Print Inspection: RL010440

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, 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

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 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: 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: 1. Resident 4 was admitted to the facility in 2017 with diagnoses including dementia and essential hypertension. Review of the resident’s 03/01/26 through 03/31/26 MAR and current physician orders identified the following: * The resident was prescribed amlodipine 10 mg tab, one tablet every night at bedtime. The order included parameters to notify the physician and hold the medication if the resident’s systolic blood pressure was less than 100 or the diastolic blood pressure was less than 60. There was no documented evidence the resident’s blood pressure was being taken prior to staff administering the amlodipine. In an interview on 04/01/26 at 1:05 pm, Staff 2 (RN) verified that staff had not been taking the resident’s blood pressure prior to administering amlodipine. The need to follow physician orders as written was discussed with Staff 1 (ED), Staff 3 (RCC), and Staff 8 (Director of Clinical Operations) on 04/02/26 at 3:45 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 12/2025 with diagnoses including vascular dementia. The resident was identified during the acuity interview to have skin issues (rash under breasts). Resident 1's current physician orders, dated 03/12/26, and MARs from 03/01/26 through 03/31/26 were reviewed, and the following was identified: The resident was prescribed nystatin 100,000 units/gram powder, topically apply twice a day until resolved for rash under breasts. The medication was not administered as prescribed on five occasions between 03/01/26 and 03/31/26. In an interview on 04/1/26 at 10:45 am, Staff 16 (MT) stated she held the treatment on those occasions as the rash appeared resolved. In an interview on 04/01/26 at 1:15 pm, Staff 2 (RN) confirmed the rash was not resolved, treatment was currently ongoing, and there was no order to hold the scheduled treatment. The need to ensure treatment orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RCC) on 04/02/26 at 1:00 pm. They acknowledged the findings.

Recording of blood pressure was added for Resident 4 to the order immediatley. The RN assesed resident #1 for the need to continue use of Nystain. A MAR audit was completed for all residents and medications/treatments. For all new medication/treatments a three check process will take place with Med Tech, RCC and RN. During this three check process all vitals and perameters will be put in place following doctors orders. On going MAR audits quarterly and with COC. A quarterly MAR audit will be done for each resident or with a COC. Monthly med tech meeting to be held for continuing education relating to medication policy and procedures. RN, RCC and Administrator will monitor.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: 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: 1. Resident 1’s ABST evaluation did not reflect the care that was being provided to the resident as noted in their service plan or the time and frequency that was required to complete the ADL task was not accurate as follows: * No time was assigned for cueing or redirecting due to cognitive impairment or dementia. Interviews with staff indicated they spent approximately 10 minutes per occurrence redirecting the resident. * No time was assigned for providing treatments. Review of the resident’s MAR and interviews with staff indicated staff were providing a prescribed treatment BID. * No time was assigned for escorting to and from meals. During the survey, staff were observed escorting the resident to and from meals. * No time was assigned for supervising, cueing, or supporting while eating. During the survey, staff were observed needing to repeatedly provide verbal cueing to keep the resident focused on eating. * The time assigned for assisting with bathing (8 minutes) was not accurate. Staff interviewed stated it took between 15 and 20 minutes to complete the bathing task with Resident 1. * The time assigned for dressing/undressing (seven minutes) and grooming (four minutes) was not accurate. The resident recently sustained a hip fracture, and interviews with staff indicated it now took approximately 20 minutes each morning to assist the resident with dressing and grooming. The need to ensure each resident’s ABST evaluation accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 04/02/2026 at 1:00 pm. They acknowledged the inaccuracies in the ABST. 2. Resident 2’s ABST evaluation did not reflect the care that was being provided to the resident as noted in their service plan or the time and frequency that was required to complete the ADL task was not accurate as follows: Resident 2’s service plan and progress notes indicated staff were monitoring and documenting on the resident’s behavior frequently, and the resident was frequently displaying escalated verbal and physical behavior, for which staff were intervening and redirecting the resident to other activities. The resident’s ABST assigned no time for: * Monitoring behavioral conditions or symptoms; * Ensuring non-drug interventions for behaviors; or * Cueing or redirecting due to cognitive impairment or dementia. * Additionally, the time assigned for assisting with bathing (ten minutes) was not accurate. Staff interviewed stated it took between 25 and 45 minutes to complete the bathing task with Resident 2. The need to ensure each resident’s ABST evaluation accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was discussed with Staff 1 (ED), Staff 2 (RN) Staff 3 (RCC), Staff 8 (Director of Clinical Operations) on 04/02/2026 at 4:00 pm. They acknowledged the inaccuracies in the ABST. 3. Resident 4’s ABST evaluation did not reflect the care that was being provided to the resident as noted in their service plan or the time and frequency that was required to complete the ADL task was not accurate as follows: The time assigned for supervising, cueing, or supporting while eating (ten minutes, five times per day) was not accurate. Observations during the survey and interviews with staff indicated staff spent between 20 to 45 minutes assisting the resident with eating during meal and snack times. The need to ensure each resident’s ABST evaluation accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was discussed with Staff 1 (ED), Staff 3 (RCC), and Staff 8 (Director of Clinical Operations) on 04/02/2026 at 3:45 pm. They acknowledged the inaccuracies in the ABST.

The RCC updated the service plan for Residents 1, 2 an 4 to reflect the care being provided by direct care staff. A review and update of the ABST was completed to capture all 22 elements. Observation of care being provided for all residents then the ABST was updated to reflect the number of mintues identifed to complete services for each resident. Observation of care and mintues will be updated quarterly or with COC. Administrator, RN and RCC

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by:

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 C295.

Refer to C 295 and C 362

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:

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 C303 and C362.

Refer to C303

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: