Print Inspection: CHOW006645

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment during meal service. Findings include, but are not limited to: Observations of meal service were completed between 09/08/25 through 09/10/25 and revealed the following: * Multiple care staff responsible for resident care and meal service were observed to serve food and beverages to residents without donning a protective barrier over potentially contaminated clothing. * Multiple care staff retrieved items from the kitchen, touched residents, and touched wheelchairs/walkers, without performing hand hygiene prior to or between tasks. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 09/10/25. They acknowledged the findings.

1. Community will ensure that aprons are available for staff to wear during meal service. Clean aprons are to be used for one meal only and then are considered dirty. 2. Dirty aprons will be placed in a bin after each meal service. 3. NOC shift employees to wash dirty aprons during their shift to ensure clean aprons are always available. 4. Staff to be trained about wearing aprons during staff meeting that will be held on 9/25/25. 5. Staff to be trained on infection prevention/hand washing during staff meeting on 9/25/25. 6. Dining Services Manager to monitor and ensure that staff wash hands after touching different things.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be 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. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (ED) and Staff 4 (Director Maintenance) on 09/10/25 at 10:40 am. There was no documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside the building in the event of an actual fire at least annually. The need to ensure fire and life safety instruction was provided to each resident annually was discussed with Staff 1, and Staff 2 (Health Wellness Director) on 09/10/25 at 12:07 pm. They acknowledged the findings.

1. Executive Director to create a checklist. Checklist includes: a. Topics that need to be covered annually b. Signature sections for both resident/staff member training c. Date for when it was completed. 2. Health and Wellness Director to go over training with resident during quarterly evaluations (every 90 days). This practice to be implemented 9/22/25 3. Executive Director to monitor this quarterly when quarterly reviews are due.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be 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. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: