Print Inspection: RL001107

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: 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 main facility kitchen on 11/04/24 from 9:30 am through 2:00 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Pipes, drain, walls and flooring behind/underneath of the dish machine; * Floors/walls/edges between tables/workspaces; * Trash cans; * Ceiling vents and light fixtures; * Walls behind prep spaces/cooking areas or trashcans; * Stove, oven and grill knobs, doors, and exteriors; * Interior of ovens; * Shelving in walk in cooler, freezer; * Industrial mixer; * Base holding mixer; * Floor and wall behind, beside and under mixer; * Large can opener and housing; * Interior of reach in deli cooler; * Rack shelving in dry good storage; * Rack shelving storing equipment and dishes; * Utility carts; * Interior and exterior of meal service delivery carts; * Plastic bulk bins and lids in dry storage; * Interior of microwave; * Wall behind stove/grill; and * Interior of ice machine. b. The following areas needed repair: * Caulking in ware washing area with black matter debris buildup; * Large gap in ceiling tile above cooking area creating space for potential pests/insects or other potential contaminants from celing space entry to kitchen/food; and * Large sections of walls in office in kitchen that were damaged needing repair. c. Multiple food items/packages/containers found in cold food and dry food storage that were stored open to potential contamination. d. Container of bulk dry goods was found to have cups or scoops stored in them with handle touching food surfaces potentially contaminating food. e. Multiple kitchen staff that were preparing food and/or handling clean dishes/equipment, did not have facial hair or hair restrained as required. f. Dining area was observed to have preset silverware and service ware that was not protected from potential contamination as required. On 10/04/24 at 12:45pm, Staff 2 (Regional Dining Services Director/Person in Charge) was interviewed and acknowledged the above areas in need of correction. At 1:15pm Staff 1 (Executive Director) was interviewed and they acknowledged the identified areas.

1. Dining Team will clean all area cited with cleaning task list created by DSM 2. Dining Service Manger will give servers and cooks cleaning tasks for daily cleaning, weekly cleaning, and monthly cleaning. 3.This will be done every day 4.DSM will oversee daily and report to ED weekly and will be completed by 1/2/25

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to coordinate care with outside providers, and to ensure staff were informed of new interventions and the service plan was adjusted if necessary for 2 of 3 sampled residents (# 1 and 2) who received outside services. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 04/2023 with diagnoses including an embolic stroke, hemiplegia (paralysis of one side of the body), and a seizure disorder. During the acuity interview on 11/04/24, the resident was identified to receive outside PT services. Resident 1's outside provider notes, dated 10/11/24 through 10/29/24, and charting notes, dated 08/05/24 through 11/04/24, were reviewed during the survey and revealed the following recommendations: * 10/11/24 - " Further plans to order replacement hospital bed as current equipment is in disrepair;” and * 10/25/24 – Noted the resident’s existing hospital bed needed repairs. There was no documented evidence the information left by the outside provider had been communicated to staff or that the facility had coordinated with the outside provider to ensure the resident’s bed had been repaired or replaced. Observation of Resident 1's hospital bed on 11/06/24 at 1:33 pm, revealed the half-length side rails on the bed were loose and in disrepair. At 1:59 on 11/06/24, Staff 4 (Wellness Director) was informed about Resident 1’s side rails. Staff 4 had maintenance repair and secure the resident’s side rails. The need to ensure outside provider care was coordinated and communicated to staff was discussed with Staff 1 (ED) and Staff 12 (Director of Operations) on 11/07/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 08/2024 with diagnoses including acute kidney failure and acute embolism. The resident’s clinical records, including the service plan dated 09/04/24, progress notes from 08/08/24 through 11/04/24, and outside provider notes were reviewed and revealed the following: * A home health communication form completed on 09/25/24 by a HH nurse stated, “Wound appeared larger today d/t [due to] moisture build up in dressing.” The communication instructed facility staff “please remember to change dressing 1x week [once a week] between SN visits (recommend this Friday, Saturday, or Sunday)”; and * A home health communication form completed on 09/30/24 by a HH nurse included the following instruction: “Please [change] dressing every Wed/Thurs for moisture prevention.” During the resident interview on 11/05/24, the surveyor requested to observe Resident 2’s wounds. The resident refused. No additional information was obtained. There was no documented evidence the resident’s service plan was adjusted to incorporate outside provider recommendations and follow-up reporting protocols. The need to ensure the facility coordinated on-site health services for residents who cannot or choose not to self-manage their health services including adjusting the resident’s service plans and implementing reporting protocols was reviewed with Staff 1 (ED) and Staff 10 (Regional Director of Operations) on 11/07/24. They acknowledged the findings.

1.Health & Wellness Director will audit all residents charts with outside agency and put TCPs in place for staff 2.This will be monitored daily by H&W and weekly by ED 3.This will be done every day 4.H&W will oversee daily and report to ED weekly and will be completed by 1/2/25

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by:

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired direct-care staff (#11) demonstrated competency in assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 11/05/24 and 11/06/24 with Staff 7 (Office Manager), and the following was identified: Staff 11 (MT), hired 09/11/24, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire: * The role of service plans in providing individualized resident care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Other duties as applicable (medications and treatments). On 11/07/24 at 2:00 pm, Staff 1 (ED) and Staff 12 (Director of Operations) were notified Staff 11 could not administer medications until s/he had documented evidence of demonstrating competency. Staff 12 indicated the evaluation of Staff 11’s competence would be reviewed and documented prior to Staff 11 administering medications. The need to ensure newly hired direct-care staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 and Staff 12 on 11/07/24. They acknowledged the findings.

1. • An audit of remaining staff training records completed to assure compliance. 2.• Office Manager will audit employee training files routinely to verify completion of required training. 3.This will be done upon completion of the initial training process and twice monthly 4.This will be monitored weekly by OM and monthly by ED and will be completed by 1/2/25

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. 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 general fire and life safety requirements were being met. Findings include, but are not limited to: Fire and life safety records revealed the facility lacked documented evidence residents had received annual training in the following areas: * General safety procedures; * Evacuation methods; * Responsibilities during fire drills; and * Designated meeting places inside or outside the building.. The need to ensure residents received annual training in fire and life safety, and the requirement to ensure a written record of fire safety training, including content of the training sessions and the residents attending was kept was discussed with Staff 1 (Executive Director) and Staff 3 (Maintenance) on 11/04/24 and 11/05/25 at 2:10 pm. They acknowledged the findings.

1.Maintenance will have floor meeting with all residents to go over fire evacuation drill 2.Yearly training will be done along side the yearly full evacuation drill 3.Once a year/audit once monthly to assure its completed timely 4.ED will over see that all residents have received training by 12/15/24

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: