Jurgens Park Senior Living

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 07/09/25 at10:45, the facility kitchen was observed to need cleaning and repair in the following areas:

PONDEROSA kitchen (food prep for entire campus):

* Ceiling vents – heavy build up of dust;

* Wall above three compartment sinks – build up of black matter/finish worn/uncleanable;

* Wall under counter next to dishwashing machine – splatters/drips/spills;

* Wall above counter next to dishwashing machine – in need of painting/uncleanable; and

* Floor under counter next to dishwashing machine – significant build up of debris/black matter.

BEECHWOOD kitchen:

* Microwave interior – significant amount of food splatters.

ALPINE kitchen:

* Wall above three compartment sink – build up of black matter; and

* Exterior of garbage can and sink leg next to it – significant food drips/spills.

Other areas of concern included:

PONDEROSA kitchen:

* Garbage can uncovered when not in use;

* Colored cutting boards – finish worn/heavily scored; and

* Thermometer for dishwashing machine – not working/full of moisture (temperature checked by other means/chlorine parts per million appropriate).

ALPINE kitchen:

* Dishwasher thermometer – working appropriately although significant amount of moisture build up; and

* Shelf above coffee station – pulling away from wall.

The areas of concern were observed and discussed with Staff 1 (Food Services Director) and discussed with Staff 2 (Executive Director) on 07/09/25. The findings were acknowledged.

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 follow licensing rules for Residential Care and Assisted Living Facilities.

Findings include, but are not limited to:

Refer to C240.

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 licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:

During the CHOW survey, conducted 12/17/24 through 12/19/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.

Refer to deficiencies in report.

OAR 411-054-0025 (1) Facility Administration: Operation

(1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure reasonable precautions were implemented to ensure a resident received sufficient assistance with bed mobility, during incontinent care, to maintain their health and safety for 1 of 1 sampled resident who was dependent for care (#3). Resident 3 expressed distress and anxiety during care related to how staff were moving the resident in bed.
Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 11/15/24 service plan, 09/17/24 through 11/26/24 observation notes, physician communications, and incident investigations were completed.

The resident was noted to be dependent with all ADLs. The resident required two staff assistance for transfers and dressing and a Hoyer lift for transfers. The resident was nonverbal. The resident’s muscles and limbs were very tight to move, straighten and bend fully. The resident was noted to have anxiety and behaviors with ADL cares due to his/her confusion. Staff were instructed to tell the resident step by step what was occurring during care to help alleviate any distress.

Observations of ADL care including incontinent care, bed mobility, Hoyer transfer and dressing were completed between 12/17/24 and 12/19/24 and showed the following:

Afternoon incontinence care on 12/17/24:

* The resident was assisted by two staff and a Hoyer from his/her wheelchair into his/her bed.
* The resident required incontinence care and a clothing change during the observation.
* The resident was turned side to side to remove and replace his/her brief, provide cleaning and change the resident’s pants.
* The resident was positioned too close to the outer edge of the mattress during multiple rolls side to side.
* On two occasions Staff 18 (CG) put a hand on the side of the resident’s head and used his/her head as leverage to help turn the resident, while the other hand was at the resident’s hip. Staff 18 was told by Staff 9 (CG) and by the surveyor not to use the resident’s head to help turn him/her.
* When rolled to the right, the resident’s entire upper body and arms were observed hanging off the bed. Staff were standing on the right side of the bed near the resident’s waist. The resident’s torso was dangling off the bed when staff were asked by the surveyor, to adjust the resident.
* When the resident was rolled to the right while lying on the very outer edge of the bed, s/he began to yell out, grab at staff and/or flail his/her arms.
* The resident was not placed in the center of the bed, or his/her placement readjusted prior to providing care or rolling.

Start of day dressing, incontinence care and mid-morning incontinence care on 12/18/24:

* The resident was dressed for the day and his/her brief changed as part of his/her morning routine.
* The resident’s position in bed was not checked or adjusted prior to rolling the resident for clothing and brief changes.
* The resident was rolled to the left side with his/her head landing extremely close to the wall. The resident’s head did not contact the wall. The resident was making noises, yelling and moaning during care. The resident was not told what was occurring before it happened.
* The resident was rolled to the right side but was extremely close to the edge. The resident showed signs of distress when turned to the right, was unstable and grabbing at staff clothing and bodies. The resident was heard moaning, yelling, and observed flailing his/her arms.
* The resident was rolled so far to the right s/he was partially on his/her stomach. The resident’s face was pressed closely to the staff’s pants/leg and his/her yelling/crying out was muffled.
* Staff 12 and 18 (CGs) were again asked by the surveyor to readjust the resident’s position to keep him/her away from the edge when rolling and to ensure the resident’s face was not up against the bedding or staff clothing/legs.
* The side of the resident’s head was used to assist in a roll as previously observed on 12/17/24. Additionally, the back of the resident’s head/upper neck was used to help lift the resident up to adjust his/her shirt placement.
* Staff 18 (CG) was told by the surveyor not to use the side of the resident’s head or the back of his/her neck for any position adjustments as it could cause injury.
* Neither of the two staff taking care of the resident provided him/her information on what was occurring with care or spoke to the resident to try and soothe him/her when showing signs of distress and being upset during most of the care.
* While agitated and calling out, the resident was grabbing at staff, his/her brief and putting hands near peri area. Staff 12 (CG) was observed to pull the residents sweatshirt up over the resident’s now crossed arms and place her own hand on top of the sweatshirt over the resident’s arms. The resident pulled his/her arms free, and staff did not attempt a similar move during the remainder of care.

In an interview on 12/18/24, Staff 12 and Staff 18 indicated they understood the resident should be positioned away from the edge of the bed before rolling.

In an interview on 12/18/24, Staff 1 (ED) and Staff 5 (RCC) were provided with information on the observations of care for Resident 3. Staff 1 and Staff 5 indicated the care staff should not be talking over the resident and should be telling the resident what was going on during care to help with distress. Staff 1 and Staff 5 acknowledged that the resident should not be rolled so closely to the edge of the bed, or any attempt made to restrain arms or hands with clothing. Staff 1 indicated additional training was required. Staff 1 and Staff 5 indicated they would be reviewing proper care of the resident with the staff observed as well as the staff normally assigned to the house.

In an additional interview on 12/19/24, Staff 1 indicated they reviewed transfers and resident care at the staff meeting on 12/18/24 as well as working on individual trainings.

An additional observation of morning care was completed on 12/19/24 with improvement in some areas of the transfer and provision of care. A draw sheet was utilized, and the resident was adjusted in bed prior to rolling side to side.

The need to ensure staff took reasonable precautions to provide appropriate care to ensure the safety and well-being of a dependent resident, during ADL care, was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN) and Staff 5 (RCC) on 12/18/24 and 12/19/24. The staff acknowledged the findings.

Refer to C 200.

OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:

OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents, including ensuring resident call pendants alerted staff when residents used them to call for assistance, and to establish and implement an effective policy to ensure resident safety during times of extreme temperatures, including heat. This is a repeat citation. Findings include, but are not limited to:



a. The call system in the Ponderosa cottage was reviewed on 08/13/25. An unsampled resident was observed to activate the call system via pull cord in the living space of his/her apartment at 2:32 pm. The wall unit audibly alerted and had a blinking red light.



At 2:52 pm, 20 minutes after the call system was activated, no staff had entered the resident’s room to assist the resident.



Multiple staff were interviewed at 3:04 pm and stated that when a resident utilized his/her pull cord or pendant, a notification should arrive on the facility phone, which was carried by one or more care staff depending on how many phones are currently working. The staff stated that there was one working phone on 08/13/25, and it was carried by a caregiver. The caregiver reviewed the phone and found there was no indication on the phone that the unsampled resident had pulled the cord at 2:32 pm. Staff stated that this happens frequently, and multiple unsampled residents consistently verbalized difficulty reaching staff to assist with addressing the residents’ ADL needs.



In an interview on 08/14/25 at 10:40 am, Witness 8 (Resident’s Spouse) stated that his/her spouse consistently had difficulty reaching staff to assist with ADL care. S/he stated that within the past week, s/he had to physically get up to look for staff members to assist the resident after they utilized the call system and waited over 20 minutes with no response.



On 08/14/25, the call system in the Alpine cottage was observed. The call pendant was pulled in room 6 at 10:58 am and was observed to be activated. At 11:18 am, 20 minutes later, staff had not responded. During interviews at 11:20 am, staff stated the system had not notified them that the call system had been activated for room 6.



In an interview on 08/14/25 at 12:00 pm, Staff 31 (Administrator) and Staff 30 (Regional Director of Health Services) stated they were aware that the call system was not working, and no solution had been put into place to ensure residents were assisted when they utilized the call system to request help from facility staff.



b. Two of the three cottages which made up the facility, Alpine and Beechwood, were endorsed memory care communities (MCCs) and had a secured outdoor courtyard which residents could access. (Keep this info)

In an interview on 8/12/25 at 12:00 pm, Staff 30 (Regional Director of Health Services) provided the surveyor with a copy of the facility’s inclement weather policy, which stated “In temperatures above 85 degrees, the [courtyard] doors will be locked.” At 12:15 pm on 08/12/25, signs were observed on all courtyard doors which stated that the courtyard doors would be locked if the temperature was above 85 degrees.



Between the hours of 12:30 pm and 1:25 pm on 08/12/25, the temperature in the outdoor courtyards reached between 90 and 93 degrees Fahrenheit. Multiple areas in the courtyards, including walking paths and benches, were not shaded and were exposed directly to the sun.



In an interview on 08/12/25 at 2:14 pm, Staff 33 (CG) stated that residents entered and exited the courtyard “on their own”, including Resident 12 who enjoyed being outside and gardening during the summer.



At 12:30 pm and 1:25 pm on 08/12/25, the doors to the courtyards were tested and found to be unlocked, with no visible system which would allow the door to be locked.



In an interview on 08/12/25 at 1:35 pm, Staff 31 (Administrator) confirmed that there was no way to lock the courtyard doors, as per the facility policy and posted signage. The facility was unable to provide documented evidence of any other system in place to ensure resident safety in the courtyard in times of extreme heat.



The need for the facility to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents, including ensuring resident call pendants alerted staff when residents used them to call for assistance, and to establish and implement an effective policy to ensure resident safety during times of extreme temperatures, including heat, was reviewed with Staff 28 (Director of Health Services/LPN), Staff 30, and Staff 31 on 08/14/25 at 12:00 pm. They acknowledged the findings.

OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was treated with dignity and respect and maintained a safe and homelike environment during ADL care for 1 of 3 sampled residents (#3). Resident 3 experienced distress and abrupt handling during ADL care. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 11/15/24 service plan, 09/17/24 through 11/26/24 observation notes, physician communications, and incident investigations were completed.

The resident was noted to be dependent with all ADLs. The resident required two staff assistance for transfers and dressing and a Hoyer lift for transfers. The resident was nonverbal. The resident’s muscles and limbs were very tight to move, straighten and bend fully. The resident was noted to have anxiety and behaviors with ADL cares due to his/her confusion. Staff were instructed to tell the resident step by step what was occurring during care to help alleviate any distress.

Observations of ADL care including incontinence care, bed mobility, Hoyer transfer and dressing were completed between 12/17/24 and 12/19/24.

a. The resident was dressed/undressed, had a brief change, cleaned and rolled side to side with minimal to no interaction from staff. Additionally, the resident required a Hoyer lift for transfers out of his/her bed and wheelchair. During several observations, the resident was moved with the lift without interaction from staff or verbal reassurance before or during transfers.

Multiple instances of bed mobility showed the resident dangling off the bed, rolled over the edge of the bed with marginal support of torso, turned so far to the right that s/he was close to being on his/her stomach and/or the resident pulled so far to the right while at the edge that s/he was pointed towards the floor. The resident would flail around for something to hold onto and yell.

One of these observations the resident’s face was so close to Staff 18’s pant leg and thigh that the resident’s yells were muffled, and his/her hands were unable to move due to the position of the resident’s body. The surveyor instructed staff to adjust the resident’s positioning to keep him/her away from the edge of the bed and to keep his/her face away from clothing, staff legs and bedding.

b. The resident was abruptly turned and moved around the bed for care. Multiple occasions the side of the resident’s head was used as a contact point to try to move the resident.

Staff were advised by the surveyor not to use the side of the resident’s head as a transfer point.

c. The resident’s soiled brief was removed, and the resident left uncovered while additional wipes were located for clean-up.

d. The resident was aggressively and abruptly cleaned after a bowel movement. The resident was not told what was happening, not advised wipes might be cold and not prepared for the next bit of care. The resident startled and made sounds when the wipes first touched his/her skin.

e. The resident showed signs of distress during care. The resident was calling out and hitting out at staff. The resident’s sweatshirt was pulled up over his/her arms and briefly held in place before the resident pulled an arm free. There were no further attempts to restrain the resident.

f. The resident was observed during three meals. Staff provided the resident with his/her pureed diet and thickened liquids. The staff provided bites that were larger than indicated by the service plan, had minimal to no interaction with the resident during the meal, rushed fluid intake and were task oriented rather than person oriented.

g. The resident showed signs of pain and discomfort during his/her breakfast meal on 12/18/24. Soon after the resident began crying out a strong odor appeared around the resident. The resident ate less than 25% of his/her meal, would not take any additional bites and was wheeled near the living room and parked. The fecal odor around the resident was very strong.

The surveyor informed the MT of the odor around the resident and that it began while the resident was having breakfast. Staff did not assist the resident with incontinence care until approximately 60 minutes after the odor first appeared and approximately 30 minutes after the MT was informed.

When Staff 12 (CG) and Staff 18 (CG) transferred the resident to bed, it was determined the resident’s pants were soiled and required changing along with his/her brief. The resident’s pants were forcefully removed, and, in the process, fecal matter was flung about the resident’s bed. The resident required numerous turns and wipes to get all areas sufficiently clean. The resident was distressed throughout the process with some flailing of arms, grabbing at staff and vocalization of sounds. The staff continued to talk over the resident in English and Spanish but rarely to the resident himself/herself.

In an interview on 12/18/24, Staff 1 (ED) and Staff 5 (RCC) were provided with information on the observations of care for Resident 3. Staff 1 and Staff 5 indicated the care staff should not be talking over the resident and should be telling the resident what was going on during care to help with distress. Staff 1 and Staff 5 acknowledged that the resident should not be rolled so closely to the edge of the bed, or any attempt made to restrain arms or hands with clothing. Staff 1 indicated additional training was required. Staff 1 and Staff 5 indicated they would be reviewing proper care of the resident with the staff observed as well as the staff normally assigned to the house.

In an additional interview on 12/19/24, Staff 1 indicated they reviewed transfers and resident care at the staff meeting on 12/18/24 as well as working on individual trainings.

An additional meal observation and care observation on 12/18/24 and 12/19/24 showed staff were seated in front of the resident and speaking with him/her about the meal. Smaller bites were offered more slowly, and single sips of fluids were offered one at a time. Staff were interacting with the resident more efficiently during ADL care and ensuring the resident was positioned away from the edge of the bed. The resident showed less distress with this observation of ADL care.

The need to ensure staff treated residents with dignity and respect and provided a safe and home like environment when providing care was discussed with Staff 1, Staff 2 (Health Services Director/LPN) and Staff 5 on 12/18/24 and 12/19/24. The staff acknowledged the findings.

Refer to C160.

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 interview and record review, it was determined the facility failed to report incidents of abuse to the local Seniors and People with Disabilities (SPD) office and failed to report injuries including injuries of unknown cause as suspected abuse to the local SPD office unless an immediate facility investigation reasonably concluded and documented the injuries were not the result of abuse for 4 of 5 sampled residents (#s 1, 3, 4 and 7) whose records were reviewed. Findings include but are not limited to:

1. Resident 1 was admitted to the facility in 09/2019 with diagnoses including dementia. The resident was noted to require the assistance of two staff for ADL cares.

Review of the resident's 09/19/24 through 12/17/24 progress notes showed the following:

* 11/07/24 - "Care staff reported to MT that when they assisted resident out of bed this morning, they noticed skin discoloration on the back of [his/her] left arm just above the elbow about the size of a golf ball appearing purple in color”; and
* 11/29/24 - “During MT checks this MT observed skin discoloration on the top of the resident’s right hand. The discoloration is slightly larger than the size of a golf ball. Resident did not appear to be in any pain and was unable to provide information about how the discoloration occurred.”

The facility lacked documented evidence the injuries of unknown cause were investigated to rule out abuse and neglect as cause of the injuries or reported to the local SPD office as suspected abuse.

The need to report injuries of unknown cause as suspected abuse to the local SPD office unless an immediate facility investigation reasonably concluded and documented the injuries were not the result of abuse was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings. The facility was asked to report the injuries to SPD. Conformation was received by survey exit.



2. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia with behavioral disturbances.

Observations of the resident, interviews with staff, and review of the resident's 11/22/24 service plan, 09/22/24 through 12/10/24 observation notes, physician communications, and incident investigations were completed.

The resident was noted to exhibit intermittent aggressive and/or sexually inappropriate behaviors. The resident required one staff assistance for ADL care and was able to independently ambulate around the facility with a walker. The resident could make some needs known and had poor safety awareness.

Review of the resident's records showed the following:

* An observation note dated 11/29/24, indicted the resident was walking the common area yelling that his/her roommate would touch Resident 7’s genitals. Staff told the resident not to discuss it with others.

There was no investigation completed, and no report made to the local SPD office.

The facility was asked to report the 11/29/24 incident to the local SPD office and provide the confirmation of the report.

The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect and reported when required, was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings.


3. Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 11/15/24 service plan, 09/17/24 through 11/26/24 observation notes, physician communications, and incident investigations were completed.

The resident was noted to be dependent with all ADLs. The resident required two staff assistance for transfers and dressing and a Hoyer lift for transfers. The resident was nonverbal. The resident’s muscles and limbs were very tight to move, straighten and bend fully. The resident was noted to have anxiety and behaviors with ADL cares due to his/her confusion.

Review of the resident's records showed the following:

* An observation note dated 09/15/24 indicated the resident had “oozing spots on inner thighs…odd odor/discharge” from genitals.

The resident was seen by their physician on 09/17/24 and Nystatin powder was initiated for the areas on the inner thighs.

There was no investigation documented regarding the areas to determine cause and plan to prevent reoccurrence.

The need to ensure all incidents and injuries of unknown cause were promptly investigated to rule out abuse and/or neglect and were documented, was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings.

4. Resident 4 was admitted to the facility 06/2024 with diagnoses including dementia.

Review of the resident's records showed the following:

* An observation note dated 11/19/24 indicated the resident had complaints of enlarged/swollen genitalia. Staff observed the area, the physician was notified, and the resident was sent to urgent care for evaluation.

There was no investigation documented.

The need to ensure all incidents and injuries of unknown cause were promptly investigated to rule out abuse and/or neglect and were documented, was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

(Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to immediately report incidents of abuse to the local Seniors and People with Disabilities (SPD) office, failed to report injuries of unknown cause as suspected abuse to the local SPD office unless an immediate facility investigation reasonably concluded and documented the injuries were not the result of abuse, and take measures necessary to protect residents and prevent the reoccurrence of abuse or suspected abuse for 3 of 3 sampled residents (#s 8, 9, and 10) whose records were reviewed. This is a repeat citation. Findings include but are not limited to:

1. Resident 8 moved into the memory care community in 06/2023 with diagnoses including Alzheimer’s disease.

The resident’s Observation notes, dated 02/17/25 through 05/01/25, and Incident Reports, dated 03/17/25 through 04/30/25, were reviewed and the following incidents were identified:

* 03/17/25: Bruising to right top arm (reported to the local SPD office on 03/21/25, four days later);
* 03/24/25: Resident to resident altercation;
* 03/31/25: Elopement off of the unit (reported to the local SPD office on 04/08/25, eight days later);
* 04/28/25: Lump on left side of hip; and
* 04/30/25: Redness on lower left arm.

There was no documented evidence the above incidents were immediately reported to the local SPD office, injuries of unknown cause were investigated to rule out abuse or suspected abuse and immediately reported to the local office if the investigation could not reasonably conclude the injuries were not the result of abuse, and/or take measures necessary to protect residents and prevent the reoccurrence of abuse or suspected abuse.

On 05/06/25, the facility provided documentation that the incidents occurring 03/24/25, 04/28/25, and 04/30/25 were reported to the local SPD office.

The need to immediately report incidents of abuse to the local SPD office, investigate injuries of unknown cause and report to the local office if the facility investigation was unable to reasonably rule out suspected abuse, and take measures necessary to protect residents and prevent the reoccurrence of abuse or suspected abuse with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings.

2. Resident 9 moved into the memory care community in 01/2024 with diagnoses including dementia.

The resident’s Observation notes, dated 02/17/25 through 04/29/25, were reviewed and the following was identified:

* 03/24/25: Resident to resident altercation.

There was no documented evidence the above incident was immediately reported to the local SPD office, or the facility took the measures necessary to protect residents and prevent the reoccurrence of abuse or suspected abuse.

On 05/06/25, the facility provided documentation that the incident was reported to the local SPD office.

The need to immediately report incidents of abuse to the local SPD office and take measures necessary to protect residents and prevent the reoccurrence of abuse or suspected abuse with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings.

3. Resident 10 moved into the memory care community in 08/2020 with diagnoses including Alzheimer’s disease.

The resident’s Observation notes, dated 02/17/25 through 05/04/25, and Incident Reports, dated 03/05/25 through 04/30/25, were reviewed and the following incident was identified:

* 04/30/25: Wrist was swollen and red in color.

There was no documented evidence the above incident was investigated to rule out abuse or suspected abuse and immediately reported to the local office if the investigation could not reasonably conclude the injuries were not the result of abuse.

On 05/06/25, the facility provided documentation that the incident that occurred 04/30/25 was reported to the local SPD office.

The need to investigate injuries of unknown cause and report to the local office if the facility investigation was unable to reasonably rule out suspected abuse was shared with Staff 1 (ED) on 05/06/25 at approximately 2:40 pm. She acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

(Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

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 were reflective of residents' needs and preferences, provided clear direction to staff regarding the delivery of services, or was implemented for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2019 with diagnoses including dementia.

The resident's 12/08/24 service plan was reviewed, observations made of the resident and interviews with staff occurred throughout the survey.

The service plan was not reflective of the resident's current needs and preferences, was not implemented or lacked clear instructions to staff in the following areas:

* Repositioning including use of a draw sheet while sitting in geriatric chair;
* Positioning of geriatric chair while in common areas of the facility;
* Incontinence care including use of barrier cream with brief changes; and
* Hair care including use of headband verses hair tie.

The need to ensure Resident 1's service plan was reflective of the resident’s needs, gave clear instruction to staff and was implemented was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings.


2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including dementia.

The resident's 11/12/24 service plan was reviewed, observations made of the resident and interviews with staff occurred throughout the survey.

The service plan was not reflective of the resident's current needs and preferences and lacked clear instruction to staff in the following areas:

* Toileting schedule;
* Dining including preference to sit separate from other residents, meal assistance; and
* Best practices for proving ADL supports when resident was ambulating throughout the unit.

The need to ensure Resident 2’s service plan was reflective and gave clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings.


3. Resident 3 was admitted to the facility in 01/2013 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the service plan, dated 11/15/24, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas:

* Evacuation assistance;
* Barrier cream, toileting and incontinence care;
* Bed mobility, Hoyer use and positioning in the wheelchair and bed;
* Floating heels and foot support in bed and wheelchair;
* Behaviors including anxiety, striking out and distress with ADL care;
* Hygiene, grooming and dental needs;
* Dressing and bathing assistance;
* Nonverbal communication from resident;
* Meal assistance, positioning, size of bite, divided dish; and
* Fall and safety interventions including bed alarm, scoop mattress, fall mat and low bed.

The need to ensure resident service plans were reflective of current care needs, was consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 5 (RCC) on 12/18/24. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 06/2024 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the service plan, dated 11/25/24, showed the service plan was not reflective of the resident's current care needs, and/or did not provide clear direction to staff in the following areas:

* Evacuation assistance;
* Skin monitoring and edema;
* Behaviors including agitation and sexually inappropriate contact;
* Transfers, mobility and walker use;
* Dressing, grooming and bathing assistance;
* Toileting, incontinence care and nighttime needs;
* Anxiety, sadness related to loss of spouse and searching for them; and
* Fall and safety interventions.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 5 (RCC) on 12/18/24. They acknowledged the findings.

5. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the service plan, dated 11/22/24, showed the service plan was not reflective of the resident's current care needs, and/or did not provide clear direction to staff in the following areas:

* Evacuation assistance;
* Exit seeking;
* Sleep patterns and insomnia;
* Behaviors including agitation and sexually inappropriate contact;
* Transfers, knee buckling, mobility, walker compliance and gait belt use;
* Dressing, grooming and bathing assistance;
* Toileting, incontinence care and nighttime needs; and
* Falls, safety interventions and awareness of resident location.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 5 (RCC) on 12/18/24. They acknowledged the findings.





6. Resident 5 was admitted to the facility in 09/2019 with diagnoses including dementia and chronic kidney disease.

The resident’s 10/19/24 service plan was reviewed. Observations of the resident and interviews with staff were completed during the survey.

The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Fall interventions including when to use fall mats;
* Non-pharmaceutical interventions for pain;
* Privacy preferences related to keeping the door open;
* Ability to use the call light system;
* Depression, including how it was exhibited and interventions when observed;
* Preferences for use of a warmer for skin wipes;
* Amount of time to sit up in the wheelchair; and
* Safety checks for use of side rails.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24 at 2:55 pm. They acknowledged the findings.

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 were reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, or were implemented for 4 of 4 sampled residents (#s 8, 9, 10, and 11) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 moved into the facility in 12/2023 with diagnosis including aphasia following cerebral infraction (related to language disorder as a result of a stroke) and major depressive disorder.

The resident's record, including the current service plan dated 03/07/25, Observation notes dated 02/17/25 through 04/30/25, and Change in Plan of Care documentation, was reviewed, observations were made, and interviews with Resident 11 and facility staff were conducted. The following was identified:

The resident's service plan was not reflective of resident’s current needs and did not provide clear direction regarding the delivery of services in the following areas:

* Mobility status and devices used that included a manual wheelchair;
* Dining set-up assistance that included the use of an adult sippy cup, raised plate, oversized utensils, and use of clips to secure a “clothing protector” over a bib; * Use of an adult sippy cup in the resident’s room that included cleaning instructions;
* Instruction related to resident being “uncomfortable” when an unsampled resident followed him/her around the facility;
* Side rail instruction and safety precautions;
* Vision loss in right eye and instruction to staff related to diagnosis;
* Current use of assistive devices for activities and interests; and
* Preference to receive assistance with toileting after lunch service.

The need to ensure service plans were reflective of residents' current care needs and preferences and provided clear direction regarding the delivery of services was reviewed with Staff 1 (ED) on 05/07/25 at 10:12 am. She acknowledged the findings.

2. Resident 10 moved into the memory care community in 08/2020 with diagnoses including Alzheimer’s disease.

The resident’s service plan, dated 02/19/25, and temporary service plans, dated 02/20/25 through 04/29/25, were reviewed. Resident 10 was observed, and staff were interviewed. The service plan was not reflective of the resident’s current needs, lacked clear instructions to staff, and/or was not implemented in the following areas:

• Use of an air mattress;
• Use of a floor mat;
• Use of heel protectors including instruction on when it should be on or off;
• Transfer status including one-person versus two-person assistance and use of a gait belt;
• Toileting status including level of assistance required
• Eating status; and
• Dressing and undressing status.

The need to ensure service plans were reflective of the resident’s needs, provided clear instruction to staff and were implemented was discussed with Staff 1 (ED) on 05/06/25 at approximately 2:40 pm. She acknowledged the findings.

3. Resident 8 moved into the memory care community in 06/2023 with diagnoses including Alzheimer’s disease.

The resident’s service plan, dated 04/10/25, and temporary service plans, dated 03/17/25 through 05/04/25, were reviewed. Resident 8 was observed and staff were interviewed. The service plan was not reflective of the resident’s current needs or lacked clear instructions to staff in the following areas:

* Use of glasses;
* Interventions relating to the risk of elopement;
* Interventions for agitation (e.g. allowing space to walk in facility, ruling out pain);
* Spouse's involvement;
* Instruction to staff relating to taking time to assist with ADLs as to negate behaviors;
* Ability to be redirected; and
* Behavioral interventions relating to resident to resident altercations (e.g. Resident 8 be kept in line of staff's sight when around any particular resident[s]).

The need to ensure service plans were reflective of the resident’s needs and gave clear instruction to staff was discussed with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings.

4. Resident 9 moved into the memory care community in 01/2024 with diagnoses including dementia.

The resident’s service plan, dated 03/17/25, and a temporary service plan, dated 03/11/25, was reviewed. Resident 9 was observed and staff were interviewed. The service plan was not reflective of the resident’s current needs or lacked clear instructions to staff in the following areas:

* Chronic lower extremity swelling and interventions for staff to try;
* Daily lotion application;
* What causes agitation and how the resident exhibits it; and
* Interventions for resistance to care in the mornings.

The need to ensure service plans were reflective of the resident’s needs and gave clear instruction to staff was discussed with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings.

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 were reflective of residents’ needs and preferences, provided clear direction regarding the delivery of services, and/or were implemented for 3 of 3 sampled residents (#s 1, 12, and 13). This is a repeat citation. Findings include, but are not limited to:



In an interview on 08/14/25 at 12:00 pm, Staff 28 (Director of Health Services/LPN) stated that the resident’s service plans and evaluations were separate documents, and both documents were included in the service plan binders available to all staff. She stated that staff were instructed to review both documents. The term “service plan,” as referenced below, refers to both the service plan and evaluation as documents instructing staff on the provision of care for residents.



1. Resident 1 moved into the facility in 09/2019 with diagnoses including dementia.



During the acuity interview on 08/12/25, Resident 1 was identified as needing a mechanical lift and assistance from two care staff for care and transfers, was non-ambulatory, had a history of impaired skin integrity including history of wounds on his/her heels, and required full feeding assistance during meals and snacks.



The resident's current service plan, dated 06/18/25, and TSPs dated 06/18/25 through 08/12/25 were reviewed, the resident was observed, and staff were interviewed.



The resident’s service plan did not provide clear direction to staff and/or was not being implemented in the following areas:



* Use of protective soft boots to decrease pressure on his/her heels;

* Use of a headband instead of a hair tie due to the resident’s history of placing a hair tie in his/her mouth;

* Use of a clothing protector during meals and snacks; and

* Activity engagement.



The need to ensure service plans provided clear direction regarding the delivery of services and were implemented was reviewed with Staff 28, Staff 30 (Regional Director of Health Services), and Staff 31 (Administrator) on 08/14/25 at 12:00 pm. They acknowledged the findings.



2. Resident 12 moved into the facility in 06/2023 with diagnoses including dementia.



The resident was identified during the acuity interview on 08/12/25 as having a history of behaviors and resident-to-resident altercations.



The resident's current service plan, dated 07/28/25, and TSPs dated 07/28/25 through 08/12/25 were reviewed, the resident was observed, and staff were interviewed.



The resident’s service plan did not reflect his/her current needs and preferences and/or was not being implemented in the following areas:



* Frequency of toileting and incontinence care;

* Behavior plan; and

* Activity engagement.



The need to ensure service plans were reflective of residents’ needs and preferences and were implemented was reviewed with Staff 28, Staff 30 (Regional Director of Health Services), and Staff 31 (Administrator) on 08/14/25 at 12:00 pm. They acknowledged the findings.



3. Resident 13 moved into the facility in 04/2024 with diagnoses including dementia.



The resident was identified during the acuity interview as having a history of falls, pureed diet, and requiring feeding assistance.



The resident's current service plan, dated 07/30/25, and TSPs dated 07/30/25 through 08/12/25 were reviewed, the resident was observed and interviewed, and staff were interviewed.



The resident’s service plan did not reflect his/her current needs and preferences and/or was not being implemented in the following areas:



* Use of fall interventions, including fall mat;

* History of weight loss;

* Cueing from staff seated next to him/her during meals; and

* Use of a straw with drinks.



The need to ensure service plans were reflective of the resident’s needs and preferences and were implemented was reviewed with Staff 28, Staff 30 (Regional Director of Health Services), and Staff 31 (Administrator) on 08/14/25 at 12:00 pm. They acknowledged the findings.

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 interview and record review it was determined the facility failed to ensure actions or interventions were determined, documented, and communicated with staff on all shifts for changes of condition and failed to ensure changes were monitored, with progress noted at least weekly until resolution, and/or referred to the facility nurse for a significant change of condition for 6 of 6 sampled residents (#1, 2, 3, 4, 5, and 7) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia.

The resident's 11/15/24 service plan, 09/17/24 through 11/26/24 observation notes, incident investigation notes and physician communications were reviewed.

a. The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas:

* Breast rash;
* Vomiting;
* Constipation;
* Hospital/Emergency Department return; and
* Rash, sores, discharge and redness to the inner thighs and genitals.

b. The resident experienced a seven pound weight loss between 07/22/24 and 08/19/24 which equaled a 5.25% weight loss in one month, a 10 pound weight loss from 09/23/24 and 10/21/24 which equaled a 7.5% loss in one month, a seven pound weight gain between 10/21/24 and 11/04/24 which equaled a 5.69% gain in less than two weeks and a 7.4 pound loss between 11/25/24 and 12/19/24 which equaled a 5.89% weight loss in one month.

The resident’s significant weight losses and gain were not reported to the facility RN for completion of a significant change of condition assessment.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution, provided clear, resident-specific directions to staff, and was referred to the facility RN for significant weight changes was discussed with Staff 1 (ED), Staff 4 (Regional Director of Health Services) and Staff 5 (RCC) on 12/18/24 and 12/19/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 06/2024 with diagnoses including dementia.

The resident's 11/25/24 service plan, 09/19/24 through 12/16/24 observation notes, incident investigations and physician communications were reviewed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas:

* Medication changes
* Falls;
* ER/Hospital return;
* Knee pain;
* “Discoloration” to the left thigh and buttock and “bruise” to the left leg;
* Enlarged/swollen genitals and edema; and
* Palliative care admission.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 4 (Regional Director of Health Services) and Staff 5 (RCC) on 12/18/24 and 12/19/24. They acknowledged the findings.

3. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia.

The resident's 11/22/24 service plan, 09/22/24 through 12/10/24 observation notes, incident investigations and physician communications were reviewed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas:

* Agitation, threatening others and yelling;
* Chest pain and shoulder pain;
* Sexual behaviors and entering other residents’ apartments;
* Increased confusion;
* Medication changes: and
* Falls.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 4 (Regional Director of Health Services) and Staff 5 (RCC) on 12/18/24 and 12/19/24.They acknowledged the findings.


4. Resident 1 was admitted to the facility in 09/2019 with diagnoses including dementia.

Progress notes dated 09/19/24 through 12/17/24, 12/08/24 service plan, and Interim Service Plans (ISP’s) were reviewed and revealed the resident experienced the following short-term changes of condition in the review period:

* 10/19/24 - Excoriation to left buttock;
* 10/21/24 - “Dime sized skin tear on second toe, skin discoloration on big toe and fourth toe on right foot”;
* 10/25/24 - New medication order, “start Nystatin powder [for rash] apply three times a day to inner thighs and groin between folds”;
* 11/07/24 - “Skin discoloration back of left arm just above elbow, size of a golf ball”; and
* 11/29/24 - “Skin discoloration top of right-hand golf ball sized”.

The facility lacked documented evidence each concern had interventions or actions developed and communicated to staff on each shift, and the changes were monitored with progress noted at least weekly through resolution.

The need to ensure short-term changes of condition had interventions or actions developed and communicated to staff on each shift and documentation to reflect monitoring at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings.

5. Resident 2 was admitted to the facility in 08/2022 with diagnoses including dementia.

Progress notes dated 09/26/24 through 12/16/24, 11/12/24 service plan, and Interim Service Plans (ISP’s) were reviewed and revealed the resident experienced redness to right forearm on 11/01/24.

The facility lacked documented evidence the skin condition was monitored with progress noted at least weekly.

The need to ensure short-term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings.

6. Resident 5 was admitted to the facility in 09/2019 with diagnoses including dementia and chronic kidney disease.

The resident's 10/19/24 service plan and progress notes dated 09/20/24 through 11/27/24 were reviewed.

The following short-term changes of condition lacked actions or interventions determined:

* 10/02/24 - Cephalexin (for infection);
* 10/04/24 - “Possible toe infection”; and
* 10/31/24 - “Popped blister” on lower buttock.

The need to ensure changes of condition had actions or interventions determined was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24 at 2:55 pm. They acknowledged the findings.




.

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 interview and record review, it was determined the facility failed to determine what resident-specific actions or interventions were needed for a resident following a short-term change of condition, communicate the determined actions or interventions, and document progress at least weekly until the condition resolved for 4 of 4 sampled residents (#s 8, 9, 10, and 11) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10 moved into the memory care community in 08/2020 with diagnoses including Alzheimer’s disease.

Review of the resident's clinical record including Observation notes, dated 02/17/25 through 05/04/25, service plan, updated on 02/19/25, temporary service plans, and 04/01/25 through 05/05/25 MARs were completed during the survey.

a. The facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and/or to monitor the change of condition, at least weekly, until resolved for the following changes of condition:

• 04/15/25: Multiple medications were discontinued including scheduled pain medication and eye drop;
• 04/30/25: Diet was changed to a mechanical soft diet; and
• Weight loss between 03/05/25 and 05/05/25.

b. The facility failed to monitor changes of condition, at least weekly, until resolution for the following:

• 03/04/25: Increased the dosage of Remeron, appetite stimulation; and
• 04/02/25: Episode of nose blood.

The need to ensure the facility determined and documented what actions or interventions were needed for short-term changes of condition, communicated resident-specific instructions and interventions to staff on each shift, and/or monitored the change of condition, at least weekly, until resolved was discussed with Staff 1 (ED) on 05/06/25 at 2:40 pm. She acknowledged the findings.

2. Resident 8 moved into the memory care community in 06/2023 with diagnoses including Alzheimer’s disease.

The resident’s service plan, dated 04/10/25, temporary service plans, dated 03/17/25 through 05/04/25, Observation notes, dated 02/17/25 through 05/01/25, and Incident Reports, dated 03/17/25 through 04/30/25, were reviewed during the survey.

The facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and/or to monitor the change of condition, at least weekly, until resolved for the following changes of condition:

* 03/17/25: Bruising to right, upper arm;
* 03/24/25: Resident to resident altercation;
* 03/31/25: Elopement off of the unit;
* 04/07/25: Witnessed fall;
* 04/09/25: Unwitnessed fall;
* 04/16/25: Witnessed fall;
* 04/17/25: Resident to resident altercation;
* 04/21/25: Unwitnessed fall; and
* 04/28/25: Resident to resident altercation.

The need to ensure the facility determined and documented what actions or interventions were needed for the short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and to monitor the change of condition, at least weekly, until resolved was discussed with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings.

3. Resident 9 moved into the memory care community in 01/2024 with diagnoses including dementia.

The resident’s service plan, dated 03/17/25, a temporary service plan, dated 03/11/25, and Observation notes, dated 02/17/25 through 04/29/25, were reviewed during the survey.

The facility failed to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and/or to monitor the change of condition, at least weekly, until resolved for the following changes of condition:

* 03/11/25: Swollen left foot;
* 03/24/25: Resident to resident altercation; and
* 04/17/25: Resident to resident altercation.

The need to ensure the facility determined and documented what actions or interventions were needed for the short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and to monitor the change of condition, at least weekly, until resolved was discussed with Staff 1 (ED) on 05/07/25 at approximately 11:45 am. She acknowledged the findings.

4. Resident 11 moved into the facility in 12/2023 with diagnosis including aphasia following cerebral infraction (related to language disorder as a result of a stroke) and major depressive disorder.

The resident's record, including the current service plan dated 03/07/25, Observation notes, dated 02/17/25 through 04/30/25, and temporary service plans documentation, was reviewed, observations were made, and interviews with Resident 11 and facility staff were conducted. The following was identified:

* 02/24/25: Canker sore on inner cheek and shaved tooth;
* 03/07/25: Side rails installed for bedside mobility;
* 03/10/25: Chapped skin on right side of mouth and open area right side of lip;
* 03/10/25: New medications including ondansetron (to prevent vomiting) and loperamide (for diarrhea);
* 03/18/25: Scratches on thigh;
* 03/27/25: Difficulty seeing, “right eye has blurry vision”;
* 04/06/25: New behavior related to stress;
* 04/10/25: Fall in bathroom;
* 04/10/25: Skin tear on right hand near thumb; and
* 04/12/25: New behavior including agitation resident is “uncomfortable” with an unsampled resident “following” him/her around the facility.

The need to ensure the facility identified, determined, documented, and communicated the determined action or intervention to staff, and documented progress until resolution was reviewed with Staff 1 (ED) on 05/07/25 at 10:12 am. She acknowledged the findings

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 an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 3 sampled residents (#3) who experienced significant changes of condition. Resident 3 experienced continued severe weight changes without intervention. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia.

Review of the resident’s service plan dated 11/15/24, observation notes, physician communications, RN notes and weight records dated 09/17/24 through 11/26/24 were completed.

The resident required full assistance from staff for all ADL care. The resident required one staff assistance for all food and fluid intake. The resident received a pureed diet and nectar thick liquids for all snacks and meals.

Multiple daily observations of the resident between 11/17/24 and 11/19/24 showed the resident up in his/her wheelchair and reclined back approximately 45 degrees. The resident was dependent for all care. Staff would assist the resident to his/her wheelchair after providing ADL care. The resident was observed during two breakfast meals, two lunch meals and part of a dinner meal. The resident did not initiate any intake on his/her own. Staff provided total assistance with all intakes.

The resident received pureed food in a three-compartment plate with raised sides. The staff were observed to offer the resident bites without much interaction. Fluids were alternated with bites of food. The resident took single sips from the cups offered. The resident did not appear able to complete successive sips. The resident ate between 25% and 50% of the meals offered. One meal staff reported the resident ate 100%, the dishes were cleared before an observation was made. The resident was not observed to receive snacks in the morning or afternoon during survey. The resident was brought to breakfast later in the morning, not long before the scheduled snack time, and provided his/her breakfast meal.

Weight records reviewed from 07/22/24 through 12/19/24 were reviewed and showed the following:

* A weight of 133.2 pounds on 07/22/24 and a weight of 126.2 pounds on 08/19/24. This constituted a seven pound, 5.25% severe weight loss in one month.
* A weight of 133 pounds on 09/23/24 and a weight of 123 pounds on 10/21/24. This constituted a 10 pound, 7.5% severe weight loss in one month.
* A weight of 123 pounds on 10/21/24 and a weight of 130 pounds on 11/04/24. This constituted a seven pound, 5.69% severe increase in less than two weeks.
* The resident’s weight on 11/25/24 was documented as 125.6 pounds.
* A current weight was requested from the facility. The resident’s weight on 12/19/24 was observed and documented as 118.2 pounds. This constituted a 7.4 pound, 5.89% severe loss from the last recorded weight.

The resident received Boost health shakes which were held and no longer administered on 09/23/24 due to swallowing concerns related to the thin consistency.

The resident was noted to be placed on weekly weights prior to June 2024. The weekly weights were discontinued on 11/25/24.

In interviews on 12/17/24 and 12/18/24, Staff 9 (CG), Staff 18 (CG) and Staff 22 (CG) indicated the resident required full staff assistance to eat. The resident could not feed himself/herself due to cognition, confusion, and physical limitations. The staff indicated the resident did not generally have very good intake, but it did vary. Staff 22 indicated the resident ate 100% of his/her lunch meal on 12/18/24 but had not eaten well for breakfast.

In an interview on 12/19/24, Staff 4 (Regional Director of Health Services) indicated the current RN was not made aware of the resident’s changes in weight. Reports were normally pulled near the beginning of the month for monthly weight review. Staff 4 stated Staff 2 (Health Services Director/LPN) would be responsible for pulling additional reports for the weekly weights, checking weights and reporting any issues or significant changes to the current facility RN.

In an interview on 12/19/24, Staff 3 (RN) indicated she was not aware of the significant changes in the resident’s weights over the last few months. The reports she had reviewed looked only at the beginning of the month so other weights during the month were not on her radar. Staff 3 assisted to get a current weight on the resident, restarted weekly weights and would look into nutritional supplements once she was able to get a baseline for the resident’s weight. Staff 3 wanted to observe the weights as they were completed to ensure proper technique and calculations were being completed.

The resident was not interviewable due to cognitive impairment and non-verbal status.

The facility failed to ensure an RN assessment was completed for the severe weight changes from July 2024 to November 2024 which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 3, Staff 4 and Staff 5 (RCC) on 12/18/24 and 12/19/24. The staff acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure a Registered Nurse assessed, documented findings and developed appropriate interventions for 1 of 2 sampled residents (# 10) who experienced an overall significant change in condition. This is a repeat citation. Findings include, but are not limited to:

Resident 10 moved into the memory care community in 08/2020 with diagnoses including Alzheimer’s disease.

Observations of the resident, from 05/05/25 to 05/07/25, showed the resident required staff assistance for transfers, meal intake and bathroom use with the help of two staff members.

During the survey, Staff 6 (RCC) and Staff 27 (MA/CG) reported the resident had an overall decline in condition approximately two to four weeks ago, specifically in the following areas:

* The resident was needing additional staff assistance with transfer, meal intake, bladder and bowel management and dressing.

Those multiple changes represented the resident experienced a significant change of condition.

There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.

The need to ensure a RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 1 (ED) on 05/07/25 at 9:55 am. She acknowledged the findings.

On 05/07/25 at 11:18 am, the RN assessment was provided by Staff 6 (RCC), and she reported the assessment was completed that morning.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner for 1 of 1 sampled resident (#1) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:



Resident 1 was admitted to the facility in 09/2019 with diagnoses including dementia.



During the acuity interview on 08/12/25, the resident was identified as having a Stage 2 pressure ulcer, which was new for the resident. The resident was identified as requiring a mechanical lift and two-person assistance from care staff for care, transfers, and repositioning.



The resident’s service plan, dated 07/30/25, and 07/21/25 through 08/12/25 temporary service plans (TSPs), observation notes, skin tracking, and assessments were reviewed, the resident was observed, and staff were interviewed.



On 07/24/25, a MT documented in the resident’s observation notes that an open wound had been identified on the resident’s left coccyx. An incident report completed the same day stated the wound was a pressure injury, and the health services director had evaluated the wound. A skin check form from 07/24/25, completed by Staff 28 (Director of Health Services/LPN), confirmed that there was an open area and noted that the “community RN has been notified of new potential pressure-related injury.” This indicated that the wound was a Stage 2, or open, pressure ulcer, which was a significant change of condition and required assessment by an RN.



There was no documented evidence that an RN completed an assessment of the pressure-related injury in a timely manner, with all required components documented including findings, resident status, and interventions made as a result of the assessment.



On 08/04/25, 11 days after the pressure ulcer was first identified, a facility RN completed a significant change of condition assessment.



During an interview on 08/14/25 with Staff 28, Staff 30 (Regional Director of Health Services), and Staff 31 (Administrator), no additional information was provided as to why the significant change of condition was not assessed in a timely manner.



The need to ensure an RN assessment was completed in a timely manner for all significant changes of condition was reviewed with Staff 28, Staff 30, and Staff 31 on 08/14/25 at 12:00 pm. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to follow established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment for 2 of 3 sampled residents (#s 3 and 5) whose ADL care was observed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia.
On 12/17/24 at approximately 1:20 pm, the surveyor observed two caregivers provide incontinence care to Resident 3. During the process, Staff 9 (CG) assisted Staff 18 (CG) to remove the resident’s soiled/wet pants and soiled incontinence brief. The resident’s soiled pants were put directly on the carpeted floor and the brief was put in a garbage sack.

Staff 18 failed to consistently change his gloves between dirty and clean tasks, such as after cleaning the resident’s perineal area and bottom and the removal of soiled items from the resident. Staff 18 touched the clean pants and brief before he was cued by Staff 9 to change his gloves. Staff 9 attempted to carry the wet pants to the laundry unbagged. The staff member was asked to put the pants in a bag before leaving the room and complied.

Observations on 12/18/24 of ADL care at approximately 9:07 am and again at 10:47 am showed the following:

* Glove changes between clean and dirty tasks were inconsistently completed by Staff 18.
* Gloves used to remove soiled items and/or clean up the resident were used to touch clean briefs, clothes and/or bedding. Staff changed the gloves when asked to do so.
* Soiled pants with both feces and urine were pulled off the resident and feces fell onto the bed, blanket and Hoyer sling pad.
* The soiled pants were pulled through the air without determining what was falling out of the pants. Staff 12 stopped Staff 18 and informed him there was feces in the resident’s pants.
* A wipe was used to grab the feces off the resident’s bed and put in the trash.
* The resident’s Hoyer sling had a brown substance on it. When staff were asked if the sling was clean and free of feces, they confirmed it was. However, when the resident was done being changed Staff 9 indicated they were changing the sling. The sling was taken to the laundry room in a bag with the resident’s pants.

An observation on 12/19/24 at approximately 9:03 am showed the following:

* The blanket covering the resident had a brown, crusty substance on the inside section of the blanket.
* Staff 18 was asked what was on the resident’s blanket and indicated after looking closely and scratching at the stain that it was probably food. The blanket was removed from the resident and placed in his/her recliner chair along with other items.
* After the resident was changed and dressed, the resident’s pajamas and the blanket with the brown substance, were removed from the room by staff. Staff 18 held the pile of laundry close to his body and carried the items to the laundry room. The items were not bagged or in any other type of receptacle. Staff 12 and 18 indicated soiled items were put in bags.

The need to ensure staff consistently used proper infection control and universal precautions when incontinence care was provided was discussed with Staff 1 (ED) and Staff 5 (RCC) on 12/18/24. They acknowledged appropriate infection control practices were not being followed.

2. Resident 5 was admitted to the facility in 09/2019 with diagnoses including dementia and chronic kidney disease. A review of his/her current service plan and interviews with staff revealed s/he was dependent on staff for all ADL care, including two person assist with toileting.

On 12/19/24 at 9:40 am, two staff were observed providing incontinence care for Resident 5 in bed. One staff failed to change gloves after wiping fecal matter from Resident 5’s bottom area. While wearing the same soiled gloves, the staff then touched resident’s legs, heel protectors, side rail and blanket.

The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 and Staff 4 (Regional Director of Health Services) on 12/19/24 at 2:55 pm. They acknowledged the findings.

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 ensure devices with restraining qualities were assessed at least quarterly by an RN, OT or PT to determine safety of the device, the risks vs benefits for the resident and if the least restrictive option was utilized for 2 of 3 sampled residents (#s 3 and 5). Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 01/2014 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 11/15/24 showed the resident had a scoop mattress with raised sides at the head and foot of the mattress. A small gap was present between the upper and lower sections of the raised sides. Additionally, the resident had a high back, tilt in space wheelchair which allowed staff to recline the resident at a variety of different angles.

The resident was unable to express any information regarding the devices. The resident’s cognition was significantly impaired and s/he required full assistance from staff for all ADL care including feeding of meals and two person assistance for transfers and dressing.

Review of the resident's record showed no documented assessment or evaluation of the scoop mattress or the tilt in space wheelchair. The resident’s service plan did not provide information to staff related to either device, safety/maintenance items to watch for or how to use the device with the resident.

The need for a PT, RN or OT to complete an assessment of any device with restraining qualities at least quarterly, was discussed with Staff 1 (ED), Staff 4 (Regional Director of Health Services) and Staff 5 (RCC) on 12/18/24 and 12/19/24. The staff acknowledged the findings.


2. Resident 5 was admitted to the facility in 09/2019 with diagnoses including dementia and chronic kidney disease.

On 12/17/24 Resident 5 was observed to have a half side rail in the up position on the right side of the hospital bed.

A current assessment for the side rail was requested on 12/18/24 at 1:25 pm. The facility provided the initial assessment for the side rail, completed on 02/08/24.

On 12/18/24, Staff 4 (Regional Director of Health Services) confirmed there was no documented evidence a quarterly evaluation for Resident 5’s side rail had been completed since the initial assessment. She indicated Staff 3 (RN) was evaluating Resident 5 for the side rail. No further documentation was provided.

The need to ensure an evaluation of any device with restraining qualities was evaluated at least quarterly, was discussed with Staff 1 (ED) and Staff 4 on 12/19/24 at 2:55 pm. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices

Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to:

The facility's ABST was reviewed and discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24 at 12:45 pm.

Review of Residents 1, 2, 3, 4 and 5’s ABST input revealed multiple ADLs were not reflective of the residents' evaluated care needs.

The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1 and Staff 4 on 12/19/24. They acknowledged the findings. No further information was provided.

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 interview and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 4 of 4 sampled residents (#s 8, 9, 10, and 11) whose Acuity Based Staffing Tool (ABST) was reviewed. This is a repeat citation. Findings include, but are not limited to:

Review of Resident 8, 9, 10, and 11’s ABST revealed multiple care elements that did not accurately capture the care time needed to complete the tasks.

The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1 (ED) on 05/07/25. She acknowledged the findings.

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 interview and record review, it was determined the facility failed to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 3 sampled residents (#s 1, 12, and 13) whose Acuity Based Staffing Tool (ABST) was reviewed. This is a repeat citation. Findings include, but are not limited to:

A review of Resident 1, 12, and 13’s ABST and service plans, observations of the residents, and interviews with staff revealed multiple care elements that did not accurately capture the care time needed to complete the tasks.

The need to ensure the facility accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 28 (Director of Health Services/LPN), Staff 30 (Regional Director of Health Services), and Staff 31 (Administrator) on 08/14/25 at 12:00 pm. They acknowledged the findings.

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 interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:

On 12/18/24, fire and life safety records dated 06/2024 through 11/2024 were reviewed and revealed the following:

* The facility provided no documented evidence staff were provided fire and life safety training on alternate months from fire drills.

On 12/19/24 at 4:27 pm, the need to provide fire and life safety instruction to staff on alternating months from fire drills was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services). They acknowledged the findings.

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 ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission. Findings include, but are not limited to:

Fire and life safety records were requested and reviewed with Staff 7 (Maintenance Director) on 12/18/24 and the following deficiency was identified:

* There was no documented evidence residents were instructed on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission.

The need to ensure residents received fire and life safety instruction within 24 hours of admission was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Health Services) on 12/19/24 at 4:27 pm. They acknowledged the findings.

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:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

(Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure the plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:



Refer to: C160, C260, C280, and C362.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

(Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to keep all interior and exterior materials and surfaces clean and in good repair. Findings include, but are not limited to:

Observations of the facility’s three cottages (Alpine, Beachwood and Ponderosa) from 12/17/24 through 12/19/24 revealed the following needed cleaning and/or repair:

a. Interior of facility cottages:
* Multiple corner guards had cracked/missing pieces (all three cottages);
* Dining room window trim had gouges/exposed drywall and missing/discolored paint (Alpine);
* Multiple walls, doors, and door frames had scrapes, dings and chips; (Alpine and Beachwood); and
* Multiple ceiling light fixtures had lights out. (Alpine).

b. Laundry rooms:
* Multiple walls had spatters/drips/gouges/exposed drywall and missing and/or peeling paint (all three cottages);
* Washing machines had peeling paint on the exterior of the machine and/or interior of the lid (all three cottages);
* Build-up/drips of laundry detergent on the exterior of washing machines and pooling on the floor (all three cottages);
* Flooring had areas that were cracked/buckled and/or dark discoloration of laminate (all three cottages);
* Debris on flooring and on interior of washing machine lids and detergent dispensers (all three cottages);
* Ceiling lighting fixtures had lights out and/or were missing covers (all three cottages);
* Door gouged with exposed wood (Alpine); and
* Hopper had missing faucet handle and was out of order (Beachwood).

c. Exterior of facility cottages:

* Multiple areas of gutters and downspouts had leaking and pooling of rainwater (all three cottages);
* Multiple areas had missing/worn/discolored paint and/or exposed wood (all three cottages); and
* Seams on porch drywall had cracks (Alpine).

The facility was toured with Staff 1 (ED) and Staff 7 (Maintenance Director) on 12/19/24 at 11:00 am. They acknowledged the areas needing cleaning and/or repair.

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 resident’s rights of privacy and dignity for 1 of 3 sampled residents (#3), who required assistance with ADL care. Findings include, but are not limited to:

Resident 3 was subjected to repeated undignified treatment during incontinence care and bed mobility including abrupt handling and movements, lack of communication of what was going on, and poor positioning in the bed which caused the resident visible distress.

Refer to C 200.

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 interview and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access their unit for multiple sampled and unsampled residents. Findings include, but are not limited to:

During an interview on 12/18/24 at 10:05 am, Staff 1 (ED) confirmed the majority of the residents did not have keys to their units.

The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1 and Staff 4 (Regional Director of Health Services) on 12/19/24 at 2:55 pm. They acknowledged the findings.

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, 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 C150, C160, C200, C231, C295, C362, C420, C422, and C513.

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 interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are limited to:

Refer to C160, C231 and C362.

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. This is a repeat citation. Findings include, but are not limited to:

Refer to: C160 and C362.

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 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, C280 and C340.

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 ensure health service were consistently provided. This is a repeat citation. Findings include, but are not limited to:

Refer to C260, C270, and C280.

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. This is a repeat citation. Findings include, but are not limited to:

Refer to: C260 and C280.

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 interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was documented in the resident's service plan for 2 of 4 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to.

Resident’s 1 and 2’s current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status and preferences of the resident.

The need to document an individualized nutrition and hydration plan in each resident’s service plan was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services.) on 12/19/24. They acknowledged the findings.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration

(c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to develop individualized activity plans for 4 of 5 sampled residents (#s 1, 3, 4 and 7) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 1, 3, 4, and 7’s records were reviewed during the survey. There was no resident specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.
The need to develop individualized activity plans, for each memory care resident was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Regional Director of Health Services) on 12/19/24. They acknowledged the findings.

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 develop individualized activity plans for 3 of 3 sampled residents (#s 8, 9, and 10) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 8, 9, and 10’s records were reviewed during the survey. There was no resident specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.

The need to develop individualized activity plans for each memory care resident was discussed with Staff 1 (ED) on 05/07/25. She acknowledged the findings.

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:

The findings of the kitchen inspection, conducted 05/02/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 05/02/24, conducted on 07/02/24, are documented in this report. The facility was found to be in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 05/02/24 at 11:00 am, the kitchens were observed with the following: * The dishwashing machines in the Ponderosa and Beechwood cottages did not have data plates to indicate proper temperature and chemical levels for sanitation; * The dishwashing machine in the Ponderosa cottage failed to properly sanitize dishware, the temperature gauge did not reach the minimum temperature of 120 degrees Fahrenheit and the chemical sanitation test strip was below the required 50 - 100 parts per million for chlorine. Staff 1 (Food Service Director) contacted service vender to request onsite visit; * The dishwashing machine in the Beechwood cottage failed to reach minimum temperature of 120 degrees Fahrenheit; and * The hood vents in the Ponderosa cottage had accumulation of dust and grease. The areas of concern were observed and discussed with Staff 1 and discussed with Staff 2 (Executive Director) on 05/02/24. The findings were acknowledged.

Based on observation and interview, 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 C 240.

I. Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24 and 02/13/24, it was confirmed the facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse for 1 of 1 sampled resident (#2) whose records were reviewed. Findings include, but are not limited to:A review of the faciltiy's policy and procedure "Incident Report - State Reporting", dated 01/05/24, indicated "the community will follow state regulations in regards to reporting incidents that negatively affect or that threaten the life, health, or safety of any resident."In an interview on 02/08/24, Staff 2 (Administrator) stated the process for reporting incidents of abuse or neglect must be done "within 24 hours", during that time an internal investigation is conducted, and the residents and staff are asked what happened. A report is submitted via email. A review of Resident 2's records indicated s/he experienced an injury of unknown cause: * Progress note, dated 04/24/23 at 12:12 pm, indicated resident had an "unwitnessed fall.... Resident stated [s/he] lost [his/her] balance. Resident was checked for injuries and non were noted at the moment."* Progress note, dated 04/25/23 at 9:07 pm, indicated no bruising had been witnessed by the writer. * Progress note, dated 04/26/23 at 11:43 am, indicated "resident has had evident bruising on [his/her] face for the last couple of days."* There was no evidence this facial bruising was investigated or reported to the Department or local AAA. * Progress note, dated 06/19/23 at 12:00 pm, indicated "caregiver found resident on the floor on top of pillows and blankets near [his/her] bed.... nude..... Resident was unable to clearly state what had occurred."* There was no evidence to indicate abuse or neglect had been ruled out or reported to the local Department office or local AAA.Resident 2 was discharged from facility on 07/29/23.On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 and Staff 16 (BOM). The facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse. Verbal Plan of Correction: Within 24 hours, the identified incidents will be reported the local Department office or local AAA and within two weeks, Administrator will provide training with nurse, medication technicians, and resident care coordinator. II. Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24 and 02/13/24, it was confirmed the facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse for 3 of 3 sampled residents (#s 3, 4, and 6) whose records were reviewed. Findings include, but are not limited to:A review of the faciltiy's policy and procedure "Incident Report - State Reporting", dated 01/05/24, inidcated "the community will follow state regulations in regards to reporting incidents that negatively affect or that threaten the life, health, or safety of any resident."In an interview on 02/08/24, Staff 2 (Administrator) stated the process for reporting incidents of abuse or neglect must be done "within 24 hours", during that time an internal investigation was conducted and the residents and staff were asked what happened. A report was submitted via email. A. A review of Resident 3's records indicated the following: * Progress note, dated 12/30/23 at 05:47 am, indicated "Resident on alert on 12/29/23 for resident altercation with [Room #]. Resident slept okay." * An Incident Report, dated 12/29/23, indicated Resident 6 walked into Resident 3's room and pulled the blanket that Resident 3 was laying on. Resident was then laying on his/her back with legs up. Paramedics were called due to resident possibly hitting his/her head when Resident 3 fell onto the floor. * There was no evidence this incident was reported to the local Department or local AAA. * Progress note, dated 01/27/24 at 11:29 am, indicated Resident 3 had an "unwitnessed fall". At 8:00 am the same morning, Resident 3 was found on the floor in another resident's room sleeping on his/her stomach with a stuffed animal under his/her head. * Service plan, dated 12/04/23, indicated s/he was monitored for wellness "4 [times] per shift."* The facility's investigation lacked any indication if the service plan was being followed at the time the resident was found in another resident' unit.B. A review of Resident 4's records indicated the following: * Progress note, dated 11/11/23 at 9:11 pm, indicated resident was placed on alert due to discoloration to his/her right arm, turning purple, and had pain when touched.* A temporary service plan, dated 11/11/23, was implemented. * An incident report, dated 11/11/23, indicated "Caregiver reported that resident has purple discoloration on [his/her] right arm." * There was no evidence to indicate abuse or neglect had been ruled out or reported to the local Department office or local AAA.C. A review of the facility's records indicated on 12/31/23 at 11:07 am, Resident 6 was in bed when skin discoloration around his/her right eye was found. The facility's investigation lacked any documented reasonable conclusion that the physical injury was not the result of abuse and was not reported to the local Department office or local AAA. On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 and Staff 16 (BOM). The facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse. Verbal Plan of Correction: Within 24 hours, the identified incidents would be reported the the local Department office or local AAA and within two weeks, Administrator did provide training with nurse, medication technicians, and resident care coordinator.

Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24 and 02/13/24, it was confirmed the facility failed ensure the implementation of services and failed to provide clear directions for 2 of 3 sampled residents (#s 4 and 5) whose records were reviewed. Findings include, but are not limited to:On 02/13/24 at 8:17 am, the Compliance Specialist (CS) observed breakfast plates delivered to Resident 4 and Resident 5. Resident 4's plated meal was regular texture and Resident 5's plated meal was pureed. On 02/13/24 at 8:26 am, the Compliance Specialist (CS) observed posted in the kitchen of Cottage A, the facility's Residents' Dietary profile which indicated Resident 4 was on a regular textured diet with thin liquids and Resident 5 was on a controlled carb diet with pureed textures. A review of Resident 4's records indicated the following: * Service plan, dated 11/14/23, provided conflicting information. One area of the service plan indicated s/he was to receive a "regular NAS, regular texture [with] thin liquid" diet and another indicated the resident was to receive "regular diet" and "mechanical soft." * A review of hospice provider notes, dated 01/31/24, indicated "nutritional concern: ...difficulty swallowing" and "nutrition diet type: mechanical soft". On 12/13/24 at 8:39 am, the CS stopped Staff 15 (CG) from feeding Resident 4 due to choking concerns and a new plate with the ordered diet type was provided.A review of Resident 5's records indicated the following: * Service Plan, dated 11/15/23, indicated in the area "Profile Overview" s/he was to receive "control carb, regular texture, thin liquids" diet. * In the area of "nutrition" his/her service plan indicated resident was to receive "regular diet". A review of Resident 5's signed physician orders, dated 10/28/23, indicated "diet- regular diet as tolerated". A review of Resident 5's nursing assessment dated 12/05/2, indicated "diet and texture: puree." There were no written physician orders found for the pureed diet. In an interview on 02/13/24 at 9:15 am, Staff 2 (Administrator) and Staff 17 (RN) confirmed the contradictory service plan directions. It was confirmed the facility failed to ensure the implementation of services and failed to provide clear directions. On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 and Staff 16 (BOM). Verbal Plan of Correction: Effective immediately, the RCC and RN did conduct a quarterly evaluation and assessment for Resident 5, and by end of day the Administrator did audit and update the facility's posted Dietary Profile in the kitchen, and implement a three check process in which new orders received were entered by staff, doubled checked by the RCC, then the RN did conduct the final review.

Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24 and 02/13/24, it was confirmed the facility failed to include a Service Planning Team (SPT) that consisted of the resident or the resident's legal representative for 3 of 3 sampled residents (#s 3, 4, and 5) whose records were reviewed. Findings include, but are not limited to:A review of Resident 3, 4, and 5s' service plans, dated 12/04/23, 11/14/23, and 11/15/23 respectively, and progress notes, dated 11/01/23 through 02/13/24, lacked any indications these service plans were reviewed with the resident or his/her legal representative. In an interview on 02/08/24 at approximately 3:15 pm, Staff 2 (Administrator) stated the RCC reviewed the service plan with the family at care conferences. The RCC would have the resident or legal representative sign the service plan during the meeting. When unable to meet in person the service plan was reviewed via telephone and documented.Staff 2 was shown Resident 3, 4, and 5 s' service plans and confirmed the lack of resident or legal representative's signatures. On 02/08/24, these findings were reviewed with and acknowledged by Staff 2 and Staff 16 (BOM). Verbal Plan of Correction: Within 30 days, the Administrator did review SPT requirements with the RCC and ensure the resident or legal representative are involved in the SPT.

Based on observation, interview, and record review, conducted during a site visit on 02/07/24, 02/08/24, and 02/13/24, it was determined the facility failed to implement an acuity based staffing tool for 2 of 3 sampled residents (#s 4 and 5) whose records were reviewed. Findings include, but are not limited to: In an interview on 02/08/24 at 3:15 pm, Staff 2 (Administrator) stated the following: * There were 52 residents that called this facility home. * Staffing levels were determined after a service plan was reviewed and entered into their Acuity Based Staffing Tool. * If there were changes to residents' needs, the ABST was updated. * The clinician team met one time a week to review resident acuity. * Facility was currently using the ODHS ABST. * Staffing levels were calculated by identifying the day of the week with the highest acuity time and dividing by 7.5 for each shift. In separate interviews on 02/08/24, Staff 9 (CG) and Staff 18 (RCC/MT) stated the following: * It took a total of 10 minutes to transfer Resident 4 and Resident 5 out of bed.* It took a total of 15-20 minutes to provide feeding assistance to Resident 4 and Resident 5.* It took a total of 5-8 minutes to transfer Resident 5 out of bed and 5-7 minutes to transfer Resident 4 out of bed.A review of the facility's ABST with Staff 2, indicated the following: * All residents were entered.* A staffing plan was generated per day per shift. * There were 22 distinct ADLs listed in the ABST. a. A review of Resident 4's records, their ABST profile and observation of the resident indicated the following; * Resident 4's Service Plan, dated 11/14/23, indicated s/he required total staff assistance with ADLs. Two staff members were required for ADLs including transfers, dressing, toileting.* The ABST was not refletive of Resident 4's two-person-assist status. * Resident 4's ABST indicated six minutes was spent on assisting resident with eating and two minutes was spent transferring the resident in/out of bed or a chair. * On 02/13/24, at 6:40 am, Staff 14 and Staff 15 provided dresssing and toileting assistance.* At 6:46 am through 6:52 am, Staff 14 and Staff 15 provided assistance with transfer from bed to chair.* Staff 15 provided feeding assistance that took a total of 45 minutes and 56 seconds. b. A review of Resident 5's records, their ABST profile, and observation of the resident indicated the following; * Resident 5's Service Plan, dated 11/15/23, indicated s/he required total staff assistance with ADLs, and assistance of two staff members for ADLs including transfers, dressing, toileting.* The ABST was not refletive of Resident 5's two-person-assist status. * Resident 5's ABST indicated seven minutes was spent on assisting resident with eating and four minutes was spent transferring the resident in/out of bed or a chair. * On 02/13/24, at 6:24 am, Staff 14 and Staff 15 provided toileting assistance.* At 6:30 am through 6:37 am, Staff 14 and Staff 15 provided assistance with transfer from bed to chair.* Staff 14 provided feeding assistance that took a total of 36 minutes and 29 seconds. The facility failed to implement an acuity based staffing tool.On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 (Administrator) and Staff 16 (BOM).

Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24, and 02/13/24, it was determined the facility failed to ensure 4 of 4 sample staff (#s 7, 9, 13, and 21) who records were reviewed completed pre-service dementia training; and the facility failed to ensure 2 of 3 sampled direct care staff (#s 9 and 21) had completed required training within 30 days of hire. Findings include, but are not limited to:A review of training records for Staff 7 (CG) hired on 11/09/22, Staff 9 (CG) hired on 08/02/23, Staff 13 (Activity Coordinator) hired on 08/02/23, and Staff 21 (CG) hired on 11/06/23, lacked documented training in one or more of the following required topics: * Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: Identify and address pain. * Environmental factors that are important to resident ' s well-being (e.g., noise, staff interactions, lighting, room temperature, etc.); * Family support and the role the family may have in the care of the resident; and * The use of supportive devices with restraining qualities in memory care communities. A review of training records for direct care staff for Staff 7 (CG) hired on 11/09/22, Staff 9 (CG) hired on 08/02/23, and Staff 21 (CG) hired on 11/06/23, lacked documented training in the following required topic: * Changes associated with normal aging. It was determined the facility failed to ensure staff members completed pre-service dementia training and the facility failed to ensure direct care staff had completed required training within 30 days of hire.On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 (Administrator) and Staff 16 (BOM).Verbal Plan of Correction: Within 30 days, the Administrator or Business Office Manager will audit current staff's training records to ensure all required training are completed.

Based on observation, interviews, and record review, conducted during a site visit on 02/07/24, 02/08/24 and 02/13/24, it was confirmed the facility failed to provide a call system that connects resident units to the care staff center or staff pagers. Findings include, but are not limited to: On 02/07/24, the Compliance Specialists observed this facility had three separate and distinct buildings referred to as Alpine Cottage A, Beachwood Cottage B, and Ponderosa Cottage C. On 02/07/24 at 12:45 pm, in an interview, Staff 1 (Community Resource Director) and Staff 5 (RCC) stated the following: * There were two pull cords available to residents- one in the bathroom and one near the head of resident's bed. Call pendants are also available for residents. * When activated the signal registered on the care staff's iPod.* The caregiver used a magnet to deactivate the call. Each caregiver must carry an iPod. * The facility's expectation for staff's call light response time is 15 minutes.* Staff carry walkie-talkies to communicate when a call light was activated.* There were no current call lights that were known to be broken, but when wall cords' batteries get low it will "beep".* There was a time "approximately end of 2023", the vendor had to get involved due to internet was not connecting to current pendants and new pendants were on back order and not available until summer. On 02/07/24, the Compliance Specialists observed the following:* When a call light was activated a light on the wall mount is red * In Cottage C, at 2:08 pm, the front public-accessible restroom's wall mounted cord did not work.* In Cottage A, between 3:20 pm and 3:45 pm, the wall mounted pull cords did not work in a bathroom in the common area near apartment 8. * Apartment 8's bathroom wall mounted pull cord did not work.* Both of apartment 6's bedsidewall mounted pull cords did not work. While at apartment 6, two direct care staff members were requested to check their iPods. It was confirmed the signal was received for the bathroom, but a direct care staff member's iPod was set to the wrong building. * Apartment 1's bedside cord did not work.* In Cottage B, between 4:23 pm and 4:40 pm, the wall mounted pull cords were pulled in apartment 10. The bathroom's wall mount was activated but no signal was received. *Apartment 5's wall mounted pull cord in the bathroom did not work. On 02/07/24, these findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Administrator). The facility failed to provide a call system that connects resident units to the care staff center or staff pagers. Verbal Plan of Correction:Within 24 hours, the facility Administrator or designee, will conduct an audit by going room to room, comparing with their vendor app, and will increase frequency of checks on residents with non-working call lights.On 02/08/24, the facility provided the Compliance Specialists the facility's Emergency Call Station Monthly Inspection form, dated 02/08/24, as verification the call system was tested and those lights that did not work were repaired with a battery replacement.

Based on interview and record review, conducted during a site visit on 02/07/24, 02/08/24, and 02/13/24, it was determined the facility failed to ensure 4 of 4 sample staff (#s 7, 9, 13, and 21) who records were reviewed completed pre-service dementia training; and the facility failed to ensure 2 of 3 sampled direct care staff (#s 9 and 21) had completed required training within 30 days of hire. Findings include, but are not limited to:A review of training records for Staff 7 (CG) hired on 11/09/22, Staff 9 (CG) hired on 08/02/23, Staff 13 (Activity Coordinator) hired on 08/02/23, and Staff 21 (CG) hired on 11/06/23, lacked documented training in one or more of the following required topics: * Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: Identify and address pain. * Environmental factors that are important to resident ' s well-being (e.g., noise, staff interactions, lighting, room temperature, etc.); * Family support and the role the family may have in the care of the resident; and * The use of supportive devices with restraining qualities in memory care communities. A review of training records for direct care staff for Staff 7 (CG) hired on 11/09/22, Staff 9 (CG) hired on 08/02/23, and Staff 21 (CG) hired on 11/06/23, lacked documented training in the following required topic: * Changes associated with normal aging. It was determined the facility failed to ensure staff members completed pre-service dementia training and the facility failed to ensure direct care staff had completed required training within 30 days of hire.On 02/13/24, these findings were reviewed with and acknowledged by Staff 2 (Administrator) and Staff 16 (BOM).Verbal Plan of Correction: Within 30 days, the Administrator or Business Office Manager will audit current staff's training records to ensure all required training are completed.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 10/18/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interviews and record review it was confirmed the facility is not providing designated awake caregivers in each building. Findings include:Interviews with Staff # 4 and Resident # 1 on 10/18/2022 with both stating that they have witnessed the facility leaving one of the cottages without staff during NOC shift on more than one occasion with the most recent being the night of 10/17/2022. Staff # 4 further stated that 2 of the 3 cottages has multiple residents that are 2-person assist and that during NOC shift if one of those cottages need assistance, the caregiver from the cottage with most independent residents will leave that cottage to assist the other cottages when needed, leaving that cottage without staff. Review of facility staff scheduled for October 2022 reveal multiple days in which the NOC shift only had 3 staff for all 3 cottages with some cottages having multiple 2-person assist residents. Review of facility posted staffing plan indicates that NOC shift should be staffed with 3 caregivers and 1 med tech. If one of the cottages with 2-person assist resident would need assistance a staff member from the other cottage would have to leave their cottage without a staff member to assist the other cottages

Based on interview and record review it was confirmed that the facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity Based Staffing Tool. Findings include the following:During an unannounced site visit on 10/18/2022 Compliance Specialist (CS) reviewed the facilities Acuity Based Staffing Tool (ABST) against the facilities current posted staffing plan and staff schedule. The facility is scheduled to staff the NOC shift with 3 caregivers and 2 med techs. Review of facility staff schedule for October 2022 reveal that the facility is consistantly staffed with 3 caregivers and 1 med tech and on some occasions staffing with only 3 care staff for NOC shift. Interview with Staff # 3 on 10/18/2022 who stated that there are occasions in which the facility is staffed with only 3 staff on NOC shift and there are times when one of the care staff will have to assist another care staff and would leave their cottage unattended while assisting the other care staff.

The findings of the re-licensure survey, conducted 02/28/22 through 03/01/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the re-licensure survey of 03/01/22, conducted 05/23/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the re-licensure survey of 03/01/22, conducted 09/06/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day



The findings of the third re-visit to the re-licensure survey of 03/01/22, conducted 11/17/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was kept clean and in good repair, and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to: The facility consisted of three separate buildings. Meals were prepared in Building C (Ponderosa). Buildings A and B also had full kitchenettes but were used mainly for serving the meals and storing snacks and desserts. 1. During the Building C kitchen tour, on 02/28/22 from 10:30 am to 10:40 am, a one-compartment stainless sink was observed. The stainless sink contained two packages of raw meat in water. Staff 15 (Cook) was asked to check the water temperature and the water temperature indicated 71 degrees Fahrenheit. On 02/28/22 at 10:35 am, the thawing process was discussed with Staff 15. Staff 15 stated there was not enough space in the refrigerator to defrost frozen meat. The surveyor informed Staff 15 of the need to discard the two packs of raw meat in the sink.On 02/28/22 at 10:55 am, observation of the kitchen and the concern regarding the inappropriate thawing of the frozen raw meat was shared with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.2. On 03/01/22 at 10:48 am, Staff 15 (Cook) was observed preparing lunch in Building C. Staff 15 prepared pureed diet food and desserts. Staff 15 stated she completed preparing the lunch meals. She was asked the food temperature of the lunch meals. She stated she did not check the temperature of the food.On 03/01/22 at 10:55 am, the minimum required cooking temperature of food including meat and fish was discussed with Staff 15. She acknowledged the findings.On 03/01/22 at 2:11 pm, during an interview with staff, the requirement to check food temperatures was shared with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.3a. On 02/28/22, during a tour of the kitchen in Building C, the following areas were observed to be in need of cleaning or repair: * Kitchen door and door frame had splatters/drips and chips and exposed metal;* Free-standing refrigerator door was sticky to the touch and had spillage and dried food matter inside;* Inside and outside of the microwave had dried food matter and was sticky;* Door and bottom of the oven were sticky with black and brown substances;* Drawers and shelves of the prep table had brown matter inside, water damage on the bottom surface and chips with exposed raw materials around the perimeter of the drawer;* Laminated countertop/prep table had chips in multiple areas;* Walls throughout the kitchen had splatters, loose food debris, grease, dirt, dust and black matter and the wall near the entrance had multiple holes; * Walls throughout the dry storage had a thick layer of dust and spider webs;* Window and blinds had a thick layer of dust;* Underneath the kitchen sink there was thick black matter, debris and food matter on the floor;* Caulking around the kitchen sink and handwashing sink had black matter and cracks;* The interior of the free-standing freezer, in the dry storage area, had spillage and dried food matter;* The ceiling vent had accumulated dust;* The dry storage doorframe was gouged; and* The floor near shelves in the dry storage room, had food matter.b. On 02/28/22 at 10:58 am, during a tour of the kitchen in Building A the following was observed to be in need of cleaning or repair:* Kitchen door and door frame had splatters/drips, chipped paint and metal exposed;* Free-standing refrigerator door was sticky to the touch and had spillage and dried food matter inside;* Inside and outside of the microwave had dried food matter and was sticky to the touch;* Door and bottom of the oven were sticky and had black and brown substances;* Food warmer had dried food matter and was sticky to the touch;* Laminated countertop/prep table had chips;* Inside drawers underneath of the beverage area had brown matter;* Drawers and shelves of the prep table had brown matter and water damage on the bottom surface;* Walls throughout the kitchen had splatters, loose food debris, grease, dirt, dust and black matter;* Walls throughout the dry storage had a thick layer of dust;* Window and blinds above the kitchen sink area had a thick layer of dust;* Underneath the kitchen sink there was thick black matter and food matter on the floor;* Caulking around the kitchen sink and handwashing sink had black matter and cracks;* The interior of the free-standing freezer, in the dry storage area, had spillage and dried food matter; and* Dry storage doorframe was gouged. c. On 02/28/22 at 11:08 am, during a tour of the kitchen in Building B the following was observed to be in need of cleaning or repair:* The interior of the free-standing cooler had spillage and dried food matter;* Door and bottom of the oven were sticky and had black and brown substances;* Drawers and shelves of the prep table had brown matter and water damage on the bottom surface;* Food warmer had dried food matter; * Inside drawers underneath the beverage area had brown matter;* Multiple ants were observed in the kitchen area;* The interior of the free-standing freezer, in the dry storage area, had spillage and dried food matter;* Ice machine exterior was sticky to the touch;* Laminated prep table had chips in multiple areas;* Underneath the kitchen sink, there was thick black matter and food matter on the floor; and* Caulking around the kitchen sink and handwashing sink had black matter and cracks.On 02/28/22 at 11:50 am, the buildings were toured with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the areas needed cleaning and repair.
Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was kept clean and in good repair, and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-00. This is a repeat citation. Findings include, but are not limited to: The facility consisted of three separate buildings. Meals were prepared in Building C (Ponderosa). Buildings A and B also had full kitchenettes but were used mainly for serving the meals and storing snacks and desserts. 1. During the Building C kitchen tour on 05/23/22 at 9:15 am the following areas were observed to be in need of cleaning or repair: * Kitchen door and door frame had splatters/drips and chips and exposed metal;* Drawers and shelves of the prep table had brown matter inside, water damage on the bottom surface and chips with exposed raw materials around the perimeter of the drawer;* Laminated countertop/prep table had chips in multiple areas;* Walls throughout the kitchen had splatters, loose food debris, grease, dirt, and dust and the wall near the entrance had multiple holes; * Walls throughout the dry storage had of dust;* Window and blinds were dusty;* Underneath the kitchen sink debris and food matter on the floor;* Caulking around the kitchen sink and handwashing sink had black matter and cracks.b. On 05/23/22 at 9:30 am, during a tour of the kitchen in Building A the following was observed to be in need of cleaning or repair:* Kitchen door and door frame had splatters/drips, chipped paint and metal exposed;* Floor under rolling bin cracked and water damaged;* Laminated countertop/prep table had chips;* Inside drawers underneath of the beverage area had brown matter;* Drawers and shelves of the prep table had brown matter and water damage on the bottom surface;* Walls throughout the dry storage were dusty; * Window and blinds above the kitchen sink area was dusty;* Underneath the kitchen sink the cabinet doors were missing;* Caulking around the kitchen sink and handwashing sink had black matter and cracks; and* Dry storage doorframe was gouged. c. On 05/23/22 at 9:30 am, during a tour of the kitchen in Building B the following was observed to be in need of cleaning or repair:* Drawers and shelves of the prep table had brown matter and water damage on the bottom surface;* Food warmer had dried food matter; * Inside drawers underneath the beverage area had brown matter;* The interior of the free-standing freezer, in the dry storage area, had spillage and dried food matter;* Laminated prep table had chips in multiple areas;* Underneath the kitchen sink, there was thick black matter and food matter on the floor; and* Caulking around the kitchen sink and handwashing sink had black matter and cracks.On 05/23/22, the buildings were toured with Staff 1 (Executive Director). She acknowledged the areas required repair, and the repairs had not yet been completed.

2. Resident 2 moved into the facility in 02/2022. The move-in evaluation failed to address the following areas:* Effective non-drug interventions for mental health issues;* Cognition including memory, orientation, confusion and decision making abilities;* Personality, including how the person copes with change and challenging situations;* Communication and sensory;* Pain including pharmaceutical and non-pharmaceutical interventions;* Skin condition;* Nutrition habits, fluid preference;* Complex medication regimen;* History of dehydration or unexplained weight loss or gain;* Elopement risk or history; and* Environmental factors that impact the resident's behavior including but not limited to: noise, lighting, room temperature.The need to ensure move-in evaluations included all required elements was discussed on 02/28/22 at 2:10 pm with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.3. Resident 4's quarterly evaluation, dated 02/07/22, was reviewed and lacked evidence the evaluation had been updated in the following areas:* Sensory including vision status and use of glasses;* Toileting status including bowel management;* Ability to use call system;* Current preferred activities and activities ability;* Fall risk including fall interventions; and * Hydration status.During an interview with Staff 2 (Regional Operation Specialist) on 02/28/22, she confirmed the quarterly evaluation had not been updated.The need to ensure quarterly evaluations were reflective of resident's status was discussed on 03/01/22 at 2:11 pm with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 2) who was recently admitted to the facility, and failed to ensure quarterly evaluations were completed timely and were updated for 2 of 3 sampled residents (#s 1 and 4) whose records were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 08/2014. The resident's most recent quarterly evaluation, dated 04/08/21 was reviewed and lacked evidence of being updated timely (quarterly), as required.On 03/01/22 the need to ensure residents' evaluations were updated quarterly was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and provided clear direction to caregiving staff regarding delivery of services for 2 of 3 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 06/2020. The resident's current service plan, dated 05/24/21, and Interim Service Plans (ISPs) were reviewed and were not reflective of the resident's current status and care needs and failed to provide clear instruction in the following areas:* Current fall status and interventions;* Current preferred activities and the ability to participate in activities; * Fluid preferences;* Sensory including vision status and use of glasses;* Changes in incontinence (bowel) and level of assistance required;* Changes in dressing status and level of assistance required;* Bathing status;* Ability to use call system; and* Use of compression stocking. The need to ensure the service plan provided clear and accurate information was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist) on 03/01/22. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 08/2014 with diagnoses including dementia, hypertension, cardiomyopathy and macular degeneration. The resident's records were reviewed, including service plan (dated 04/08/21) interim service plans, progress notes, incident reports and outside provider notes. Review of these records, interviews with staff, and observations during survey indicated Resident 1's service plan was not reflective of the resident's current care needs or did not provide clear instructions to staff in the following areas:*Visual impairment- The service plan stated Resident 1 had "no visual impairment", while the resident's list of diagnoses included glaucoma, cataracts and macular degeneration;*Toileting needs- The service plan stated Resident 1 was "continent of bladder and bowel", but also documented the resident's need for an "incontinence package" (including gloves, wipes and briefs) and "total assistance" with toileting;*Restraint device- The service plan stated Resident 1 "did not require any device with restraining qualities". However, siderails were observed on the resident's bed during survey, and staff presented the survey team with a documented assessment form for the use of siderails; and*PRN oxygen- The service plan included no mention of oxygen or instructions to staff on maintenance and use of related equipment. However, an oxygen tank, regulators and tubing were observed in the resident's room, and the MAR listed oxygen as a PRN medication.On 03/01/22 the need to develop service plans that reflected residents' current status and care needs, and provided clear instructions to staff was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operations Specialist). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 3 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to:The most recent service plans for Residents 1 and 4 were reviewed during the survey. The records lacked documented evidence that the service plans were developed by a service planning team. On 03/01/22 the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes of condition with resident specific interventions were determined and monitored for 1 of 3 sampled residents (# 4) in the areas of falls. Findings include, but are not limited to: Resident 4 was admitted to the facility in 06/2020. During the acuity interview, the resident was identified as having multiple falls in the last 90 days.Observations from 02/28/22 through 03/01/22 revealed the resident ambulated in the room with a 4-wheeled walker independently and had discoloration/bruises on his/her face and neck area.The resident's 05/24/21 service plan, 11/11/21 through 02/27/22 progress notes, Interim Service Plan(s) and incidents reports were reviewed and revealed the following:* The resident's most recent plan of care indicated the resident was a "low fall potential" and no fall interventions were listed; and* S/he experienced five falls including skin injury from the falls. A review of the resident's record revealed the facility had not evaluated, implemented or monitored resident specific interventions related to falls.The failure to evaluate the resident's status based on the evaluation and service planned needs was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist) on 03/01/22. No further information was received.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (# 4) whose orders were reviewed. Findings include, but are not limited to:Resident 4 was admitted to the facility in 06/2020.Resident 4 had a physician's order, dated 01/26/22, to apply Diaper Rash 10 % cream as directed and Nystatin powder twice daily.Resident 4's 02/01/22 through 02/28/22 MAR revealed there was no indication these orders were transcribed to the MAR.On 03/01/22, the physician orders and the MARs were reviewed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 3 sampled residents (#s 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 11/2021 with diagnoses including Alzheimer's disease.The resident's 02/01/22 through 02/28/22 MARs were reviewed during the survey and lacked resident specific instructions for the following: * PRN Tylenol tablets versus PRN Tylenol suppository for fever greater than 100 degrees;* PRN morphine versus PRN Tylenol for pain;* PRN Lorazepam versus PRN morphine for shortness of breath; and*PRN Milk of Magnesia versus PRN polyethylene glycol for constipation.On 03/01/22, the need for the facility to ensure MARs provided clear instruction to unlicensed staff was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operations Specialist). They acknowledged the findings.
2. Resident 4 moved into the facility in 06/2020.Resident 4's MARs, reviewed from 02/01/22 - 02/28/22, revealed the following inaccuracies:* To apply PRN Lidocaine 4 % patch 1- 2 patches for pain without clear instruction including when to apply 1 or 2 patches.* Staff documented they administered all medications to the resident on 02/18/22 and staff documented the resident's evening medications were "sitting popped out in the clear medication box" and documented the resident was not able to wake up to administer the medications.On 03/01/22, the need to maintain an accurate MAR for all medications administered by the facility and to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure new hires had the required abdominal thrust and First Aid training for 2 of 3 newly hired staff (#s 8 and 9). Findings include, but are not limited to:During the survey, training records were reviewed for Staff 8 (MT) hired 12/21/21, and Staff 9 (MT) hired 12/30/21.Staff 8 and 9 did not have documented evidence they had received first aid and abdominal thrust training.The need to ensure staff were trained in first aid and abdominal thrust was discussed with Staff 1(Executive Director) and Staff 2 (Regional Operations Specialist) on 03/01/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:Fire and life safety records, reviewed between 09/2021 and 01/2022, revealed the following:* No fire and life safety instruction had been completed during the six-month time frame.On 03/01/22 at 10:28 am, Staff 1 (Executive Director) confirmed there was no staff in-service on fire and life safety for the last six months.The requirements regarding fire and life safety instruction for staff was reviewed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist) on 03/01/21 at 2:11 pm. They acknowledged the findings. No further information was provided.

Based on observation and interview, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240 and C 510.
Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 510.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways to the common-use areas in good repair. Findings include, but are not limited to:The exterior grounds, courtyard areas and walkways of the building were toured on 02/28/22 at 10:45 am. There were multiple sections of the sidewalk with drop-offs of up to two inches, measured from the concrete surface to the bark dust beds. These drop-offs represented tripping/fall risks for residents.On 02/28/22 the drop-offs were reviewed with Staff 1 (Executive Director) and Staff 2 (Regional Operation Specialist). They acknowledged the findings and stated plans to have additional bark dust spread.
Based on observation and interview, it was determined the facility failed to maintain all exterior pathways to the common-use areas in good repair. This is a repeat citation. Findings include, but are not limited to:The exterior grounds, courtyard areas and walkways of the building were toured on 05/23/22 at 9:46 am. There were multiple sections of the sidewalk with drop-offs of up to two inches, measured from the concrete surface to the barkdust beds. These drop-offs represented tripping/fall risks for residents.On 05/23/22 the drop-offs were reviewed with Staff 1 (Executive Director). She acknowledged the findings and stated she had ordered barkdust and mulch that would be delivered in four to six weeks.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways to the common-use areas. This is a repeat citation. Findings include, but are not limited to:The exterior grounds, courtyard areas and walkways of the building were toured on 09/06/22. The following was identified:*The courtyard in cottage "Alpine" was observed with a concrete sidewalk below the adjacent concrete pad and there was an approximate 4 inch deep drop off between the surfaces. The sidewalk represented tripping/fall risks for the residents.On 09/06/22 the drop-offs and sunken concrete were reviewed with Staff 1 (Executive Director). She acknowledged the findings.
1. The identified section of the sidewalk is being removed and repoured in order to remove the approximate 4 inch deep drop off between the surfaces. 2. Audits will be completed using the QA- Quarterly Building Inspection form. 3. The Executive Director and Maintenance Director will review this area quarterly per the Quality Assurance Master Review Schedule. 4. The Executive Director will ensure the corrections are completed and monitored.

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 C240, C372, C420 and C510.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 240 and C 510.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 510.
Refer to C 510.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long term staff (#s 11, 12 and 13) completed the required number of hours of annual in-service training. Findings include, but are not limited to:Staff training records were reviewed on 03/01/22 and revealed the following:* Staff 11 (CG) hired 08/30/20, Staff 12 (CG) hired 07/12/05 and Staff 13 (CG) hired 10/17/17 had no documented evidence they had completed a total of 16 hours of annual in-service training related to the provision of care, including a minimum of six (6) hours related to dementia care.The need to ensure staff completed all required training in a timely manner was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Operations Specialist) on 03/01/22. They acknowledged the findings.

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 C252, C260, C262, C270, C303 and C310.