Heartwood Place.

“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 C303 and C362. Refer to C303”

“Based on observation, interview, and record review, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 1 of 1 sampled resident (# 1) who received assistance with toileting. Findings include, but are not limited to: Throughout the re-licensure survey, from 03/31/26 through 04/02/26, the following observations were made to determine adherence to universal precautions for infection control: Resident 1 was admitted to the facility in 12/2025 with diagnoses including vascular dementia. Per the service plan, dated 03/23/26, Resident 1 required two-person physical assistance with a gait belt and walker for transfer to the toilet, disposable briefs, and staff were to ensure perineal care (peri care) was provided. Two observations were made of caregivers transferring the resident to the toilet and providing peri care. On 03/31/26 at 11:05 am, Staff 14 (CG) assisted Resident 1 to the toilet, then removed the soiled gloves and placed them in her pocket. She then removed a clean brief from the closet, donned new gloves, and removed the soiled brief. Without changing gloves, she put the clean brief on the resident while s/he was sitting on the toilet. After providing peri care, she doffed her gloves and assisted the resident into the wheelchair, then into his/her recliner. She did not perform any hand hygiene between dirty and clean tasks. In an interview with Staff 14 on 03/31/26 at 11:14 am, she acknowledged placing the soiled gloves in her pocket was unsanitary. On 04/01/26 at 10:30am, Staff 10 (CG) and Staff 12 (CG) assisted Resident 1 to the bathroom then doffed their gloves without performing hand hygiene. Staff 10 remained in the room and Staff 12 left the room. Staff 12 returned to assist with transferring the resident from the toilet and did not perform hand hygiene prior to assisting. Staff 10 donned gloves without performing hand hygiene, then provided peri care. Both caregivers assisted the resident to ambulate to the sink. Staff 10 held the gait belt and guided the resident with his/her walker to the reclining chair, then doffed the soiled gloves. During both observations, Staff 10, Staff 12, and Staff 14 entered the resident’s room and donned gloves without first performing hand hygiene and did not perform hand hygiene between dirty and clean tasks. The need to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during ADL care was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/02/26 at 2:00 pm. They acknowledged the findings. All direct care staff and med techs will be re-trained on donning and doffing of gloves between dirty and clean tasks handwashing and review of all infection control policies. Upon hire infection control courses are completed. Return demenstration of hand washing and donning and doffing of gloves will be observed. Current employees will receive on going monthly training/audits of all infection control requirements. Monthly audits and return demontration will be conducted to all direct care staff on hand washing and donning and doffing of gloves during resident care. Adminstrator, RN and RCC”

“Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 4) whose MARs and physician orders were reviewed. Findings include, but are not limited to:”

“Based on observation, interview, and record review, it was determined the facility failed to ensure the resident’s Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan, for 3 of 4 sampled residents (#s 1, 2, and 4) whose ABST evaluations were reviewed. Findings include, but are not limited to: Resident 1, 2, and 4’s current service plans and ABST evaluations were reviewed during the survey. Observations were made of the residents, and staff were interviewed regarding each resident’s care needs. The following was identified:”

“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 C295. Refer to C 295 and C 362”

“The findings of the kitchen inspection, conducted 03/07/24, 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 kitchen inspection, conducted 03/07/24, 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.”