC ED) stated s/he was made aware of the incidents, and they were reported to APS. The findings were reviewed with and acknowledged by Staff 2 on 04/30/24. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: Facility had a 4-hour MT training for all staff administering medications, starting at the end of March 2024. Any new med techs are now starting out with that class, going over the medication training navigator. ED and Nurse have been sitting down with each med tech one on one for additional training. They are doing daily clinical where they are looking at MAR and orders to audit for any missed meds or meds that were not passed. If a med tech is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located. Additional education has been provided to staff regarding re-ordering medications when there is a 10-day supply left. Based on interview and record review, conducted during a site visit on 04/30/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 3 of 3 sampled residents (#'s 2, 3, and 4). Findings include, but are not limited to: A review of Resident 2's March 2024 MAR and progress notes, physician orders, and suspected abuse or unexplained injury reporting form dated 03/21/24, indicated the following: · Orders show Latanoprost 0.005% drops (Xalatan) to instill 1 drop in both eyes every evening for Glaucoma, · Suspected abuse or unexplained injury reporting form dated 03/21/24 indicated on 3/11/24  "Resident did not get eye drops, Latanoprost, due to none on hand." A review of Resident 3's March 2024 MAR and progress notes, physician orders, and suspected abuse or unexplained injury reporting form dated 03/21/24, indicated the following: · Orders show Secura Protective 10% cream (zinc oxide) Topically apply to affected areas when resident is changed to help improve healing over time. Note this is scheduled to correspond to changes, as a preventative to excoriation/urine burn · Suspected abuse or unexplained injury reporting form dated 03/21/24 indicated on 3/12/24  "Secura was held due to no redness" A review of Resident 4's March 2024 MAR and progress notes, physician orders, and Event Report dated 03/25/24, indicated the following: · MAR shows Trazodone 50 MG Tab (Desyrel) 2 Tablets (100 MG) by mouth every night at bedtime Ok to crush per MD for sleep, · Event Report dated 03/25/24 indicated medication was not given on 3/25/24  "Residents Trazadone has not arrived from pharmacy. Rx refill was sent on 03/24/24" In an interview, Staff 2 (MC ED) stated s/he was made aware of the incidents, and they were reported to APS. The findings were reviewed with and acknowledged by Staff 2 on 04/30/24. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: Facility had a 4-hour MT training for all staff administering medications, starting at the end of March 2024. Any new med techs are now starting out with that class, going over the medication training navigator. ED and Nurse have been sitting down with each med tech one on one for additional training. They are doing daily clinical where they are looking at MAR and orders to audit for any missed meds or meds that were not passed. If a med tech is unable to find a medicat”

“The findings of the on-site investigation, conducted 10/12/23 through 10/12/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 10/12/23 through 10/12/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 10/12/23 through 10/12/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 10/12/23 through 10/12/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 10/12/23 through 10/12/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 10/12/23 through 10/12/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 10/12/23 through 10/12/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 10/12/23 through 10/12/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. 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 kitchen inspection, conducted 10/10/23, 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 kitchen inspection, conducted 10/10/23, 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 revisit to the kitchen inspection of 10/10/23, conducted 02/01/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the revisit to the kitchen inspection of 10/10/23, conducted 02/01/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the second revisit to the kitchen inspection of 10/10/23, conducted 04/04/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. The findings of the second revisit to the kitchen inspection of 10/10/23, conducted 04/04/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.”

“Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen areas were reviewed on 10/10/23 from 10:45 am through 3:00 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Drains throughout kitchen; * Floors throughout the kitchen; * Reach in coolers/freezers; * Walk in freezer floor; * Ceiling vents and tiles; * Interior/exterior of microwave; * Industrial can opener and housing; * Industrial mixer and table; * Stainless steel shelving throughout kitchen; * Interior of drawers where cooking utensils stored; * Waffle makers; * Food delivery carts; * Range top, ovens, grill top; * Knobs, handles of appliances and equipment; * Caulking around the perimeter of dish machine and hand washing sinks; and * Reach in coolers with mold build up on door seals. b. The following areas were in need of repair: * Large opening in ceiling above a food prep area. c. Industrial and tabletop mixers observed stored uncovered while not in use. Industrial slicer observed not covered when stored.  Multiple cooking pots, pans and bowls stored uncovered and open to potential contamination. d. Multiple kitchen staff preparing and/or serving food did not have hair and/or facial hair effectively restrained as required. e. Multiple cutting boards were found heavily scored and stained. f. Multiple food items found stored open to contamination in freezers, reach-in and walk-in coolers. Food items observed stored without labeling or dating as required. Items noted in refrigerator stored past 7 days. g. Dry bulk food items were observed with scoops stored in the bins placing the food items at risk of contamination from the scoops. h. Trash cans observed without lids. Staff 2 (Dining Services Director) confirmed trash cans did not have lids to cover them when not in use as required. i. Multiple cans of food were found damaged/dented and stored in with ready to use stock. The surveyor toured the kitchenettes in Aspen and Maple units and observed the following: *Flooring was dirty and torn/peeling from seams and heavily scratched/scored in areas, not a smooth/cleanable surface. * Reach in refrigerators and freezers with food debris, spills, drips. * Reach in refrigerator in Maple without thermometer to ensure food items stored at appropriate temperatures. * Multiple food items found in both units without use by dates or past their use by dates. * Microwaves with dried food debris. * Microwave in Aspen found with 2 plates of food inside. Plates were spaghetti and a strong odor  was noted coming from plates. Facility had last had spaghetti greater that 24 hrs prior.  Food was discarded when identified by surveyor. * Multiple staff members observed to wash hands during meal service in kitchenette sink. There were multiple cups/dishes in the sink while staff members washed hands. * Dishwasher in Aspen unit observed to have a rack in process that was overcrowded with dishes overlapping others not allowing adequate access for all dishes to be effectively sanitized. At approximately 2:00 pm, surveyor reviewed above areas with Staff 1 (Executive Director), Staff 3 (Memory Care Administrator) and Staff 2 and they acknowledged the identified areas. Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen areas were reviewed on 10/10/23 from 10:45 am through 3:00 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Drains throughout kitchen; * Floors throughout the kitchen; * Reach in coolers/freezers; * Walk in freezer floor; * Ceiling vents and tiles; * Interior/exterior of microwave; * Industrial can opener and housing; * Industrial mixer and table; * Stainless steel shelving throughout kitchen; * Interior of drawers where cooking utensils stored; * Waffle makers; * Food delivery carts; * Range top, ovens, grill top; * Knobs, handles of appliances and equipment; * Caulking around the perimeter of dish machine and hand washing sinks; and * Reach in coolers with mold build up on door seals. b. The following areas were in need of repair: * Large opening in ceiling above a food prep area. c. Industrial and tabletop mixers observed stored uncovered while not in use. Industrial slicer observed not covered when stored.  Multiple cooking pots, pans and bowls stored uncovered and open to potential contamination. d. Multiple kitchen staff preparing and/or serving food did not have hair and/or facial hair effectively restrained as required. e. Multiple cutting boards were found heavily scored and stained. f. Multiple food items found stored open to contamination in freezers, reach-in and walk-in coolers. Food items observed stored without labeling or dating as required. Items noted in refrigerator stored past 7 days. g. Dry bulk food items were observed with scoops stored in the bins placing the food items at risk of contamination from the scoops. h. Trash cans observed without lids. Staff 2 (Dining Services Director) confirmed trash cans did not have lids to cover them when not in use as required. i. Multiple cans of food were found damaged/dented and stored in with ready to use stock. The surveyor toured the kitchenettes in Aspen and Maple units and observed the following: *Flooring was dirty and torn/peeling from seams and heavily scratched/scored in areas, not a smooth/cleanable surface. * Reach in refrigerators and freezers with food debris, spills, drips. * Reach in refrigerator in Maple without thermometer to ensure food items stored at appropriate temperatures. * Multiple food items found in both units without use by dates or past their use by dates. * Microwaves with dried food debris. * Microwave in Aspen found with 2 plates of food inside. Plates were spaghetti and a strong odor  was noted coming from plates. Facility had last had spaghetti greater that 24 hrs prior.  Food was discarded when identified by surveyor. * Multiple staff members observed to wash hands during meal service in kitchenette sink. There were multiple cups/dishes in the sink while staff members washed hands. * Dishwasher in Aspen unit observed to have a rack in process that was overcrowded with dishes overlapping others not allowing adequate access for all dishes to be effectively sanitized. At approximately 2:00 pm, surveyor reviewed above areas with Staff 1 (Executive Director), Staff 3 (Memory Care Administrator) and Staff 2 and they acknowledged the identified areas. The surveyor toured the kitchenettes in Aspen and Maple units and observed the following: " The flooring will be replaced. " Reach in refrigerators cleaned. " Weekly cleaning audit log in place. " Utilize "TempStick" and app to monitor and track refrigerator temperature. " Utilize sticker label system to identify and date food. End of day audit logs. " Training on proper food handling and storage, hand washing protocol. " Review effective dishwasher uses and cleaning. Responsible Parties: The Executive Chef is responsible to monitor the correction of deficiencies to prevent reoccurrence. The Campus Administrator will provide oversight and collaboration in all kitchen operations. The surveyor toured the kitchenettes in Aspen and Maple units and observed the following: " The flooring will be replaced. " Reach in refrigerators cleaned. " Weekly cleaning audit log in place. " Utilize "TempStick" and app to”

“Based on interview and observation, it was determined the facility failed to ensure the kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240. Based on interview and observation, it was determined the facility failed to ensure the kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240. Refer to C 240. Refer to C 240. There are no detail notes for this visit.”

“Based on observation, record review, 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, record review, 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. Refer to C240 Refer to C240 Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Refer to C 240. Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Refer to C 240. Refer to C 240. Refer to C 240. There are no detail notes for this visit.”