Print Inspection: RL000975

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that promoted privacy, respect, and dignity in a homelike environment for 1 of 3 sampled residents (#1) who received ADL assistance. Findings include, but are not limited to: Resident 1 was admitted to the facility in 06/2022 with diagnoses including vascular dementia, mixed anxiety disorder, and major depressive disorder. a. On 10/28/24 at 2:51 pm, Staff 1 (Memory Care Administrator/LPN) was asked to assist staff with Resident 1’s incontinent care over two-way radios. From 2:51 pm through 3:47 pm, Staff 8 (MT), Staff 12 (Care Associate), and Staff 13 (Care Associate), were overheard to talk loudly while providing incontinent care. The following was overhead from the corridor: * “[Resident 1] had a major blowout”; * “[bowel movement] is everywhere”; * “Smells so gross”; * “I am going to puke” and gagging sounds; * “Poop is everywhere”; * Someone help “…find the shower chair…there’s poop everywhere”; * We “…cannot find the shower chair…” and to “check [another resident’s room]”; * “I need to puke” and heard gagging sounds; * “I don’t know what to do, [s/he] keeps pooping”; * “Keep pushing…get it all out…”; * “Oh gross! Are those beans? Who gave [him/her] beans?”; * “…that’s like three poops”; * “…it just keeps coming…”; and * “Are you still pooping?” Resident 1 did not receive services in a way that protected the resident’s dignity and respect. b. On 10/29/24 at 5:56 pm, Staff 21 (Care Associate/MT), Staff 22 (Care Associate), and Staff 14 (Care Associate) were observed to transfer Resident 1 from his/her wheelchair into a sitting scale in the center of the dining room during meal service. Resident 1 did not receive services in a way that protected his/her privacy or in a way that protected his/her dignity. The need to ensure residents' right to be afforded privacy and treated with dignity and respect was discussed with Staff 1 on 10/31/24 at 12:01 pm. She acknowledged the findings.

1. Memory Care Administrator (MCA), Executie Director (ED), and Resident Services Director (RSD)conducuted an in-person training for all staff on 11/22/24 regarding resident rights and dignity. Training included review of policy for when and when taking vitals, administering medications and treatments are appropriate to preserve resident dignity. Training notes will be distributed to those not in attendance. MCA initiated performance improvement conversations with staff involved. 2. All staff will be assigned Essentials of Resident Rights training in Relias. Daily rounds during cares time to observe staff communication with residents. Feedback to be given to staff that need coaching with their communication skills. Annual resident survey with cognitively appropriate residentss to include question about satisfaction with care staff. 3. Resident rights training provided all staff pre-service and Resident Rights in Assisted Living training assigned all staff annually. Performance and accountability conversations to occur as needed. Walking rounds completed daily. 4.Executive Director, Memory Care Administrator, Resident Services Director

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) 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 provided clear direction regarding the delivery of services or were implemented for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2022 with diagnoses including vascular dementia, mixed anxiety disorder, and major depressive disorder. Observations were made of the resident's care from 10/28/24 through 10/31/24. Interviews with the resident and facility staff were conducted. The current service plan dated 10/18/24 was reviewed and the following was identified: Resident 1's service plan lacked clear instruction and/or was not implemented in the following areas: * Safety and monitoring instruction regarding assistive devices including side rails, gait belt, and foam wedge; * Frequency of toileting, incontinent care, hydration and snack prompting and cueing; * Staff to keep frequently used items within resident’s reach including water, tv remote, and control for hospital bed; * Instruction, monitoring, and frequency for repositioning resident while in bed; * Ensuring resident received cut and/or soft foods; * Non-use of upper dentures; * Resident elopement status; and * Use of wheelchair footrests. The need to ensure the service plan provided clear instruction regarding the delivery of services and services were implemented, was discussed with Staff 1 (Memory Care Administrator/LPN) on 10/31/24 at 12:01 pm. She acknowledged the findings. 2. Resident 3 moved into the MCC in 10/2024 with diagnoses including dementia and obstructive sleep apnea. The resident's current service plan, dated 10/01/24, was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 10/28/24 and 10/31/24. Resident 3's service plan did not provide clear instruction to staff and/or was not implemented in the following areas: * Home health services provided; and * Continuous positive airway pressure (CPAP) machine, including instructions for how to assist the resident in donning and doffing the apparatus, required settings, instructions for refusals, and when to report to the LPN or RN. The need to ensure service plans provided clear direction regarding the delivery of services and were implemented was discussed with Staff 1 (MC Administrator/LPN) on 10/31/24 at 10:24 am. She acknowledged the findings.

1. Resident 1 service plan was updated11/20/24 to provide clear instructions on items listed for Resident 1 in SOD. Res. Resident 3 service plan was updated on 11/8/24 to provide clear instructions on CPAP use and home health instructions. Residents with special equipment and home health services charts were audited and service plan updated with instructions and training provided to staff on new CPAP instructions 2. Outside provider notes are delivered to nursing in-box and reviewed by med tech. Med techs review upon receipta and refer any equipment and special instruction to the MCA for follow up. MCA to update TSP and/or SP as appllicable. MCA to complete NurseLearn SP training module. 3. Provider notes to be reviewed daily and referred to MCA upon receipt. SPs to be review Quarterly, with SCOC, and as new equipment is ordered. 4. Memory Care Administor

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had changes of condition had resident-specific instructions or interventions developed and reviewed for effectiveness, and/or weekly progress was documented until resolution for 1 of 3 sampled residents (#1) who experienced changes of condition. Resident 1 experienced severe weight loss. Findings include, but are not limited to: Resident 1 was admitted to the facility in 06/2022 with diagnoses including vascular dementia, mixed anxiety disorder, and major depressive disorder. The resident’s 10/18/24 service plan, 08/05/24 through 10/28/24 progress notes, Temporary Service Plans (TSPs), alert charting documentation, and 08/05/24 through 10/29/24 weight records were reviewed. Observations were made, staff and the resident were interviewed. The following was identified: a. Resident 1 was identified to have had a 9.8 pound weight loss, or 5.6% loss of his/her total body weight between 08/02/24 to 09/03/24. This constituted severe weight loss and a significant change of condition. A 09/04/24 TSP instructed staff to “monitor meal refusals and disinterest in meals” and for “staff to offer snacks in between meals,” “offer alternative meals,” and “encourage meal intake”. There was no documented evidence staff consistently monitored meal refusals, interest in meals, offered snacks in between meals, offered alternative meals, and/or encouraged meal intake. Resident 1’s documented weight record, noted the following: * 08/02/24 – 173.6 pounds; * 09/03/24 – 163.8 pounds; * 09/26/24 – 160.2 pounds; * 10/03/24 – 155.2 pounds; * 10/14/24 – 154.6 pounds; and * 10/22/24 – 147.8 pounds. Between 09/03/24 and 10/03/24, Resident 1 lost an additional 8.6 pounds, or 5.2% of his/her total body weight. On 10/14/24 a TSP written by Staff 2 (RN), instructed staff to serve the resident finger foods, easy to eat, and cut up foods. Additionally, staff were to monitor Resident 1 for difficulty swallowing and choking. On 10/17/24, Staff 2 documented a significant change of condition assessment for weight loss and identified the following interventions: * Care staff to offer finger foods at meals; * Snacks in between meals and before bedtime; and * Care staff to attempt to wake resident for every meal. There was no documented evidence staff consistently monitored if meals provided were finger foods, that snacks were offered in between meals and before bed, and if care staff attempted to wake the resident for every meal. The 10/18/24 change of condition service plan identified the following interventions: * Meals to be finger foods cut into bite size pieces; * High calorie snacks provided between meals; * Requires hands on assist to complete meal; * Give fresh water consistently through out shift, between meals, and plenty of liquids each meal; * Use verbal prompts to cue resident to drink; and * Unable to use glassware as it is too heavy to lift. There was no documented evidence staff implemented or consistently monitored if meals provided were finger foods and/or cut into bite size pieces, that high calorie snacks were provided between meals, that staff provided hands on assist for the resident to complete his/her meal, that staff offered fresh water consistently throughout the shift and between meals, that staff provided verbal prompts to cue the resident to drink, or of what glassware was provided for the resident’s use. On 10/23/24, Staff 2 documented an additional significant weight loss assessment and noted “meal intake interventions have not been effective.” No new interventions were documented. On 10/28/24 the following was observed and identified: * The resident was served a crusted chicken breast that was cut in half, green beans, and rice for lunch and consumed approximately 10% of the meal; * Resident 1 did not have in his/her upper dentures; and * Staff 12 (Care Associate) stated the resident had not worn his/her dentures “for some time” because they “no longer fit and fall out.” On 10/29/24 the following was observed and identified: * From 8:00 am to 10:00 am there were no observations of staff encouraging hydration or offering snacks to Resident 1; * From 10:55 am to 1:08 pm there were no observations of staff encouraging hydration or offering snacks to Resident 1; * At 2:01 pm, multiple direct care staff were observed and overheard to say to leave Resident 1 alone because s/he has not been feeling well; and * At 4:36 pm, Staff 13 (Care Associate) stated she had not checked on Resident 1 yet this shift because “…day shift said s/he wanted to sleep all day”; * At 4:37 pm, this surveyor requested staff to ask Resident 1 if s/he was hungry and wanted dinner that evening. Resident 1 stated s/he was hungry and wanted to go to dinner; * At 4:42 pm, Staff 21 (Care Associate/MT) stated no staff had checked on the resident because the resident was tired and needed rest; and * At 5:05 pm the resident was served a grilled ham, cheese, and tomato sandwich and a side of broccoli florets for dinner in the dining room. The resident was observed to take off the tomato, eat the inside of the sandwich and did not eat the broccoli. On 10/29/24 at 8:43 am, Resident 1’s current weight was requested by this surveyor. On 10/29/24 at 6:07 pm, the resident weighed 145.2 pounds. This constituted an additional severe weight loss of 15 pounds, or 9.3% of his/her total body weight from 09/26/24 to 10/29/24. The facility’s failure to consistently monitor the effectiveness of the interventions, and ensure staff were following the interventions, placed the resident at risk for continued weight loss. On 10/30/24, Resident 1’s weight loss was reviewed with Staff 2. Staff 2 stated she was not aware the resident was not consistently provided finger foods, cut foods or that the resident was not offered snacks throughout the day. b. The resident experienced short-term changes of condition without communication to staff, noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas: * 10/24/24: Redness and indents on heels; * 10/28/24: Loose stool; * 10/29/24: Quarter size red area on sacral area; and * 10/30/24: Superficial skin abrasion on left forearm. c. The resident was at risk for falls and the TSPs identified fall interventions including: * “Staff to keep [Resident 1] up [and] not put to bed to early…”; * “Frequent checks”; * “[Resident 1] needs constant reminders that [s/he] can not self transfer…”; * “Staff to check on [Resident 1] more [frequently] to see when [s/he] would like to get out of bed”; and * “Frequent checks [and] offer care 3-4 x each shift”. The resident experienced non-injury falls on the following dates: * 08/24/24; * 09/29/24; * 10/07/24 in the AM; * 10/07/24 in the PM; * 10/10/24; * 10/12/24; and * 10/17/24. There was no documentation in the resident's record that the facility reviewed the existing interventions for effectiveness and developed and implemented resident specific interventions to minimize the risk of repeated falls. The need to ensure changes of condition had documentation of weekly progress until resolution, interventions were re-evaluated for effectiveness and clear, resident-specific directions were provided to staff was discussed with Staff 1 (Memory Care Administrator/LPN) on 10/31/24 at 12:01 pm. She acknowledged the findings.

1. Resident 1 had a significant change of condition lookback assessment completed on 12/2/24 by RN. Service plan will be updated with weight loss interventions identified during survey and RN assessment. Care Associate training on diet order and reporting issues conducted on 11/22/24. Speech Therapy eval requested by community and completed 11/20/24. ST recommendations implemented and TSP initiated. Updated diet order communicated to Dining Services Director. 2. System correction: a. Falls tracking monitoring has been initiated. Following each fall, implement alert charting and TSP. Monitor for effectiveness of interventions. b. New skin tracking log implemented for short term COC. c. Meal monitoring was initiated for all memory care residents. d. Tracking forms maintained in binder in med room, to be checked by MCA and RSD daily. e. Clinical meeting to include review of last 24 hours of progress notes f. Notify RN of changes in condition as needed g. RN to initiate SCOC assessment within 48 hours and monitor weekly until resolved or becomes the new baseline 3. Frequency: a. Skin and fall tracking logs completed weekly, meal/snack monitor forms completed every shift b. Binder is checked every weekday c. Clinical meeting is two times a week, minimum 4. Memory Care Administrator, Resident Services Director, RN

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 effective infection prevention and control protocols to provide a safe and sanitary environment during meal service and nursing care for multiple sampled and unsampled residents and while performing ADL care for 1 of 1 sampled resident (#1). Findings include, but are not limited to: 1. Lunch service was observed on 10/28/24 through 10/30/24. Staff were observed setting tables with napkins and silverware, cutting and touching resident’s food, serving meals and beverages, touching residents, and removing dirty dishes without changing their gloves or performing hand washing. 2. On 10/30/24 during the lunch service, Staff 7 (Care Associate/MT) was observed to perform vitals (measurement of body temperature, blood pressure and pulse/respirations) on four unsampled residents in the dining room. Staff 7 was observed touching residents, did not disinfect the instruments (blood pressure cuff, oximeter, and ear thermometer) before use on the next resident and did not perform hand washing in between services. 3. On 10/30/24 at 9:31 am Staff 1 (MC Administrator/LPN) entered the dining room to assist an unsampled resident with his/her oxygen concentrator. Staff 1 removed the resident’s nasal cannula from the resident’s nose, pressed the nasal cannula to Staff 1’s hand, and then replaced the nasal cannula in the resident’s nose. Staff 1 was not wearing gloves, and hand hygiene was not visualized during this nursing task. 4. On 10/29/24 at 9:16 am, during incontinent, care Staff 15 (Care Associate) and Staff 16 (Care Associate) did not change gloves between touching soiled incontinent supplies and the resident’s clean clothes. Staff 15 and Staff 16 did not complete hand hygiene after incontinent care and before assisting other residents. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals and providing nursing services to the residents, was discussed with Staff 1 on 10/31/24. She acknowledged the findings.

1. On Friday, 11/11/24, Memory Care Administrator, Executive Director, and Resident Services Director reviewed Community policy and procedure with all staff for proper infection prevention which included: standard precautions, laundry and housekeeping procedures and preventing cross-contamination, handwashing, when to wear and change gloves, masks, and gowns, respiratory ettiquette, and cleaning equipment between residents. 2. System correction: a. Infection prevention technique to be verified during new employee orientation via skills checklist. b. Every other month at all staff meetings, there will be a a review on am element of Infection Prevention and Control. c. Saniwipes are conveniently located for staff use on equipment. 3. Frequency: Traning upon hire, bimonthly at staff meetings, annual training per Oregon Administrative Rule and individual staff training as needed. 4. Memory Care Administrator, Executive Director, Resident Services Director

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records for 05/2024 through 10/2024 were reviewed and lacked the following components: * There was no documented evidence fire drills were conducted every other month. * There was no documented evidence fire and life safety training was consistently provided to staff on alternating months of fire drills. The need to ensure fire drills were conducted in accordance with the Oregon Fire Code and the facility provided fire and life safety instruction to staff on alternate months of fire drills was discussed with Staff 1 (MC Administrator/LPN) on 10/31/24 at 12:01 pm. She acknowledged the findings.

1. RSD has reviewed and documented Fire Life safety with all memory care residents 2. Fire Life Safety teaching and training at every move in and annually 3. At every move in and annually 4. RSD and WD

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 instruct each resident within 24 hours of admission and re-instruct residents 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 for 05/2024 through 10/2024 were reviewed and lacked the following components: * There was no documented evidence residents were instructed 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 within 24 hours of admission. * There was no documented evidence residents, whose mental capability allowed, received instruction in fire and life safety expectations, 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. On 10/30/24 at 10:12 am, Staff 4 (Resident Services Director) reported there used to be a system in place to instruct residents regarding fire and life safety within 24 hours of admission and for the re-instruction of residents at least annually. The need to ensure residents were instructed 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 within 24 hours of admission and residents whose mental capability allowed for following such instruction were re-instructed at least annually was discussed with Staff 1 (MC Administrator/LPN) on 10/31/24 at 12:01 pm. She acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure exterior pathways were maintained in good repair and to ensure all poisons, chemicals, and other toxic materials were stored in locked storage. Findings include, but are not limited to: The memory care community was toured on 10/28/24 at 10:11 am. The following was identified: 1. The community had a secured outdoor area which included a large lawn and a paved patio. Between the patio and the lawn there was a drop-off of approximately 2.75”. The drop-off created a potential tripping hazard for resident’s who used the outdoor area independently. 2. The community’s janitorial closet was located in the facility’s dining room area. This closet included cleaning products and was observed to be unlocked over multiple observations. Additionally, a spray bottle of stain remover, two spray bottles of disinfectant, and a spray bottle of all-purpose cleanser were observed to be stored in an unlocked cabinet in the community’s kitchenette. The kitchenette was accessible to residents. On 10/28/24 at 11:15 am, Staff 1 (MC Administrator/LPN) was asked to ensure all toxic materials were stored in a secured location. On 10/28/24 and 10/29/24 at 3:32 pm and 8:19 am, respectively, the janitorial closet was unlocked and accessible to residents. At that time, Staff 1 was informed of the additional findings and asked to ensure the janitorial closet remained locked at all times. The janitorial closet was locked on all additional observations. The need to ensure exterior pathways were maintained in good repair and all poisons, chemicals, and other toxic materials were stored in locked storage was discussed with Staff 1 on 10/31/24 at 11:02 am. She acknowledged the findings.

1. - Drop off has been filled in - Chemicals under sink removed and placed in locked janitor closet - Janitor closet locked and keys made for staff access only. Sign in place to keep door locked 2. - Weekly walk through of MC patio and grounds by Administrator and POD - Each shift Med Tech to check and ensure janitor closet is locked 3.- Grounds: weekly - Janitor Closet: daily each shift 4. - Grounds: POD and Administrator - Janitor Closet: Med Tech, WD/Administrator,

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior 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 will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the memory care community was toured on 10/28/24. The following areas were observed to need cleaning and/or repair: * Doors and door frames throughout the memory care had scuffs and scrapes or gouges which exposed bare wood; * Walls throughout the memory care had scuffs and scrapes; * Exterior surfaces of the kitchenette cabinets and drawers were sticky to touch, had peeling laminate, and/or had a large patch of white residue; * Interior surfaces of the kitchenette cabinets and drawers had build-up of debris and stains; and * Floors and walls throughout the laundry room had build-up of lint, debris and garbage. The environment was toured, and findings were discussed with Staff 1 (MC Administrator/LPN) on 10/31/24 at 11:02 am. She acknowledged the above areas needed to be cleaned and repaired.

1. - POD has ordered all materials to begin repairs of walls/doors/frames - Kitchenette exterior and interior cabinets cleaned - Laundry room has been cleaned 2. - Weekly interior walk through by POD and Administrator to inspect doors/frames/walls for damage. - Daily cleaning list was created - Deep cleabn of laundry room weekly 3. - Interior: weekly - Kitchenette: Daily - Laundry Room: weekly 4. POD and Administrator

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry (b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to: A tour of the memory care community laundry room and interviews with staff between 10/28/24 and 10/31/24 were completed and revealed the following: The memory care community had a single laundry room where all linens were washed. The laundry room included a flushing rim sink, a utility sink, an industrial washer and dryer, and a residential washer and dryer. On 10/28/24 at 11:40 am, Staff 11 (Care Associate) described the process for washing soiled linens which included rinsing the linens in the utility sink and washing the clothing with a single laundry detergent in either of the two washing machines. When asked about the flushing rim sink, Staff 11 stated, “I don’t know what that’s for.” On 10/29/24 at 1:57 pm, Staff 6 (Plant Operations Director) confirmed the facility was not using a laundry detergent that included a chemical disinfectant. He stated that a bottle of disinfectant had been left to spray the inside of the washing machine when laundering soiled linens; however, there was not a bottle of disinfectant visualized in the laundry room during the interview. Staff 6 then confirmed the water temperature for the washing machines was set at 130 degrees Fahrenheit, or below the required level when a chemical disinfectant was not used. Staff 6 also confirmed the need for staff to use the flushing rim sink to rinse soiled linens prior to washing the linens. The need to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 1 (MC Administrator/LPN) on 10/31/24 at 11:02 am. She acknowledged the findings.

1. Disinfectant for laundry was ordered and has arrived. Disinfectant is now being used and staff training completedon 11/22/24 for the laundry system. 2. Laundry room will have posted instructions. New staff to be trained on laundry system. Weekly check by MCD to ensure disinfectant being used. 3. Training at new hire and monthly to follow up on process. Weekly laundry system checks. 4. RSD, MCD and POD

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to have a setting that ensured individual rights of privacy, dignity, and respect. Findings include, but are not limited to: Refer to C200.

Refer to C200

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide each individual privacy in his or her own unit for multiple sampled and unsampled residents who resided in shared units. Findings include, but are not limited to: During the acuity interview on 10/28/24, the survey team was provided with a resident roster which indicated there were nine double occupancy rooms in the facility. Six of the double occupancy rooms had two residents sharing one unit. Staff 1 (MC Administrator/LPN), Staff 3 (Executive Director), and a surveyor toured the double occupancy rooms on 10/30/24 at 1:25 pm. One-bedroom apartments that were shared between two people had no means to provide privacy for one of the two residents when the unit was entered, when ADL cares were provided outside of the bathroom, or when a resident walked to the bathroom. Large studio-like rooms that were shared between two residents had a curtain to offer privacy. However, the privacy curtain did not meet the wall which exposed the resident’s bed and/or other parts of the resident’s bedroom. The tour of the double occupancy rooms also revealed the bathroom doors did not have a lock to allow privacy. The need to ensure residents’ right to be afforded privacy was discussed with Staff 1 on 10/31/24 at 10:54 am. She acknowledged the findings.

1. Privacy curtains have been ordered for all shared apartments and locking bathroom door knobs for shared rooms 2. All shared apartments will have a privacy curtain going forward and locking bathroom door knobs as soon as they are delivered. POD will install new doorknobs and privacy curtains. Staff to be trained to report if curtians are missing or improperly working. 3. During annual inspections and as needed 4. POD and Administrator

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units for 1 of 3 sampled residents (#1) and multiple unsampled residents. Findings include, but are not limited to: Resident 1’s service plan dated 10/18/24, was reviewed and revealed the resident was not given a key to his/her unit. Whereas, on 10/28/24 at 1:52 pm, Resident 3 was observed wearing a spiral coil keychain with a key on his/her wrist. On 10/28/24 at 11:25 am, Resident 1 approached a surveyor and reported s/he wanted to go into his/her room but did not have a key and it was locked. In an interview with Staff 1 (MC Administrator/LPN) and Staff 3 (Executive Director) on 10/30/24 at 12:04 pm, Staff 1 stated residents who requested a key or were cognitively intact enough to use a key had one. She also acknowledged most residents who resided in double occupancy rooms were not given keys. The facility failed to ensure all residents were given keys to their unit. The need to ensure all residents were provided keys to their units was discussed with Staff 1 on 10/31/24 at 10:54 am. She acknowledged the findings.

1. A key will be given to all residents for their apartments by 12/30/24. 2. All residents will be given a key at move in. Current residents will get keys as they are made and can be given to resident and/or their POA 3. At move in and will be replaced as requested. 4. POD, MCD and Administrator

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 follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C200, C420, C422, C510, C513, and C530.

Refer to: C200 C420 C422 C510 C513 C530

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 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 C260, C270, and C295.

Refer to: C260 C270 C295

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident 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 evaluate residents for activities and develop an individualized activity plan based on the evaluation for 1 of 3 sampled residents (#3) whose records were reviewed. Findings include, but are not limited to: Resident 3 moved into the memory care community in 10/2024 with diagnoses including dementia. a. Resident 3’s initial evaluation dated 09/26/24, service plan dated 10/01/24, “My Life Story” form and “Current Individualized Activity Evaluation Form” dated 09/26/24 were reviewed. Although there was some information around the resident’s activity interests, the facility had not fully evaluated the resident’s: * Emotional and social needs and patterns; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. b. There was no individualized activity plan developed based on the evaluation that reflected the resident’s activity preferences and needs for Resident 3. The need to ensure the facility evaluated each resident for activities and developed an individualized activity plan based on the evaluation was discussed with Staff 1 (MC Administrator/LPN) on 10/31/24 at 10:54 am. She acknowledged the findings.

1. Individualized Activity service plan has been updated for resident 3 on 11/8/24 2. Prior to resident move-in date, the initial Oregon Evaluation and “My life Story” form will be completed and used to develop an individualized activity plan. The individualized activity plan will be based on the evaluation and revised as additional information becomes available within the first 30 days. 3. At pre move in assessment, move in day, 30days after move in, 90 day assessments , and at significant change of condition. 4. WD and ED

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of or inside their rooms. Findings include, but are not limited to: During observations between 10/28/24 through 10/31/24, multiple residents were observed to be unable to enter their rooms without locating staff and asking to be let in. On 10/30/24 at 9:09 am, an unsampled resident approached this surveyor and said, “can you unlock my door so I can go to the bathroom?” On 10/28/24 at 11:25 am, Resident 1 approached a surveyor and reported s/he wanted to go into his/her room but did not have a key and it was locked. On 10/29/24 at 4:35 pm, Resident 1’s room was observed closed and locked. At 4:36 pm this surveyor asked Staff 13 (Care Associate) if Resident 1 was in his/her room and his/her room was closed and locked. Staff 13 stated the resident was in his/her room, but the door should not be closed and locked. On 10/30/24 at 10:20 am, Staff 15 (Care Associate) was visualized unlocking a resident’s door and was asked why resident doors were locked. S/he stated the community used to have residents who wandered into other resident’s rooms, and it had become a habit to lock the doors. This was confirmed with Staff 1 (MC Administrator/LPN) on 10/30/24 at 12:04 pm who reported there were a lot of residents in the community who wander, and doors were locked because this made certain residents mad. The need to ensure residents were not locked out of or inside their rooms was discussed with Staff 1 on 10/31/24 at 10:54 am. She acknowledged the findings.

1. All residents have been provided a key to their room. Residents who have expressed a preference for having their door locked or unlocked when they are in their home or when they are away from their home will have this information included in their service plan. All care staff have been informed not to lock resident doors without resident consent. 2. System correction: Resident preferences related to locked doors will be included in initial evaluation and service planning process and reviewed with regular evaluation updates. 3. Frequency: At initial evaluation, 30 days, 60 days, 90 days, and upon resident request. 4. Memory Care Administrator