Ascot Park Senior Living

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).

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to: Observation of the 3 cottage kitchens and facility food storage areas on 9/22/25 at 10:30 am through 1:30 pm revealed the following: a. Cottage C was noted with an accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following: * Interior and exterior of reach in refrigerators and freezers * Stainless steel shelving in dry storage * Grill top * Range Top * Interior and exterior of ovens * Floors behind and underneath ovens/range * Windowsill * Stainless steel shelving storing pots/Pans * Juice machine where nozzles rest Multiple food items noted to be stored in reach in coolers or freezers that were not properly closed/sealed after opened to prevent potential contamination during storage. Multiple food items were observed stored in reach in coolers without open and/or prepared dates. Large section of laminate flooring was damaged under the ice machine creating a noncleanable surface. Multiple metal table bottom selves were observed/noted with rusted/worn/compromised areas and were in need of replacement/repair. The nozzle for orange juice dispenser was observed with small accumulation of small, winged pests/insects on the inside section of the spout. Staff 2 (Culinary Services Director) was informed immediately who discontinued use of the juice machine and contacted their pest control company. No other pests were noted in that or any other kitchen area. At approximately 12:00 pm, a staff member was observed to transport a meal tray to a resident’s room with beverages and dessert uncovered and not protected from potential contamination. b. Cottage A was noted with an accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following: * Industrial can opener and housing * Microwave * Interiors of reach in freezer and cooler * Walls with splatter * Interior of blender base Staff was observed to prepare mechanically altered/puree texture diets. The texture of the vegetable was observed to have visible small chunks of mechanicalized vegetables. Surveyor intervened and had the staff further process the vegetables until smooth and at an appropriate texture for puree before served to residents. Staff was observed to place plated puree meals into microwave prior to service. The staff member did not appropriately stir the product after microwaving. The staff member did not check the temperature of the food product to ensure for safety and/or palatability. Staff member was not able to verbalize correct reheat temperature for safety or correct hot holding temperature requirements. c. Cottage B was noted with an accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following: * Industrial can opener and housing * Juice machine * Interiors of reach in freezers/cooler * Interior of ovens * Range top * Behind/underneath Stove/range * Ceiling vent above work table * Edges of light fixtures above work table * Windowsill * Wall by light switch * Wall by door to dining room * Interior of green hot holding food cart Multiple trays for resident room dining were observed transported with beverages not covered/protected from potential contamination. Surveyor toured above areas with Staff 2 (Culinary Services Director) who acknowledged the identified areas. At approximately 1:30 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Business Office Manager) and Staff 2 who both acknowledged the findings.

All identified areas to be cleaned by Culinary Services Team. All items (laminate flooring, table shelving) needing painted/repaired/replaced will be completed by Maintenance Director. CSD and ED will be educated on Sinceri policy of proper transportation of food items and beverages by the National Director of Culinary. CSD and ED will educate culinary team and care staff on proper transportation of food items and beverages. The CSD will educate Culinary Staff and care staff on required food temperatures & monitoring procedures. CSD and ED will be educated on diet motifications and textures by National Culinary Services Director. CSD and ED will educate culinary team and care staff on diet motifications and textures. The CSD will educate Culinary staff on cleaning expectations and schedules to include regular inspections of the juice machines. Daily, weekly and monthly cleaning schedules are posted in the kitchen for staff to follow. CSD will audit cleaning schedules/cleanliness at least 3 days/week. Weekly kitchen inspection report to be compeleted by CSD. Executive Director (ED) will audit kitchen cleaning and schedules weekly x 4 weeks, bi-weekly x 4 weeks, and then randomly ongoing. CSD to be educated by National Culinary Services Director on importance of refrigerated and dry storage dates/labels. CSD will educate culinary team on maintaining dates/labels on food items.CSD or designee will perform an audit of storage and labeling at least weekly x 4 weeks, bi-weekly x 4 weeks.

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).

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.

Based on observations and interviews, 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.

See C240 Plan

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.

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.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to: During the change of ownership survey, conducted 01/27/25 through 01/30/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity of the citations. 1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following area: C 555: OAR 411-054-0200 (11-13) Call System, Exit Door Alarms, Phones, TV, or Cable. The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety. 2. Refer to deficiencies in the report.

Executive Director (ED) will educate all managers on this POC and their responsibilities in this POC by 2/24/2025 ED is responsible for daily follow up at stand up with items on this POC ED will educate staff on call light system response & appropriate equipment usage. Training will be added to New Employee Orientation. ED is responsible to review call light times daily and address identified issues daily. One regional team member will be onsite two times time per month to audit and spot check x 3 months.

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.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: A review of Resident Council Meeting Notes dated 10/15/24, 12/10/24, and 01/07/25 identified the following resident concerns: On 10/15/24, staff documented residents stating: * "We are bored, we need more socialization”; * “We want family outings and hotdogs”; * “We want more poker nights and play cards”; * “We would like a pizza night and [non-alcoholic] mai tais”; * “We need to get out more and do, we need models and tinker toys to keep us busy”; * “More movie nights”; * “Ladies would like to put together paper flowers, go Christmas shopping”; * “All residents stated they would like to incorporate food into an activity so they can make things they like instead of hoping they get it on the menu”; * “Need books, such as westerns, mystery, and romance”; * “Need more music and dances”; * “We would like soup of the day not just at dinner time”; * “Residents stated they would like more options with food, they would like hot dogs instead of hamburgers all the time”; * “Memory care said they are not getting their snacks”. Staff documentation on 12/10/24 was as follows: * “Staff need to sanitize hands prior to entering rooms and upon leaving rooms”; * “Hand sanitizer wall mounts are empty; residents want to remain healthy as possible and would like to get the wall mounts filled so staff can utilize them”; and * “Bus needs to be painted or rewrapped as you can still see Farmington Square as the community”. On 01/07/25, staff documented the following concerns: * “A resident brought to the attention that when ringing for assistance no one comes. [S/He] said [s/he] thinks the system is broken and what can we do to be able to get the assistance that the residents need”; * “It was stated the [call] system wasn’t working for a week and they had an interim plan of 15-minute round checks to visually lay eyes on each resident.” * “A resident pressed [his/her] wrist pendant to see how long it would take care staff to respond, this was at the beginning of the meeting [2:00 pm] at the end of the meeting [3:00 pm] a [CG] came.” “[CG] was informed that the pendant had been activated since the beginning of the meeting and that it was not appropriate to take so long to respond.” “[CG] reported the phone was dead, so it was charging”; * “Residents feel they are forgotten by staff when they are sick and trying to minimize exposing others by remaining in rooms”; * “Cottage A is upset as they are not getting their snacks, often times snacks are not furnished or available”; and * “Residents stated laundry is challenging and items don’t always make it back to the residents”. There was no documented evidence the above concerns identified during the Resident Council Meetings had been addressed, responded to, or resolved. In an interview on 01/28/25 at 12:28 pm, Staff 1 (ED) acknowledged the lack of documented follow-up response to complaints or suggestions from Resident Council Meetings. She stated her plan moving forward was to document resident complaints and how the facility attempted to resolve complaints. The need to improve the facility's method for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 2 (Regional Director of Operations) on 01/28/25. They acknowledged the findings.

ED will review all Resident Council Notes within 24 hours after monthly Resident Council Meetings ED will identify concerns and note them in Grievance Binder ED will address concerns with appropriate Team Member within 48 hour of Resident Council Meeting ED will follow up with Team Member daily to during Stand Up Meeting to ensure concerns are resolved ED will file completed Grievance form in Completed Grievance binder

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.

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.

Based on interview, and record review, it was determined the facility failed to ensure incidents were investigated and when abuse could not be immediately ruled out, reported to the local SPD (Seniors and People with Disabilities) office for 4 of 5 sampled residents (#s 1, 3, 4, and 5) who were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 11/2024 with diagnoses including Alzheimer’s disease and dementia with psychosis. Observations of the resident and interviews with staff were conducted. Resident 3's service plan, Observation notes, dated 11/26/24 through 01/27/25, and incident reports, dated 12/04/24 through 01/22/25, were reviewed and revealed the following: * 01/02/25: Staff found the resident on the floor in another resident’s unit. When staff asked Resident 3 what happened, the resident stated that s/he didn’t remember. It was not clear if the resident sustained any injuries. * 01/22/25: Staff found the resident in his/her bedroom floor. Staff documented that Resident 3 “expressed some pain” in his/her “left hip” and “left elbow.” The incidents did not have a thorough investigation that ruled out abuse or suspected abuse. On 01/29/25 at 12:17 pm, Staff 1 (ED) verified the investigations were not complete and they had not been reported to the local SPD office. On 01/29/25 at 5:11 pm, Staff 1 provided documentation that both incidents had been reported to the local SPD office. The need to ensure incidents were immediately investigated and if abuse or suspected abuse could not be ruled out, the incidents were reported to the local SPD office was discussed with Staff 1 on 01/30/25 at 12:33 pm. She acknowledged the findings. 2. Resident 5 was admitted to the facility in 03/2019 with diagnoses including dementia. Interviews with staff, and review of the resident's 10/31/24 service plan, and 11/06/24 through 01/27/25 interim service plans, progress notes, and incident investigations were completed. The following was identified: On 01/21/25, Resident 5’s progress note following a hospice visit included “discolored wrists” The hospice visit note included documentation indicating the resident had discolorations to both wrists. On 01/28/25 survey requested a copy of the incident investigation. Staff 1 (ED) reported there had not been an incident report or immediate investigation completed for the discolorations to Resident 5’s wrists, and it had not been reported to the local SPD office. The need to ensure all incidents and injuries of unknown cause were reported to local SPD office was discussed with Staff 1, and Staff 2 (Regional Director of Operations) on 01/28/25. They acknowledged the findings. The facility was instructed to report the injury of unknown cause to the local SPD office on 01/28/25. Proof of reporting was received from the facility 01/28/25. 3. Resident 1 was admitted to the facility in 05/2024 with diagnoses including vascular dementia. A review of the resident's facility record, including Observation notes dated 10/14/24 through 01/27/25, and Temporary Service Plans were completed, and staff were interviewed. The following was identified: * 10/21/24: Staff documented in a progress note, the resident "was in bed with another resident"; and * 10/24/24: A progress note indicated the resident was bothering another resident, pulling on the other resident’s jacket, and was aggressive towards the other resident. There was no documented evidence the above incidents were promptly investigated at the time they occurred to rule out abuse, nor that they were reported to the local SPD office if abuse could not be ruled out. On 01/28/25, Staff 1 (ED) confirmed investigations were not promptly completed. Survey requested the facility report the incidents to the local SPD office. On 01/30/25 at 12:24 pm, verification was received of reporting the incidents to the local SPD office. The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office and were promptly investigated was discussed with Staff 1 and Staff 2 (Regional Director of Operations) on 01/30/25. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 09/2024 with diagnoses including dementia. Observations of the resident and interviews with staff were conducted. Resident 4's clinical records were reviewed and revealed the following: * 12/31/24: A progress note indicated the resident had swelling to his/her upper eye lid. There was no documented evidence of an immediate investigation as to how the injury occurred to rule out abuse or suspected abuse. * 01/09/25: A progress note indicated the resident was experiencing burning, discomfort, and swelling in his/her genital area. There was no documented evidence of an immediate investigation as to how the injury occurred to rule out abuse or suspected abuse. On 01/30/25 at approximately 11:00 am, Staff 1 (ED) verified there was no evidence of investigations which ruled out abuse or suspected about. On 01/30/25, the need to ensure an immediate investigation after injuries of unknown cause were identified to rule out abuse or suspected abuse was discussed with Staff 1 (ED). She acknowledged the findings. At approximately 3:20 pm survey received confirmation the incidents had been reported to the local SPD office.

ED will complete abuse/neglect/reporting training by 2/28/2025 All incidents were reported while survey team was on site. All staff will complete abuse/neglect training. The Business Office Manager (BOM)/designee will create a tracker list and monitor for completeness. ED/designee will investigate and self report to APS as required any report of potential abuse/neglect as required. This will be monitored by the RN Delegate 1 day/week x 3 months, 2 days/week or until compliance is achieved. This will be monitored by review of incident reports, progress notes, and shift report logs daily during Clinical Huddle.

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.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs;

Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to: During the survey, conducted 01/27/25 through 01/30/25, observations were made in all three resident-occupied buildings (Cottages A, B, and C). Residents in Cottages A, B, and C were observed staying in their rooms, sitting in chairs sleeping, looking around, and/or exit seeking throughout the survey. The only scheduled activity observed during survey was on 01/29/25 at 1:00 pm, when Bingo was played in Cottage A, with multiple residents in attendance. The survey team did not consistently observe a daily program of social and recreational activities, which created opportunities for participation for the community at large. On 01/29/25, the need to ensure a daily activity program of social and recreational activities that were based on individual and group interests, physical, mental and psychosocial needs, and created opportunities for active participation in the community at large was discussed with Staff 1 (ED). She acknowledged the findings.

Resident Experience Team to attend Life Enrichment Training through OCP on 3/7/2025 ED/Resident Experience Director/Designee will be reeducated on activities/programming and following the calendar of daily programming by National Program Director by 3/07/2025. ED/Resident Experience Director/Designee will reeducate all staff on programming and activity calendar by 3/15/2025. ED/Designee will audit activities in all community houses daily x4weeks then weekly x3 months until compliance is met. Results of audits will be reported to Continuous Quality Improvement committee next scheduled meeting

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs;

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

Based on interview and record review, the facility failed to ensure evaluations were updated quarterly and reflective of the residents’ current status and condition for 2 of 6 sampled residents (#s 1 and 8) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 05/2024 with diagnoses including vascular dementia and a fractured left tibia. Resident 1’s quarterly evaluation was completed on 12/25/24. The evaluation failed to be reflective of the resident's current status and condition in the following areas: * Mental health status including behavioral or mood problems and effective non-drug interventions; * Sexual activity with another resident; * Hospice admission; * Level of assistance required for ADLs; * Pain, including pharmaceutical and non-pharmaceutical interventions; and * Skin condition. On 01/30/25, the need to ensure the quarterly evaluation was reflective of the resident's condition was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 2. Resident 8 was admitted to the facility in 09/2023 with diagnoses including dementia and type II diabetes. a. The most recent quarterly evaluation for Resident 8 was completed on 04/18/24. The subsequent quarterly evaluations, due on 07/17/24, 10/15/24, and 01/15/25 were not completed. b. The current evaluation failed to be reflective of the resident's current condition in the following areas: * Sleep patterns; * Recent ER visits; * Sexual activity with another resident; * Resident-to-resident physical altercation; * Pain, pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Skin condition; and * Fall risk or history. On 01/30/25, the need to ensure quarterly evaluations were completed timely and were reflective of the resident's current condition was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

Residents #1 and #8 service plans were updated by the LPN on 2/6/2025 to capture details and all requirements to meet needs. An audit of all evaluation due dates will be completed by the ED//Designee. The ED/Designee will audit all evaluations/service plans to ensure that all required items are captured with input from care staff, programming staff, resident and families. A weekly audit of evaluation/service plan dates will be done by the ED/Designee bi-weekly x 4 and then monthly so that evaluations/service plans are completed prior to move in, within 30 days, quarterly and with changes of condition.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

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.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were updated at least quarterly, reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, and/or were implemented for 6 of 9 sampled residents (#s 1, 2, 3, 4, 5 and 8) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 03/2019 and had diagnoses including dementia. The resident's current service plan, dated 10/31/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, and did not provide clear instruction to staff in the following areas: * Use of divider plate for meals; * Air mattress overlay on bed; * Side rails with instructions; and * Specialty wheelchair with instructions. The need to ensure service plans were reflective of resident needs and preferences and provided clear direction to staff was discussed with Staff 1 (ED), and Staff 2 (Regional Director of Operations) on 01/29/25. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 12/2022 with diagnoses including cerebral palsy. Review of the resident’s clinical records, including the most recent service plan, dated 12/23/24, indicated s/he needed a modified dietary texture that included nectar thick liquids. On 01/29/25 at approximately 8:45 am, the resident was observed drinking a glass of water which was regular consistency, and not nectar thick. Resident 2 began to cough while drinking the regular consistency water. Staff 27 (Cook) overheard Resident 2 struggling with their water and quickly switched the resident’s water for a glass of nectar thick water. On 01/30/25, the need to ensure the service plan was being implemented was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 3. Resident 4 was admitted to the facility in 09/2024 with diagnoses including dementia. Observations, interviews and review of the current service plan, dated 12/28/24, revealed the service plan was not reflective of the resident's current status and/or lacked clear instructions to staff in the following areas: * Transfers; * Toileting; and * Dressing. On 01/30/25, the need to ensure service plans were reflective of resident care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 4. Resident 1 was admitted to the facility in 05/2024 with diagnoses including vascular dementia and a fractured tibia. The resident's 09/24/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Diagnosis of skin cancer; * Hospice services and schedule; * Behavioral changes and interventions; * Sexual activity with another resident; * Two person assist with transfers and use of gait belt; * Incontinence care provided in bed; * Current skin condition and treatment; and * Pain areas and treatment. On 01/30/25, 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 2 (Regional Director of Operations). They acknowledged the findings. 5. Resident 8 was admitted to the facility in 09/2023 with diagnoses including dementia and type 2 diabetes. The resident’s 04/18/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan had not been updated quarterly, was not reflective of the resident’s current needs, and did not provide clear direction to staff in the following areas: * Sleep disturbance and caregiving instructions; * Sexual activity with another resident; * Resident-to-resident physical altercation and interventions; * Pain status; and * Recent falls and interventions to minimize falls. On 01/30/25, the need to ensure resident service plans were updated quarterly, reflective of the resident’s current care needs, and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 6. Resident 3 was admitted to the facility in 11/2024 with diagnoses including Alzheimer’s disease, dementia with psychosis, and anxiety. The resident’s 11/20/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan was not reflective of the resident’s current needs, did not provide clear direction to staff, and/or was not implemented in the following areas: * Confusion and how that affected communication and orientation; * How Resident 3 exhibited aggression; * Redirection to a low stimulus environment when the resident was exhibiting restlessness or anxiety; * Signs of anxiety, agitation, and overstimulation; * Where the key to his/her unit was located; * The use of glasses and assistance needed from staff; * Behavior interventions; * Assistance needed for ADLs; * Activity preferences; * Fall interventions; and * Specific instruction to staff relating to if s/he chose not to eat the meal served. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and/or were implemented was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings.

Residents #1(2/6/2025), #2 (2/13/2025), #3 (2/6/2025), #4 (2/11/2025), and #8(2/6/2025) Service plans were updated by the Regional Director of Health Services on the dates in parentheses to provide clear instruction to the care staff. Resident #5's service plan will be updated by the LPN by 2/25/2025. An audit of all evaluation due dates will be completed by the ED/Designee. The ED/Designee will audit all evaluations/service plans to ensure that all required items are captured with input from care staff, programming staff, resident and families. A weekly audit of evaluation/service plan dates will be done by the ED/Designee bi-weekly x 4 and then monthly so that evaluations/service plans are completed prior to move in, within 30 days, quarterly and with changes of condition and they are readily available to staff. Weekly Audit with Department Head Team to ensure Service Plans are accurately reflecting current needs & preferences, review one resident weekly.

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.

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.

Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident following a short-term change of condition, document on the progress of the condition at least weekly until resolution and ensure documentation of interventions was made part of the resident record for 9 of 9 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 8 and 9) with changes of condition or who required monitoring. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 09/2024 with diagnoses including dementia. Resident 4’s clinical record was reviewed for changes of condition and revealed the following: * 10/29/24: The resident was experiencing a rash to his/her groin area; * 12/03/24: Staff documented the resident “just wanted to die”; * 12/31/24: Resident 4 was experiencing swelling to his/her upper eyelid; * 01/08/25: The resident was found on the floor from a non-injury fall; and * 01/09/25: Resident 4 was experiencing burning, discomfort, and swelling in his/her genital area. There was no documented evidence the facility determined and documented actions or interventions for the changes of condition, those actions or interventions were communicated to staff on each shift, and/or the change was monitored through resolution. On 01/30/25, the need to ensure residents who experienced a change of condition had resident specific interventions and were monitored through resolution was discussed Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 12/2022 with diagnoses including cerebral palsy. Resident 2’s clinical record was reviewed for changes of condition and revealed the following: * 12/01/24: The resident was placed on alert charting for exposure to COVID. There was no documented evidence the resident’s condition had resolved. On 01/30/25, the need to ensure residents who experienced a change of condition had documented evidence of resolution was discussed Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 3. Resident 3 was admitted to the facility in 11/2024 with diagnoses including Alzheimer's disease and dementia with psychosis. The resident’s Observation notes, dated 11/26/24 through 01/27/25, and Temporary Service Plans, dated 11/26/24 through 01/24/25, were reviewed and staff were interviewed. The following changes of condition were identified: * 11/25/24: Admission to the community; * 12/02/24: Exposure to Covid; * 12/04/24: Fainting episode resulting in a fall and hospital admission; * 12/09/24: Fall; * 12/10/24: Discontinuation of a medication; * 12/12/24: Elopement attempt; * 12/13/24: Elopement attempt; * 12/13/24: Suicide ideation; * 12/15/24: Suicide ideation; * 12/20/24: Resident to resident altercation; * 12/25/24: Addition of a medication; * 01/02/25: Fall; * 01/09/25: Addition of two medications; * 01/21/25: Sexual behavior; * 01/22/25: Decrease of a medication; and * 01/22/25: Fall. There was no documented evidence the facility determined and documented actions or interventions for the changes of condition, those actions or interventions were communicated to staff on each shift, and/or the change was monitored through resolution. The need to ensure the facility determined and documented actions or interventions for the changes of condition, communicated the actions or interventions to staff on each shift, and/or the change was monitored through resolution was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings. 4. Resident 6 was admitted to the facility in 11/2024 with diagnoses including dementia. The resident’s Observation notes, dated 11/06/24 through 12/18/24, service plan, dated 10/29/24, and the initial evaluation, dated 10/29/24, were reviewed. The following changes of condition were identified: * 11/06/24: Admission to the community; and * 12/02/24: Exposure to Covid. There was no documented evidence the facility determined and documented actions or interventions for the changes of condition, those actions or interventions were communicated to staff on each shift, and/or the change was monitored through resolution. The need to ensure the facility determined and documented actions or interventions for the changes of condition, communicated the actions or interventions to staff on each shift, and/or the change was monitored through resolution was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings. 5. Resident 7 was admitted to the facility in 08/2024 with diagnoses including Alzheimer’s disease and type 2 diabetes. The resident’s observation notes, dated 10/11/24 through 01/27/25, and the 12/10/24 service plan was reviewed. The following changes of condition were identified: * 10/11/24: Decrease in medication; * 12/02/24: Exposure to Covid; * 01/08/25: Emergency room visit resulting in a diagnosis of bronchitis and prescribing Zithromax (an antibiotic); and * 01/10/25: Discontinuation of a PRN order for insulin. There was no documented evidence the facility determined and documented actions or interventions for the changes of condition, those actions or interventions were communicated to staff on each shift, and/or the change was monitored through resolution. The need to ensure the facility determined and documented actions or interventions for the changes of condition, communicated the actions or interventions to staff on each shift, and/or the change was monitored through resolution was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings. 6. Resident 1 was admitted to the facility in 05/2024 with diagnoses including vascular dementia and a fractured left tibia. The resident's 09/24/24 service plan, Temporary Service Plans and progress notes, dated 10/14/24 through 01/27/25, were reviewed and identified the following: * 10/14/24: A progress note indicated the resident had an “old scratch/bump on [his/her] face” and was on alert for it bleeding after the resident had scratched it; * 10/15/24: A progress note indicated the resident was on alert for two scratches on his/her face and nose; * 10/17/24: A progress note indicated the resident had an area “on [his/her] face [on] the right side that is open and raised and a second one on [his/her] nose that is not yet opened” and a third one was appearing on the left side of his/her face. Noted that the resident’s doctor was faxed; * 10/18/24: A progress note indicated the “scratch on cheek was open and leaking red colored bodily fluid.” Noted that the “MT attempted to cover open wound, but adhesive would not adhere to skin”; * 10/21/24: Staff documented in a progress note, the resident "was in bed with another resident"; * 10/23/24: Staff documented in a progress note, the resident was on alert for behavior changes. “Resident was aggressive at activities”; * 10/24/24: A progress note indicated the resident was bothering another resident, pulling on the other resident’s jacket, and was aggressive towards the other resident; * 10/25/24: Staff documented in a progress note, the resident’s “toenails are yellow and thick and seemed to be tender to the touch”; * 11/11/24: A progress note indicated the resident had a fall with injury to his/her right shoulder; * 11/19/24: A progress note indicated the resident was going to be sent to urgent care regarding his/her wound on his/her face; * 11/30/24: Staff documented in a progress note, “resident noted to have blood on [his/her] face and clothing, dry blood, on [his/her] face growth to right of face was bleeding”; * 12/04/24: A progress note indicated the resident was admitted to hospice due his/her diagnosis of advance squamous cell carcinoma; and * 01/17/25: A progress note indicated the hospice Certified Nursing Assistant noted the resident’s left leg and ankle was visibly swollen. There was no documented evidence the facility had evaluated the resident, determined actions or interventions specific to each change of condition, communicated the determined actions or interventions to staff, and/or monitored any of the above documented changes of condition to resolution. During an interview on 01/28/25 at 11:15 am, Staff 1 (ED) confirmed there was no additional documentation of skin monitoring by the nurse. On 01/30/25, the need to ensure changes of condition were evaluated to determine what actions or interventions were needed, actions or interventions were communicated to staff on each shift, and conditions were monitored with progress noted at least weekly through resolution was discussed with Staff 1 and Staff 2 (Regional Director of Operations). They acknowledged the findings. 7. Resident 8 was admitted to the facility in 09/2023 with diagnoses including dementia and type II diabetes. The resident's 04/18/24 service plan, temporary service plans and progress notes dated 11/02/24 through 01/27/25 were reviewed and identified the following: * 11/02/24: A progress note indicated the resident was on alert “for sore in mouth on right side”; * 11/3/24: A progress note indicated the resident had started a new medication; * 11/03/24: Staff documented in a progress note the resident had a non-injury fall; * 12/16/24: Staff documented the resident was out of his/her metoprolol (for high blood pressure) medication; * 12/20/24: Staff documented the resident was involved in a resident-to-resident physical altercation; * 12/27/24: Staff documented in a progress note the resident missed his/her dose of olanzapine (for psychiatric disorders); * 01/09/25: A progress note indicated the resident had an injury fall with shoulder pain; * 01/21/25: Staff documented the resident was out of his/her Ozempic (for lowering blood sugar) medication; * 01/22/25: A progress note indicated the resident was on alert protocol for potential flu; and * 01/24/25: Staff documented the resident missed his/her dose of Jardiance (for lowering blood sugar). There was no documented evidence the facility determined what resident-specific actions or interventions were needed for these changes of condition, that determined actions or interventions were communicated to staff, and/or that progress was documented weekly until the condition resolved. On 01/30/25, the need to ensure resident-specific actions or interventions were determined and documented for changes of condition, communicated to staff, and progress monitored and documented at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 8. Resident 5 was admitted to the facility in 03/2019 with diagnoses including dementia. The resident's 10/31/24 service plan, progress notes, interim service plans, and incident reports, dated 10/28/24 through 01/28/25, were reviewed. The following short-term changes of condition lacked documented actions or interventions for the changes of condition, communicated to staff on each shift, and/or the change monitored through resolution: * 12/02/24: Covid exposure; * 12/31/24: Fall with head strike; * 01/09/25: Diet change to mechanical soft; * 01/11/25: Fever; and * 01/21/25: Discolored areas to both wrists. The need to ensure changes of condition had actions/interventions determined, communicated to staff on all shifts, and were monitored through resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 01/29/25. They acknowledged the findings. 9. Resident 9 was admitted to the facility in 09/2023 with diagnoses including Alzheimer’s disease and osteoarthritis. The resident's 10/21/24 service plan and progress notes, interim service plans, and incident reports dated 10/28/24 through 01/28/25 were reviewed. The following short-term changes of condition lacked documented evidence actions/interventions were determined, with instructions provided to staff on all shifts, and monitoring of progress noted weekly through resolution: * 11/24/24: Non-injury fall; * 11/25/24: Unwitnessed fall; * 12/02/24: Covid exposure; * 12/25/24: Increased confusion, increase in ADL assist needed; * 01/15/25: Bruising to the left hand and arm; and * 01/24/25: Fall in bathroom. The need to ensure changes of condition had actions/interventions determined, with instructions provided to staff on all shifts, and monitored through resolution was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 01/29/25. They acknowledged the findings.

All falls whether witnessed or unwitnessed will be investigated within 24 hours by the ED or designee and appropriate interventions placed on a TSP and on the service plan and reviewed with care staff. The ED/Designee will monitor the EHR at least 4 days/week for incidents and progress notes. The ED or designee is responsible to complete an investigation on every incident within 24-48 hours, and document on the QAPI. The ED or designee will put into place a TSP for each incident. The HSD or designeee will be notified and will review the TSP, add the interventions to the care plan, and monitor effectiveness of the interventions. The ED or designee will self report to APS as required any report of potential abuse/neglect. The ED or designee is responsible to notify the RN Delegate of any resident with 2 or more falls. Clinical Team Supporting Community has completed the "Role of the Nurse"course, HSD will complete course upon return from Medical Leave. The HSD/Designee will clearly document resolution of each COC in MAR. This review will be completed daily in Clinical Huddle. Regional Director of Health Services (RDHS) to audit weekly x 4 weeks, bi-weekly x 4 weeks, and then will spot check.

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.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

Based on interview, and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented as unsuccessful prior to PRN psychotropic medication being administered for 1 of 2 sampled residents (# 3) who were prescribed as needed psychotropic medications. Findings include, but are not limited to: Resident 3 was admitted to the facility in 11/2024 with diagnoses including Alzheimer’s disease and dementia with psychosis. The resident's 12/01/24 through 01/27/25 MARs and physician’s orders were reviewed. Staff were interviewed and the following was identified: Resident 3 had a physician’s order for PRN quetiapine (for hallucinations, agitation, and dementia with behaviors). The resident received the PRN medication four times between 12/01/24 and 01/27/25. On 01/29/25 at 9:35 am, Staff 1 (ED) was requested to check the computer medication system for direction relating to non-drug interventions to try with Resident 3 prior to administering the PRN psychotropic. Staff 1 confirmed there were no interventions listed for staff to try prior to administration in 01/2025’s MAR and staff failed to document non-drug interventions tried and failed prior to giving the PRN to the resident. Although there were non-drug interventions listed to try prior to administrating the PRN on the 12/2024 MAR, there was no documented evidence staff attempted non-drug interventions prior to the administration of the medication. The need to ensure non-pharmacological interventions were documented as attempted and failed prior to the administration of PRN psychotropics was discussed with Staff 1 on 01/30/25 at 12:33 pm. She acknowledged the findings.

ED(Executive Director)/HSD(Health Services Director)/Designee will reeducate all med techs/staff on using non-pharmcological interventions and documenting the use of all non-pharmcological interventions prior to administration of psychotropics. Resident #3 had interventions in place on the MAR, the medication techs were identified and re-educated on documentation requirements by the Health Services Director on 2/21/2025. HSD/Designee will audit all PRN psychotropic medications ordered to ensure accuracy, and that each prn psychotropic has listed resident specific non-pharmacological interventions that staff are to attempt prior to the administration The Health Services Director/Executive Director/Designee will audit PRN psychotropic medication administration during clinical huddle to verify that non-pharmacological interventions are attempted and documented. The ED/HSD/Designee will spot check at least 3 x's/week x 4 weeks and then and then monthly at the Continuous Quality Improvement meeting.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident, including sufficient staff to meet the fire safety evacuation standards. Findings include, but are not limited to: The facility was licensed as a Memory Care with a capacity of 66 beds. a. On 01/27/25 during the entrance conference, survey requested a facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs. The facility acuity-based staffing tool (ABST) for all residents was reviewed during the survey in addition to the facility’s staffing plan. During the acuity interview on 01/27/25 and subsequent resident record reviews, the following care needs were identified: * The facility had a census of 43 residents that resided in three cottages; * Nine residents were identified as requiring two-person transfers or assistance with care; and * Two cottages were locked units and the residents who resided in them (18 residents living in Cottage A and 10 residents living in Cottage B) required the minimum of a one-person assistance for emergency evacuations. The facility ABST was not accurately being used to determine the correct staffing minutes in all cottages relating to the residents who required two staff members for transfers or care. b. The facility's staffing plan, posted during the survey, showed the following: * Cottage A - Day shift: 2 Caregivers and 1 Med Tech; - Swing shift: 2 Caregivers and 1 Med Tech; and - NOC [Night] shift: 1 Caregiver and 1 Med Tech. * Cottage B - Day shift: 2 Caregivers and 0.5 Med Tech; - Swing shift: 2 Caregivers and 0.5 Med Tech; and - NOC shift: 1 Caregiver and 0.5 Med Tech. * Cottage C - Day shift: 2 Caregivers and 0.5 Med Tech; - Swing shift: 2 Caregivers and 0.5 Med Tech; and - NOC shift: 1 Caregiver and 0.5 Med Tech. The facilities schedule did not include a minimum of two care staff present on night shift in cottages B and C, both that had residents requiring two-person assist with transfers and/or care. The facility's failure to ensure staff adequate in number to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings.

HSD/ED/Designee will update the ABST tool prior to a resident moving in, with quarterly service plan updates and with any change of condition. ED/Designee will audit 10% of resident evaluations/service plans per month to ensure accuracy of services provided and time of care provided. ED/Designee will ensure that staffing meets or exceeds the ABST tool to meet resident's scheduled and unscheduled needs

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

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.

Based on observation, interview, and record review, it was determined the facility failed to have accurate care minutes included on the acuity-based staffing tool (ABST) for 4 of 5 sampled residents (#s 1, 2, 3, and 4) and two unsampled residents. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2022 with diagnoses including cerebral palsy. Observations of the resident, interviews with staff, and review of the resident’s records revealed Resident 2's ABST minutes and/or frequencies were not reflective in the following areas: * Supervising, cueing, or supporting while eating; and * Transfers. On 01/30/25, the need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 2. Resident 4 was admitted to the facility in 09/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident’s records revealed Resident 4's ABST minutes and/or frequencies were not reflective in the following areas: * Transfers; * Dressing and undressing; and * Toileting, bowel, and bladder management. On 01/30/25, the need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations). They acknowledged the findings. 3. Resident 3 was admitted to the facility in 11/2024 with diagnoses including Alzheimer’s disease and dementia with psychosis. Observations of the resident, interviews with staff, and review of the resident records revealed Resident 3's ABST minutes and/or frequencies were not reflective in the following areas: * Monitoring behavioral conditions or symptoms; * Ensuring non-drug interventions for behaviors; * Cueing or redirecting due to cognitive impairment or dementia; and * Resident-specific housekeeping or laundry services performed by care staff. The need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings. 4. Resident 1 was admitted to the facility in 05/2024 with diagnoses including vascular dementia and a fractured left tibia. Observations of the resident, interviews with staff, and review of the resident’s records revealed Resident 1's ABST minutes and/or frequencies were not reflective in the following areas: * Monitoring behavioral conditions or symptoms; * Ensuring non-drug interventions for behaviors; * Cueing or redirecting due to cognitive impairment or dementia; * Providing treatments (e.g. skin care, wound care, antibiotic treatment); * Supervising, cueing, or supporting while eating; * Repositioning in bed or chair; and * Transferring in or out of bed or chair. The need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 01/30/25. They acknowledged the findings. 5. During the acuity interview on 01/27/2025, staff identified two unsampled residents needing two staff members for transferring. On 01/27/25 at 3:08 pm, the unsampled residents were reviewed in the facility’s ABST and reflected zero minutes needed for transferring. The need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings.

Health Services Director/Executive Director/Designee will update the ABST tool prior to a resident moving in, with quarterly service plan updates and with any change of condition. Residents 1,2,3, and 4 ABST were updated on 2/6/2024 by the Regional Director of Health Services utilizing staff input, and resident observation. ED educated the Resident Care Coordinator on 2/19/2025 on how time is to be entered into the ABST based on the evaluation, actual time of resident care. ED/Designee will audit 10% of residents each week x 4 weeks utilizing evaluations/service plans, timing resident care, and staff interviews to ensure accuracy of services provided and time of care provided and update the ABST as required. ED/Designee will ensure that accurate care minutes are included on the ABST.

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.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) before a resident moved into the facility for 2 of 2 sampled residents (#s 3 and 6) and for nine unsampled residents, and no less than quarterly for 1 of 1 unsampled resident. Findings include, but are not limited to: Review of the ABST on 01/27/25 revealed the following: * Resident 3 admitted to the facility in 11/2024. The ABST reflected care minutes were entered three days after the resident moved in; * Resident 6 admitted to the facility in 11/2024. The ABST reflected care minutes were entered two days after the resident moved in; * The ABST reflected that nine unsampled residents had their care minutes entered between one and twelve days after admitting to the facility; and * One unsampled resident’s ABST had not been updated since 09/2024. The need to ensure residents' ABST was updated prior to move-in and at least quarterly was reviewed with Staff 1 (ED) on 01/30/25 at 12:33 pm. She acknowledged the findings.

ED will educate Resident Care Coordinator (RCC)/HSD on ABST update requirements to include: prior to move in, quarterly service plans and with any change of condition. Regional Director of Health Services completed an audit of the ABST tool on 2/6/2025 and on 2/12/2025 on all residents to ensure that all residents had been updated quarterly and with change of conditions, any time that was not reflective of needs was updated. ED/HSD and/or Designee will audit ABST prior to any new resident move in to ensure that care time is reflected accurately. Health Services Director/Executive Director/Designee will update the ABST tool prior to a resident moving in, with quarterly service plan updates and with any change of condition. ED educated the Resident Care Coordinator on 2/19/2025 on how time is to be entered into the ABST based on the evaluation, actual time of resident care. ED/Designee will audit 10% of residents each week x 4 weeks utilizing evaluations/service plans, timing resident care, and staff interviews to ensure accuracy of services provided and time of care provided and update the ABST as required. ED/Designee will audit the ABST one time per month to ensure ABST is updated prior to move in, at least quarterly and with change of condition and report to the Continuous Quality Improvement meeting.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

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.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Six months of fire drill records were reviewed on 01/28/25 and revealed the following: a. Fire drills lacked documentation of one or more of the following components: * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * Number of occupants evacuated. In an interview on 01/28/25, Staff 1 (ED) and Staff 2 (Regional Director of Operations) acknowledged the documentation lacked one or more of the required components. b. The facility failed to provide fire and life safety instruction to staff on alternate months. In an interview on 01/28/25, Staff 1 confirmed staff were not provided fire and life safety instruction on alternating months. The need to ensure fire drills were conducted according to Oregon Fire Code with all required components documented and fire and life safety instruction to staff was provided on alternating months was discussed with Staff 1, and Staff 2 on 10/28/25. They acknowledged these findings.

Maintenance Director (MTD) will be educated by Director of Facilities on expectations of fire drills and requirement of alternating monthly fire and life safety trainings. The updated fire drill report was placed in use on 1/29/2025 and contains all required information: escape route used; problems encountered and comments relating to residents who resisted/failed to participate; evacuation time needed and number of occupants evacuated. Fire Drills and monthly all staff meeting education will be tracked utilizing the appropriate forms and uploaded into TELS. Fire drills will be reported through the monthly CQI meeting. * BOM/Designee will track all staff training as completed and report to ED. Executive Director/Designee will audit the fire drill forms monthly to ensure all required information is contained. ED/Designee will monitor through the monthly CQI meeting training topics and fire drills.

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.

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling.

Based on observation, and interview, it was determined the facility failed to ensure resident areas maintained a minimum temperature of no less than 70 degrees Fahrenheit during the day. Findings include, but are not limited to: Observations during the survey from 01/27/25 through 01/30/25 revealed temperatures inside Cottage C were consistently below 70 degrees during daytime hours. Temperatures obtained from the common area thermostat included the following: a. Rear corridor thermostat: * 01/27/25 at 12:15 pm, 1:30 pm, and 2:30 pm, thermostat was at 69 degrees; * 01/28/25 at 10:00 am, thermostat was at 68 degrees; and * 01/28/25 at 12:27 pm, thermostat was at 69 degrees. b. Front corridor thermostat: * 01/28/24 at 10:00 am, thermostat was at 66 degrees; and * 01/28/25 at 12:27 pm, thermostat was at 67 degrees. On 01/28/25, the need to ensure resident areas were maintained at a minimum of no less than 70 degrees during the day was discussed with Staff 1 (ED). She acknowledged the findings and reported the facility would get corridor thermostats adjusted.

Maintenance Director (MTD) to track internal temperatures weekly utilizing approriate forms and upload into TELS. ED to check temperatures in common areas daily x 4 weeks during rounds and notify MTD of concerns, and then spot check at least twice per month.

OAR 411-054-0200 (8) Heating and Ventilation (8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction. (a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit. (A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours. (B) During times of extreme summer heat, fans must be made available when air conditioning is not provided. (b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside. (c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit. (d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit.

Based on observation, interview, and record review, it was determined the facility failed to provide a call system that connected resident units and bathrooms to the care staff center, staff pagers, or a wireless call system. Residents were unable to contact staff to request help when needed, constituting a threat to their health, safety, and welfare. The facility also failed to have a system to notify staff of residents exiting the facility. Findings include, but are not limited to: The facility was made up of three separate cottages. Cottages A and B were secured memory care units, and Cottage C was an unlocked residential care unit. 1. The facility’s call system was connected to an iPad that was stored in the Medication Room. CGs reported that they used to carry iPhones. Both MTs and CGs were supposed to have walkie talkies with them while they were on shift. When a resident called for assistance, the MTs would use the walkie talkie to let CGs know which room, or which resident needed help. Staff confirmed that not everyone had an operable walkie talkie as sometimes they were not properly charged, and other times facility and/or agency staff would take them home. There were no iPhones available for staff use during survey. The following issues with the call system were identified: a. Resident Council Meeting minutes for 01/07/25 were reviewed on 01/28/25 and indicated there was a problem with the call system: * One unsampled resident expressed his/her concerns about how the residents would be able to get the assistance they needed and said, “The system is broken.” * Staff documented that during the Resident Council Meeting on 01/07/25, an unsampled resident pressed his/her wrist pendant to see how long it would take care staff respond. This was at approximately 2:00 pm, which was the beginning of the meeting. At approximately 3:00 pm, when the meeting was coming to a close, a CG came to answer the resident’s pendant. Staff documented that the CG “was informed that the pendant had been activated since the beginning of the meeting and that it was not appropriate to take so long to respond.” The CG responded that the iPhone’s battery “was dead” and that it “was charging”. b. Interviews and observations were conducted during the survey with residents, care staff, and visitors, and the following was reported: * On 01/28/25 at 4:23 pm, Resident 4 knocked on the door where survey was working and asked about getting a haircut. The surveyor asked Resident 4 if it was alright if the resident pressed the necklace pendent to call staff, and observed the resident push the button firmly. By 4:45 pm, no staff came to assist. At approximately 4:50 pm, Staff 5 (RCC) was walking down the hall and the need for scheduling a haircut appointment was discussed. By 5:11 pm, Resident 4 was sitting in the dining room getting ready to eat dinner and confirmed no one had checked on him/her or reset the pendent. * During an interview with Staff 10 (MT), on 01/29/25, it was reported resident rooms had pull cords for assistance. The alerts went to facility iPad and iPhones the caregivers carried with them. Staff 10 reported that without the iPhones staff would not know if a resident had pressed their pendent or used the pull cord. Staff 10 was not sure how many iPhones caregivers had between the three cottages, but believed there were only two iPads, and there was a cottage without an iPad to alert staff if a resident needed assistance. * On 01/29/25 at 3:22 pm, an unsampled resident reported that it “usually” took an hour or more to get assistance after pushing his/her call light, and s/he could tell when it was not the result of calling for assistance as staff “don’t reset [the call light] when they come in.” * Resident 4 reported that the call light system works “sometimes but not all of the time.” * Resident 9 resided in Cottage B had returned to the facility on 01/09/25, after a hospitalization with surgical intervention. Records reviewed revealed that after returning to the facility the resident fell on 01/21/25 and 01/27/25. During an interview with Resident 9 on 01/29/25 about use of the call light, s/he reported using it “sometimes”, and then stated, “no one ever comes, so it’s useless if you ask me.” * There was only one iPad in Cottage A, and “no one knows how to use it for call lights.” * There were no iPads available in Cottage B. “No one carries one in Cottage B.” * On 01/29/25 at 5:45 pm, Staff 11 (CG) reported the call system had not been working for two to three months. The CG reported thinking it was possible that some residents may have tried to pull their call light, and it never got answered so they got up and fell but wasn’t sure. * On 01/28/25 at 03:35 pm, Staff 19 (CG) reported that resident’s roommates had been helping each other with caregiving tasks since nobody came to answer the call lights. * The family of a resident who was dependent on staff for transfers and ADLs had to purchase a handheld bell for the resident, so the resident could ring the bell for assistance. * On 01/29/25 at 3:26 pm, a resident’s family member reported having to run and find staff for their loved one since the call system was broken. c. An audit of call light response times was conducted and revealed the following: * Call light times from 01/12/25 through 01/27/25 were reviewed for Residents 2 and 4, both of whom lived in Cottage C, and revealed 21 occasions when staff response time was greater than 15 minutes. Eight of the 21 occasions were greater than two hours. On 01/28/25 at 12:50 pm, Staff 1 (ED) confirmed she was aware the facility did not have an operable call system and stated she had ordered more iPads. The facility failed to ensure residents had a working call system, which left residents unable to call for assistance when needed and placed the resident’s health, safety, and welfare at risk. On 01/29/25 at 4:00 pm the facility was asked to complete and provide an immediate plan of correction. The plan of correction was received and accepted at 5:29 pm. The facilities plan included having one designated staff in each of the three cottages at all times to provide resident checks every 30 minutes or one hour, depending on the needs of the residents. This was to continue until the arrival and implementation of the iPads, as well as staff education relating to the new call system response protocol. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to have an operational call system that connected residents to the care staff or staff pagers was discussed with Staff 1 and Staff 2 (Regional Director of Operations) on 01/29/25. They acknowledged the findings. 2. Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include but are not limited to: Observations on 01/28/25 revealed exit doors in Cottages A and B did not have an operational alarm or other acceptable system to alert staff when residents exited the building. The alarms on entrance doors and the two doors leading to the secured courtyards of both A and B cottages were not alerting staff when the doors were opened. The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 01/28/25. They acknowledged the findings.

iPad/iPhone arrival date 01/31, walkie talkie arrival date 02/04, all staff training on appropriate usage of equipment completed 02/10, ongoing as needed. 1. Additional Documentation to Ensure Regular Safety Checks on Resident: o One person in each building will be designated to just know the whereabouts of each resident and document it. o Tracking of these checks will be completed on a resident roster. Ascot Park staff (not agency) will sign off stating what the resident is doing either every 30 minutes or hour depending on the unique needs of residents. This will continue until the arrival and implementation of iPads. 2. Designation of Care Staff Center Personnel: o One (additionally added) Ascot Park staff member per shift will be designated as the Care Staff Center contact. o This individual will be responsible for receiving and monitoring call system notifications. 3. Assignment of Call Light Response Personnel: o Each building will have one designated staff member assigned to a walkie-talkie to receive call system notifications from the Care Staff Center designee. o This staff member will be responsible for responding to call lights. If they are providing care, they will request assistance the rounder or the Med Tech. 4. Training and Implementation: o All staff will be provided an in-service on the new call light response protocol upon arrival and implementation of the iPads. o Training will include proper use of the call system, walkie-talkie assignments, and the process for ensuring timely responses. 5. Assignment and Accountability: o The Executive Director (ED) or designee will be responsible for assigning a Care Staff Center designee and designated call light response personnel for each building per shift. o Walkie-talkies will be signed out by the Care Staff Center designee to the designated call light response staff at the beginning of each shift. o At the end of each shift, the walkie-talkies will be returned and signed back in by the Care Staff Center designee. o Community currently has 6 working Walkie Talkies. We have ordered 10 additional arriving ETA 2/1. Upon arrival of the walkie talkies, there will be enough for AM& PM shifts. We will alternate though charging of equipment. 6. Monitoring and Compliance: o The ED, HSD or designee will conduct random audits to ensure compliance with the new protocol. o Any issues with response times or staff compliance will be addressed through additional training or corrective action as needed. o 7. Installation of Sounded Door Alarms for Cottage A & B o Completion Date (upon arrival of equipment), no later than February 2, 2025. o Until Completion, Action Item #1 will remain in place. 8. Call Light System Audits to Ensure System is Running Effectively o Weekly Audits through 3/2025 o Bi-Weekly Audits through 4/2025 o Monthly Audits Moving Forward Responsible Party: Executive Director, Health Services Director (HSD) or Designee

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to no locks on bathroom doors for residents who had shared bathrooms. Findings include, but are not limited to: On 01/28/25, observations of the shared bathrooms with Staff 1 (ED) and Staff 2 (Regional Director of Operations) revealed the doors to residents’ shared bathrooms did not have locking mechanisms to ensure privacy and dignity. On 01/30/25, the need to ensure shared bathroom doors had locks were reviewed with Staff 1. She acknowledged the findings.

Director of Facilities & MTD to ensure each unit has a locking door on the bathroom to ensure privacy and dignity, to be completed on or before 3/15/2025.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

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.

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: C 150, C 154, C 231, C 242, C 360, C 363, C 420, C 540, and C 555.

Refer to C150, C154, C231, C242, C360, C363, C420, C540, C555

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.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

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 C 252, C 260, C 270, C 330, and C 362.

Refer to C252, C260, C270, C330, C362.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

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.

Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 2 of 3 sampled residents (#s 1 and 8) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 8’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, preferences, and needs of the resident. The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (ED) on 01/30/25. She acknowledged the findings.

Resident # 1 and Resident #8 nutrition and hydration plans were updated by the Regional Director of Health Services(RDHS) on 2/6/2025 to include preferences, limitations, abilities. The RDHS/ED will complete an audit of all evaluations to ensure the nutrition/hydration plans are reflective of preferences, limitations, abilities; resident/family/staff interviews will be utilized where needed. The ED/Designee will audit nutrition and hydration plans upon move in, and with quarterly updates.

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.

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.

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 4 sampled residents (#s 1 and 8) whose records were reviewed. Findings include, but are not limited to: Resident service plans and activity evaluations were reviewed. There was no documented evidence the facility had fully evaluated and developed individualized plans based on the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions, if necessary. On 01/30/25, the need to ensure residents had individualized activity plans developed based on their activity evaluations was discussed with Staff 1 (ED). She acknowledged the findings.

Life Stories will be obtained for all residents by the Resident Experience Director (RED)/Executive Director/Designee. RED/ED will give a list of resident specific likes/dislikes for activities to the ED/HSD to update service plans. Service plans will be updated by the ED/HSD/Designee to reflect activity/engagement plans. The ED/HSD/Designee will provide ongoing audit of service plans for activity plans with move in, change in condition, and at least quarterly. Results of audits will be reported to the Continuous Quality Improvement team at next scheduled meeting

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.

OAR 411-057-0160(e) Behavior (e) Behavioral symptoms which negatively impact the resident and others in the community must be evaluated and included on the service or care plan. The memory care community must initiate and coordinate outside consultation or acute care when indicated.

Based on interview, and record review, it was determined the facility failed to ensure behavioral symptoms that negatively impacted the resident or others in the community were included on the service plan for 3 of 3 sampled residents (#s 1, 3, and 8) with documented behaviors. Findings include, but are not limited to: During the acuity interview on 01/27/25, Resident’s 1, 3, and 8 were identified as being involved in resident-to-resident altercations and/or sexual behaviors. The residents’ facility records were reviewed, which included Resident 1, 3, and 8’s service plans that were available to staff, and Observation notes. The Observation notes contained documented evidence which confirmed the behaviors identified during the acuity interview. The three identified residents’ service plan did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 01/30/25, the need to include residents’ behavioral symptoms on the service plan was discussed with Staff 1 (ED). She acknowledged the findings.

Resident #1, Resident #3 and Resident #8 behavioral plans were updated on 2/6/2025 by the LPN to reflect person centered interventions for behaviors. The ED/Designee will obtain behavioral health referrals for Resident #1 and Resident #8. RDHS/LPN/Designee will audit all service plans for the residents in Memory Care and update Behavioral plans, ensuring person centered interventions are in place. Interventions will be communicated to the care team via Temporary Service Plans (TSPs). ED/HSD/Designee will audit TSPs, progress notes and interventions in the clinical huddle.

OAR 411-057-0160(e) Behavior (e) Behavioral symptoms which negatively impact the resident and others in the community must be evaluated and included on the service or care plan. The memory care community must initiate and coordinate outside consultation or acute care when indicated.

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room.

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to: The MCC was toured on 01/29/25 and 01/30/25. * Resident rooms in Cottage A - 101, 103, 106 and 108; and * Resident rooms in Cottage B - 103, 104, 105, 107 and 112 lacked any individualized identification to assist residents in recognizing their room. The need to ensure each resident room was identified for the resident was reviewed with Staff 1 (ED) on 01/30/25 at 11:45 am. She acknowledged the findings.

ED, RED and Designee will contact families for current residents to collect resident pictures on or before 3/15/2025. RED & MTD will ensure all resident rooms have personalized pictures posted outside of their units to identify their living space on or before 3/20/2025. ED, RED and Community Resource Director (CRD) will ensure a new resident picture is collected upon move in. The ED/MTD will audit room personalization monthly on the internal CBC walkthrough and report to the Continuous Quality Improvement Meeting monthly.

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room.

Based on interview and record review, conducted during a site visit on 10/10/24, it was determined the facility failed to determine and document what action or intervention is needed if a resident experiences a short-term change of condition for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of the facility's policy and procedures for change of condition, indicated the following: · The licensed nurse will determine the type of intervention and follow-up that is indicated, including appropriate notification of the Resident's family or responsible party and physician. Notifications to the Residents'  responsible party and primary provider will be noted in the Resident health Record. · The resident will be place on alert charting. A review of Resident 1's February-March 2024 progress notes indicated the following: · 02/21/24 at 3:55 AM  "resident is on alert for skin issue. Resident was asleep this shift, will continue to monitor " · 02/21/24 at 1:06 PM  "Resident received new orders for script for shingles" · 02/22/24 at 6:14 PM Nursing note  "Resident is on alert for new shingles diagnosis. MT came to me and notified me of redness and blisters below right breast that followed the nerve line. This was report to NP [in house provider] on 02/21/24 and resident was diagnosed with Shingles."   "Add resident to alert charting and ISP to monitor shingles". In an interview on 10/10/24, Staff 1 (Executive Director) and Staff 2 (Regional Nurse) stated the following: · Staff 1 was unaware of the situation as s/he started working at the facility on 08/20/24. · Short term change of conditions was to be reported to the nurse, and then the doctor and family should have been notified. · They would use a TSP or ISP for initial notification to staff and put it in the binder. · The med tech should document every shift when on alert. Compliance specialist requested Interim Service Plan from facility, however, they were unable to provide them. There was no documentation regarding what actions or interventions were needed or what staff was to monitor and report. Witness 1 reported on 03/07/24, Resident 1 was at the doctor's office with Shingles around his/her torso on 02/22/24 and there had been no communication to him/her from the facility prior. Findings were reviewed with and acknowledged by Staff 1 on 10/10/24. It was determined the facility failed to determine and document what action or intervention is needed if a resident experiences a short-term change of condition.

Based on interview and record review, conducted during a site visit on 10/10/24, it was determined the facility failed to have a safe medication and treatment system in place for 1 of 3 sampled residents (#1). Findings include, but are not limited to: A review of Resident 1's August 2024 MAR and progress notes, and physician orders indicated the following: · Docusate Sodium 100 MG softgel to be given 1 capsule by mouth twice daily for constipation was not administered on 08/12/24 at 8:00 PM or on 08/13/24 at 8:00 AM due to  "Med not on hand". · Hydroxychloroquine 200 MG tab to be given 1 tablet by mouth twice daily for inflammatory polyarthropathy. Resident missed 4 doses between 08/12/24-08/14/24 due to  "Med not on hand". · Memantine HCL 5 MG tablet to be given 1 tablet by mouth once a day for Alzheimer's disease was not administered on 08/13/24 at 7:00 AM due to medication not available. A review of Resident 2 and Resident 3's August 2024 MAR and progress notes did not indicate any discrepancies. In an interview, Staff 1 (Executive Director) stated  "missed meds, historically, were a problem and are decreasing" . S/He stated the process was getting better. The findings were reviewed with and acknowledged by Staff 1 on 10/10/24. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Plan of correction: Daily clinicals are in place to audit alert charting, missed medications, medication errors, and change of condition. Weekly re-education by the nurse and management for MTs regarding medication administration, orders, and re-fills. Facility is also sending out quarterly renewal letters to physicians.

Based on interview and record review, conducted during a site visit on 10/10/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: A review of Resident 1's August 2024 MAR and progress notes, and physician orders indicated the following: · Docusate Sodium 100 MG softgel to be given 1 capsule by mouth twice daily for constipation was not administered on 08/12/24 at 8:00 PM or on 08/13/24 at 8:00 AM due to  "Med not on hand". · Hydroxychloroquine 200 MG tab to be given 1 tablet by mouth twice daily for inflammatory polyarthropathy. Resident missed 4 doses between 08/12/24-08/14/24 due to  "Med not on hand". · Memantine HCL 5 MG tablet to be given 1 tablet by mouth once a day for Alzheimer's disease was not administered on 08/13/24 at 7:00 AM due to medication not available. In an interview, Staff 1 (Executive Director) stated  "missed meds, historically, were a problem and are decreasing" . S/He stated the process was getting better. The findings were reviewed with and acknowledged by Staff 1 on 10/10/24. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Plan of correction: Daily clinicals are in place to audit alert charting, missed medications, medication errors, and change of condition. Weekly re-education by the nurse and management for MTs regarding medication administration, orders, and re-fills. Facility is also sending out quarterly renewal letters to physicians.

Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to immediately notify the Department's Central Office of severe interruption of physical plant services. Findings include, but are not limited to: Compliance Specialist (CS) reviewed an email sent to Staff 1 (ED) dated 01/25/24 notifying him/her that the fire panel in Cottage C suffered a complete failure. Reviewed another email from the Department dated 02/23/24 notifying the facility that they had just become aware of the situation and the facility had failed to notify the Department immediately. In an interview on 03/11/24, Staff 1 (ED) stated the fire panel had been reported to him/her from maintenance, however, s/he was not aware that was something s/he needed to report to the Department.   On 03/11/24, findings were reviewed with and acknowledged by Staff 1. The facility failed to immediately notify the Department's Central Office of severe interruption of physical plant services. Verbal plan of correction: Supervisor went over the reporting requirements with the ED so that s/he knows what and when to report to the Department in the future.

Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but not limited to: Resident 1's medication error report dated 01/15/24, January 2023 Medication Administration Record (MAR), progress notes, and physician orders, indicated that on 01/15/24, s/he was given another resident's insulin dose in error. Resident 1's order was for 0.5 ml (3 mg) Sub-Q once every week on Monday, however, s/he was given another resident's Trulicity dose of 1.5 ml in error. During an interview, Staff 1 (ED) stated there were portable lights in the med room during a power outage and the MT reported the wrong dose was given because s/he couldn't see. The findings were reviewed with and acknowledged by Staff 1 on 03/11/24. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: Better lighting was provided to the med techs during the power outage. The Director of Nursing and the ED have been working on trainings with staff on policy and procedures as things come up, including ensuring the right medication before administering to the residents.

Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to maintain their fire detection and protection equipment. Findings include, but are not limited to: Compliance Specialist (CS) reviewed an email sent to Staff 1 (ED) dated 01/25/24 notifying him/her that the fire panel in Cottage C suffered a complete failure. In an interview on 03/11/24, Staff 1 (ED) stated the company requires 3 quotes before approving a purchase. S/He stated the part had been ordered and should be arriving on 03/22/24. Staff 1 also stated fire watch was being done every 15 minutes. On 03/11/24, findings were reviewed with and acknowledged by Staff 1. It was confirmed the facility failed to maintain their fire detection and protection equipment. Verbal plan of correction: The facility has ordered the part needed to fix the system which will arrive on 3/22/24. The repair is scheduled for 3/25/24. In the meantime, they have a safety plan in place. Fire watch is on every 15 minutes and is being reported to the Fire Marshall.

Based on interview and record review, conducted during a site visit on 11/28/23, it was confirmed the facility failed to notify the Department of any incident of abuse or suspected abuse for 1 of 3 sampled residents (#1). Findings include, but are not limited to: A review of Resident 1's records including Medication Administration Record (MAR), dated 11/2023, and progress notes, dated 10/2023 through 11/2023, indicated the following: * On 11/16/23 at 9:24 pm, a progress note entered stated: "Resident on alert for missed dental med. Resident [showed] no [complaints] of any this shift. Will continue to monitor." * On 11/22/23 at 9:45 pm, a progress note entered stated: "Resident on alert for missed dental medication. Zero [complaint] side effects of missing [antibiotic] before dental visit...." * On 01/05/23, "Cephlexin 500 mg capsule" was ordered to "give four capsules (2000 mg) by mouth 30 minutes prior to dental visit". There was no evidence this medication was provided. * The Compliance Specialist requested the records related to this incident. At 12:30 pm, a document containing only the name of the Resident 1 was provided. * At approximately 2:30 pm, an incident report was provided and stated "the medication had not been checked to verify it being here and available until after the [actual] dental appointment. It did get order and was administered as soon as it came to the facility." * At 5:20pm, a incident summary, dated 11/15/23, stated: "Date of Incident 11/14/23 at 2:32 pm; Resident did have a dental appointment scheduled for yesterday and per doctor's orders should of had an antibiotic administered to [him/her] before the scheduled appointment. The medication had not been properly ordered and was not available till 7:00 am this morning....." In an interview, Staff 1 (RN) stated Resident 1 had a dentist appointment on 11/13/23 and was prescribed an antibiotic to be given before his/her dentist appointment but he/she did not receive it. The incident report is incomplete and requested the involved staff member to complete the report. A review of facility's records, including policy and procedures, and documented investigations,  indicated the following: * The "Accidents, Incidents, and Unusual Occurrences" policy and procedure, dated 11/01/2014, indicated medications errors are considered an 'accident or incident' and 'whenever a accident or incident occurs: follow state and local laws regarding notification to authorities or agencies." * A review of 10 separate incident reports, dated 11/2023, lacked evidence of administrator's review. On 01/10/24, via telephone, these findings were reviewed with and acknowledged by Staff 16 (Administrator) who stated s/he started in the role on 12/04/23 and did not have access to the incident reporting system to review incident report but that has been corrected. Verbal Plan of Correction: Since these incidents, the facility has hired a new Director of Health Services Nurse and has been focusing on staff training and will provide staff training on abuse reporting.

Based on interview and record review, conducted during a site visit on 11/28/23, it was confirmed the facility failed to ensure service plans were updated quarterly and readily available to staff for 2 of 2 sampled residents (#s 1 and 2) and several unsampled residents. Findings include, but are not limited to: A review of the facility's service plan binders indicated eight residents service plans had not been updated quarterly. Resident 1's service plan was dated 08/24/23 and Resident 2's service plan was dated 07/27/23. During separate interviews on 11/28/23, Staff 1 (Regional Cooperate Nurse) stated, "There are only four service plans that are out of date, the other four have been completed. The service plans just have not been added into the binders for staff to view." Staff 2 (RN) stated, "No service plans have gotten completed since the old LPN quit around the end of October." It was confirmed the facility failed to ensure service plans were updated quarterly and readily available to staff. On 11/28/23, the findings were reviewed with and acknowledged by Staff 1 (Regional Corporate Nurse). Verbal plan of correction: Acting ED and new HSD will audit service plan binders to ensure service plans are all up to date.

I.

Based on interview and record review, conducted during a site visit on 11/28/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: A review of Resident 1's medication administration records (MARs) indicated the following medications not provided due to medication not on hand at the facility: ·Travoprost for Glaucoma- one drop dose in each eye daily at bedtime was not given from 10/15/23 through 01/25/23. ·Temazepam for insomnia, 15MG capsule was not given on 10/04/23. ·Systane nighttime eye ointment was not given from 10/12/23 though 10/15/23. ·Levothyroxine for hypothyroidism, 88MCG tablet one daily was not given on 10/27/23. During an interview on 11/28/23, Resident 1 stated, "I have not received some medications and/or have received my medication late on several occasions." During an interview on 11/28/23, Staff 2 (RN) acknowledge when s/he has run medication audit reports there have been several occasions where medication had been administered late or not have been administered. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. On 11/28/23, the findings were reviewed with and acknowledged by Staff 1 (Regional Cooperate Nurse). Verbal plan of correction: Retrain staff, disciplinary action if required. II. Based on interview and record review, conducted during a site visit on 11/28/23, it was determined the facility failed to carry out medication orders as prescribed for 4 of 4 sampled residents (#1, 5, 6, 7) whose records were reviewed. Findings include, but are not limited to: In an interview, Staff 2 (RN) stated eight residents missed their 7:00 pm medications on 11/08/23 in Cottage C after an "agency [staff member] popped meds for 7 pm, and another agency [staff member] was supposed to complete the pass but didn't." a. A review of  Resident 7's records including, medication administration record (MAR), dated November 2023, and progress notes, dated 12/2022 - 11/2023, indicated the following: * On 11/09/23 at 10:32 am, a progress note stated in the "[morning] medication technician (MT) observed a stack of medication cups with pills in them on top of the med cart this morning. Individual resident name was written on the cups. [S/He] called over RCC and RN. RCC contacted the agency MT who worked that shift and asked what happened. [S/he] stated that the agency MT asked [him/her] to pop all the 7pm medications before [s/he] left and [s/he] would come over and give them later. The agency MT who popped the medications also documented them as 'given' in the eMAR. The 2nd MT did not come pass them, as the pills were observed in the med cart this morning. No concerns with resident at this time...." * On 11/14/23 at 5:33 pm, a progress note stated "received fax from PCP regarding med error on 11/07/23..... [Resident 7's] trazodone was missed." * A facility incident report, dated 11/09/23 indicated on 11/08/23 at 7:00 pm, "agency med techs preparing medications" led to this med error. [Resident 7] was identified as having missed 1 medication. b.  A review of Resident 5's records including medication administration record (MAR), dated November 2023, and progress notes, dated 12/2022 - 11/2023, indicated the following: * "Carbamide Peroxide 6.5% Ear DP, instill 5 drops in the right ear twice daily for 5 days for impacted cerumen" was started on 11/15/23. This medication was not administered at 5 pm on 11/16, 11/17, and 11/18. The noted exception stated: "unable to locate medication", "med not available", and "medication is not in the box" respectively. * "Mucus relief ER 600 mg tablet. Give 1 tab by mouth twice daily for secretions" was started on 08/23/23. This medication was not administered at 7:00 pm on 11/13 and 11/14. The noted exception stated: "med not available." * A facility incident report, dated 11/27/23, indicated on 11/27/23 at 2:30 pm, Resident 5 was administered a dose of ear drops after the medication was discontinued. c. A review of Resident 6's records including medication administration record (MAR), dated November 2023, and progress notes, dated 12/2022 - 11/2023, indicated the following: * On 11/09/23 at 10:34 am, a progress note stated in the "[morning] medication technician (MT) observed a stack of medication cups with pills in them on top of the med cart this morning. individual resident name was written on the cups. [S/He] called over RCC and RN. RCC contacted the agency MT who worked that shift and asked what happened. [S/he] stated that the agency MT asked [him/her] to pop all the 7pm medications before [s/he] left and [s/he] would come over and give them later. The agency MT who popped the medications also documented them as "given" in the eMAR. The 2nd MT did not come pass them, as the pills were observed in the med cart this morning. No concerns with resident at this time...." * A facility incident report dated 11/09/23 indicated on 11/08/23 at 7:00 pm, "agency prepouring medications" led to this med error. [Resident 5] was identified as having missed 4 different medications which included "calcium carbonate/vitamin D3", "loratadine", "melatonin", and "trazodone". d. A review of Resident 1's records including Medication Administration Record (MAR), dated 11/2023, and progress notes, dated 10/2023 through 11/2023, indicated the following: * On 11/16/23 at 9:24 pm, a progress note entered stated: "Resident on alert for missed dental med. Resident [showed] no [complaints] of any this shift. Will continue to monitor." * On 11/22/23 at 9:45 pm, a progress note entered stated: "Resident on alert for missed dental medication. Zero [complaint] side effects of missing [antibiotic] before dental visit...." * On 01/05/23, "Cephlexin 500 mg capsule" was ordered to "give four capsules (2000 mg) by mouth 30 minutes prior to dental visit". There was no evidence this medication was provided. * The Compliance Specialist requested the records related to this incident. At 12:30 pm, a document containing only the name of the Resident 1 was provided. * At approximately 2:30 pm, an incident report was provided and stated "the medication had not been checked to verify it being here and available until after the [actual] dental appointment. It did get ordered and was administered as soon as it came to the facility." * At 5:20pm, an incident summary, dated 11/15/23, stated: "Date of Incident 11/14/23 at 2:32 pm; Resident did have a dental appointment scheduled for yesterday and per doctor's orders should of had an antibiotic administered to [him/her] before the scheduled appointment. The medication had not been properly ordered and was not available till 7:00 am this morning....." In an interview, Staff 1 (RN) stated Resident 1 had a dentist appointment on 11/13/23 and was prescribed an antibiotic to be given before his/her dentist appointment but he/she did not receive it. The incident report is incomplete and requested the involved staff member to complete the report. A review of facility's Med Error Incident reports, dated 11/09/23, indicated on 11/08/23, a total of seven residents missed medications for a total of 26 different medications that were missed. On 11/28/23, these findings were reviewed with and acknowledged by Staff 1 (Regional Director of Health Services) and Staff 2. Verbal Plan of Correction: All medication technicians will be re-trained and disciplinary action may be required.

Based on interview and record review, during a site visit conducted on 11/28/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, 3 of 3 sampled residents (#1, 2, 3). Findings include, but are not limited to: During an interview on 11/28/23, Resident 1 stated the following:   ·"I have received medications late due to lack of staff." ·"The staff take a long time to respond to call lights."   ·"I went 11 days without a shower." During an interview on 11/28/23, Staff 3 (MT) stated the following, ·"I had to clock in early today because the night staff were sitting on their phones and residents were yelling for assistance."   ·"It is often that residents left soiled."   ·"I feel the facility is short staffed during swing and night shift, not typically during the day."   ·"If staff are assigned to a building they shouldn't need to go to another building unless covering for breaks." A review of the posted staffing plan showed the following, ·Building A oDay, swing, and night: one MT and one CG   ·Building B oDay and swing: one MT and one CG oNOC: zero MT and one CG ·Building C oDay and swing: one MT and two CG oNOC: one MT and one CG A review of the shower schedule for Resident 1 and Resident 3 were scheduled to receive two showers a week. Resident 1 was to receive showers on Monday and Fridays. Resident 1's September through November 2023 shower sheets indicated 12 of 26 showers were not provided.  Resident 3 was to receive showers on Wednesday and Fridays. Resident 3s shower sheets for November 2023 indicated the resident received three of nine showers on 11/01/23, 11/15/23, and 11/24/23. A review of the call lights response log dated 11/05/23 and 11/28/23, indicated 39 call light response times that exceeded 15 minutes, 31 of which exceeded 20 minutes. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. On 11/28/23, the findings were reviewed with and acknowledged by Staff 1 (Regional Corporate Nurse). Verbal plan of correction: None was provided.

Based on interview and record review, during a site visit conducted on 11/28/23, it was confirmed the facility failed to verify that direct care staff had demonstrated satisfactory performance in any duty they were assigned. Findings include, but are not limited to: A review of Staff 13 (Caregiver), Staff 14 (Caregiver), and Staff 15 ' s (Caregiver) competency training checklists indicated each staff had not completed the necessary training. Staff 13 hired on 10/19/23, Staff 14 hired on 10/21/23, and Staff 15 hired on 10/24/23. In looking at Staff 14 and Staff 15's training records, training in lifting and transferring had not been completed. During separate interviews on 11/28/23, Staff 1 (Regional Corporate Nurse) acknowledged the facility had staff that had not completed all necessary training required. Staff 3 (MT) stated, "I did not believe caregivers nor med techs have received proper training." It was confirmed the facility failed to verify that direct care staff had demonstrated satisfactory performance in any duty they were assigned. On 11/28/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The new HSD and RCC will audit staff to see who has received training and who has not and have those staff complete the necessary training.

Based on interview and record review, conducted during a site visit on 10/13/23, it was confirmed the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse. Findings include, but are not limited to: A review of 18 suspected abuse or unexplained injury reporting forms with an incident date of 01/22/23 revealed the missed medications were discovered on 01/24/23 and reported to APS on 01/30/23. In an interview on 10/13/23, Staff 2 (RN) stated when the incidents occurred, s/he was new to the community and out in training for the week. S/he stated, "the med tech decided not to pass meds" and "I initiated the report". Staff 2 also stated that it took awhile to get ahold of the med tech and gather all the information once s/he had been informed of it. The findings were reviewed and acknowledged with Staff 1 (Business Office Manager) and Staff 2 on 10/13/23. It was determined the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse. Verbal pan of correction: Facility had an all-staff meeting after the incident and informed staff. MT training was done by RN on what and when to report. Initiating chain of command with new management so staff are aware of who to report to. They also have an RCC designated to each cottage now.

Based on interview and record review, conducted during a site visit on 10/13/23, it was confirmed the facility failed to provide three daily nutritious meals and snacks for the residents. Findings include, but are not limited to: In an interview on 10/13/23, Staff 4 (MT) stated Resident 1 gets fed in his/her room after the dining room is served first, and s/he was forgotten. S/he stated it was not something that occurred frequently, just the one time. Resident 1's service plan dated 07/27/23 revealed the resident was nonverbal and was a total assist for eating. An incident report dated 09/26/23 indicated that Resident 1's dinner tray was found in the microwave between 8:30 pm-9:00 pm, and it wasn't until 9:45 pm that someone was able to feed him/her dinner. The above information was shared with Staff 1 (Business Office Manager) on 10/13/23. S/he acknowledged the findings. It was confirmed that the facility failed to provide three daily nutritious meals and snacks for the residents. Verbal POC: The facility implemented meal attendance logs in order to ensure residents are getting their meals and snacks.

Based on interview and record review, conducted during a site visit on 10/13/23, it was confirmed the facility failed to ensure service plans were updated quarterly for 1 of 1 sampled resident (#4), whose service plans were reviewed. Findings include, but are not limited to: Compliance Specialist reviewed Resident 4's service plans dated 05/18/22 and 02/20/23. There was no indication the facility had completed any other service plans between the two dates. During an interview on 10/13/23 Staff 4 (MT) stated the RCC's did the quarterly updates. S/he stated they were not getting done in the past, but they are beginning to do them better. The findings were shared with Staff 1 via email on 10/18/23. It was confirmed the facility failed to ensure service plans were updated quarterly. Verbal POC: Facility has been working on getting service plans updated with change of management/staff. RCC's and RN are making sure they are being updated quarterly.

Based on interview and record review, conducted during a site visit on 10/13/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to: In review of the facility's ABST and resident roster on 10/13/23, all 42 residents were listed on the ABST. The facility was using the ODHS tool and the posted staffing plan matched the ABST generated staffing. Resident 1's last edit date was on 03/07/23 and Resident 2's last edit date was on 03/29/23. In a phone interview on 10/13/23, Staff 2 (RN) stated the prior ED was mostly responsible for updating the ABST, along with the RN and RCC. S/he stated they are working with the regional nurse to get that going. On 10/18/23, findings were reviewed via email with Staff 1 (Business office Manager). The facility failed to fully implement and update an ABST.

The findings of the on-site investigation, conducted on 10/13/23, are documented in this report. The investigation 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. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the three cottage kitchens and food storage areas on 7/11/23 at 10:15 am through 2:30 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Walls throughout kitchens; * Interior of reach in coolers and freezers; * Reach in cooler and freezer handles; * Stainless steel shelving; * Flooring in door thresholds, corners, edges, between and under equipment; * Ceiling, vents and fire sprinklers; * Interior and exterior of all plastic drawers; * Interior of reach in fridges and freezers; * Industrial can openers and housings; * Interior of ovens; * Interior of microwaves; * Industrial and countertop mixer; * Ceiling vents, fire sprinklers, light fixtures; * Mobile and stationary heating carts; * Cottage B hood vents; and * Floor in electrical room where freezer located. b. The following areas were found in need of repair: * Caulking behind hand washing sink; * Bottom shelves of metal tables rusted and corroded; * Large metal grate to grease trap by ware washer was rusted/corroded; * Holes in walls where large freezer located; * Ceiling damage in room where large freezer located; * Floor seam in Cottage C split/gapped; and * Microwave in cottage C damaged on ceiling with visible rust. c. Multiple cutting boards were found damaged and in poor repair. d. Multiple potentially hazardous food items found not labeled or dated. Multiple food items found past their use by dates. Some food items found with visible food/water separation and or mold. Food items not separated when stored as required. e. Facility not using pasteurized eggs for undercooked egg foods like poached, soft fried eggs. f. Staff member preparing and/or serving food did not have hair/facial hair effectively restrained as required. g. Scoops were found stored in bulk food item bins. h. Clean dishes were found stored on dirty towels. i. Kitchen staff observed to not wash hands after potentially contaminating hand when switching serving from one kitchen to the next. Kitchen staff observed handling clean dishes with potentially contaminated hands and touching food contact surfaces of those dishes. j. Kitchen staff observed to have painted nails and was not wearing gloves when preparing or serving food. k. The incorrect menu was posted for residents in Cottage C. Two residents receiving pureed food were served only the protein portion for their lunch (chicken). No starches/vegetables or dessert was offered. Kitchen staff stated s/he was not used to serving lunch for Cottage C. Surveyor reviewed above areas with Staff 2 (Dining Services Manager) and s/he acknowledged the identified areas.  At approximately 2:00 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Executive Director). S/he acknowledged the areas.

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observation of the three cottage kitchens and food storage areas on 10/19/23 at 12:15 am through 1:15 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Ceiling vents, light fixtures, smoke detectors; * Industrial can openers and housings; * Interior of ovens; * Range top and grills; and * Interior of microwaves. b. The following areas were found in need of repair: * Bottom shelves of metal tables rusted and corroded; and * Floor seam in Cottage C split/gapped. Food particles and debris observed accumulating. Surveyor reviewed above areas with Staff 2 (Dining Services Manager) and s/he acknowledged the identified areas.  At approximately 1:15 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Executive Director). S/he acknowledged the areas.

Facility will implement routine (daily, weekly  & Monthly) cleaning schedule to address spills, splatters, loose food and trash debris, dirt, dust, black matter and grease, to include ceiling vents, light fixtures, smoke detectors, industrial can openers and housings, interior of ovens, range tops and grills and interior of microwaves. A cleaning log with be signed & dated and maintained by the Culinary Services Director & Maintenance Director for compliance. Metal tables will be replaced with new tables. Culinary Services Director and Maintenance Director will coordinate delivery, removal and installation of new tables. Floor seam has been temporarily repaired using epoxy until our vendor can come to the community to do a full and complete repair. Full repair will be completed by qualified contractor. During survey, there was a hole identified in the ceiling where some wiring was passing thru. We were asked to seal off these type of holes. Hole has now been sealed with caulking. We will continue to look for and fix any other holes similar to this to ensure compliance. Culianry Services Director and Maintenance Director will monitor this along with Executive Director.

Based on observation, record review, 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.

Based on observation, record review, and interview, 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 C240.

ED will opperate memory care community in compliance with OAR 411-057-0140

Based on interview, observation, and review of documentation, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

Community has implemented this POC and submitted to licensing within the allotted 10-day time frame. Community ED will inspect and review POC with appropriate department heads weekly to ensure all deficiencies are corrected by the compliance date provided in the POC.

The findings of the kitchen inspection, conducted 7/11/23, are documented in this report. It was determined the facility was 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.

The findings of the re-visit to the kitchen inspection of 07/11/23, conducted 10/19/23, 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 07/11/23, conducted 12/27/23, are documented in this report. It was determined the facility was 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 interview and record review, it was confirmed that the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. Findings include: In interviews on 12/27/22, Staff #2-4 stated that paper incident reports are being filled out for staff as an incident occurs. Staff will then send it to the administrator who will report abuse or neglect. Staff #1 stated that staff will call and let them know about incidents and they will tell them if it is reportable. Staff #5 stated that if there is a fall, it is documented in the progress notes, incident report and family and physician will be informed. Higher up staff will call APS. CS reviewed of the facility's policy and procedures for incident reports, reporting abuse and neglect, and Resident #1-3s service plans, completed incident reports and progress notes for December 2023. Resident #1 has an incident report dated 12/16/22 that reports an unwitnessed fall involving another resident (both are memory care residents). Incident report states that the Resident #1 was sitting in their wheelchair when the other resident was trying to get the resident out of the chair. Resident #1 slipped onto the floor. No other documentation or follow up regarding how abuse or neglect was ruled out or whether or not this was reported to APS. Incident Report has a status of incomplete with no review or updated of service plan. Resident #2 (memory care resident) has 6 incident reports for December 2022 reporting unwitnessed falls and all of the statuses are documented as  " incomplete "  with no review and update to resident's care plan as needed by the HSD. An incident report on 12/15/22 reported that resident  "complaints that only his/her bottom hurt because of his/her sores. They had reopened " . No detailed investigation done to rule out abuse or neglect and nothing documented about reporting to APS. Another incident on 12/15/22, Resident #2 was found on the floor and was yelling  " the other guy left him/her "  Resident was agitated and refused vitals to be checked. No other documentation regarding investigation to rule out abuse or neglect or reporting to APS. The above information was shared with Staff #1 on 01/09/23 via email.

Based on interview and record review, it was confirmed that 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. Findings include: In separate interviews on 12/27/22, Staff # 2-4 stated that if a resident had orders to monitor meals, they would document that on the MAR. They do not have any concerns about this. Staff #5 stated that if there is a fall or an incident, an incident report would be filled out, it would be documented in the progress notes, the nurse would need to evaluate the resident for changes and alert charting would be done. CS reviewed Resident #1-3s service plans, progress notes for December 2023, medication administration records (MAR) for January 2023, incident reports for December 2022, and policy and procedures for incident reports and change of condition and monitoring. Resident #1 and Resident #2 both had falls document in incident reports for December 2022, without any assessments documented, interventions put in place, or alert charting in the progress notes. No temporary or permanent updates to the service plans were made. Resident #2 has notes in the incident reports about a bed alarm but nothing documented in the service plan or progress notes about when this was implemented. The above information was shared with Staff #1 on 01/09/22 via email.

Based on interview, observation and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include: In an interview on 12/27/22, Staff #1 stated that the facility has changed ownership on 12/01/22 and they are now using the state ABST. Their current census is 44, however, they do need to make some updates with recent changes. CS observed that the facility is staffing per their current staffing plan and ABST during walkthrough on 12/27/22. CS reviewed staffing schedules for December 2022, posted staffing plan, and service plans for Residents #1-3. CS determined that there are a total of 43 residents listed on the ABST with 3 residents that have incomplete information filled out and 1 resident that didn't have any information filled out at all. The above information was shared with Staff #1 on 12/27/22, who acknowledged the findings. Plan of correction: Facility to finish updating the ABST and update their posted staffing plan with any changes. Admin has an ABST call on 12/28/22 regarding their ABST.

Based on interview and record review, it was confirmed that the facility failed to provide records to the Department upon request. Findings include: CS requested documents from the facility for an investigation on 12/27/22 and did not receive them. Reviewed emailed requests dated 12/30/22, 01/06/23, and 01/09/23 following up on the requests for documentation still needed. The facility is not providing documentation timely upon request. Per phone conversation with Staff #1 on 01/03/23, they stated they would get the documents sent right away and did not see the email from 12/30/22 with the deadline of 01/02/23. On 01/04/23 Staff #2 called CS to ask what documents were requested again and stated they would have them ready for pickup ASAP. On 01/06/22, CS emailed and called the facility and was told the documents would be available for pickup before 3:30pm. Documents were again not ready. The above information was shared with Staff #1 via email on 01/09/23.

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 12/27/2022.  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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview, observation and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include: CS reviewed the posted staffing plan, staff schedules for September 2022,  and service plan for Resident #1. The ABST was not reviewed as it has not been implemented. CS observed that the facility is staffed per the schedule, and staffing plan on 10/07/22. The above information was shared with Staff #1 on 10/07/22 and via email on 10/17/22, who aknowledged that they do not have an ABST. In an email response on 10/17/22, Staff #1 reported that they do not have a completed ABST, but will be working on it right away. Plan of correction: The wellness team will get started on completing/updating the ABST.

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 10/7/2022.  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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation, record review and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchens, food storage areas, food preparation, and food service on 08/15/22 revealed: * Splatters, spills, drips, and debris noted on: - Cage and blades of fan blowing from window into the kitchen; - Carts used to deliver food; - Shelving throughout kitchen; - Interiors of reach in refrigerators; - Hand-washing sinks; - The blade and casing of can openers; - Microwave interiors; - Interior of the ovens; - The deep fat fryer; - Range tops; and - Interior of drawers, cupboards and cabinets. * Hand-washing sinks were used to hold staff personal items. * There was not a small diameter probe thermometer available  to measure thin foods. * Garbage cans in food preparation areas did not have lids for when not in use. * There was no documented evidence of staff monitoring the temperatures of food prepared in the kitchen. * No evidence of monitoring of the sanitizer levels of the low temperature dish sanitizer. Staff were not able to locate sanitizer strips. The supplier of the dish sanitizer was contacted and strips were provided the same day. * A bag of raw chicken was observed in a container of standing water. Staff 2 immediately began running cold water over the chicken. * Staff were observed to not change gloves between tasks during the preparation of lunch or sanitize hands upon entering the kitchen. * Caregiving staff assisting with meal service and delivery were not using aprons. The areas in need of cleaning and repair were reviewed with Staff 1 (Administrator) and Staff 2 (Dietary Services Manager).  They acknowledged the findings.

1. The kitchen received a deep clean, personal items were removed from sink, lids placed on garbage cans, and additional thermometer ordered. 2. The dining services staff will receive additional training on the kitchen Cleaning Schedule, Food Temperature Logs, Food thawing processes, and proper glove use. The caregiving staff will receive additional training on wearing aprons when assisting with meal service. 3. The Dining Services Director will review this area weekly per the Quality Assurance - Dining Review Schedule. 4.  The Executive Director will be responsible for ensuring 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 C 240.

Refer to C 240.

The findings of the kitchen inspection, conducted 08/15/22, 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 08/15/22, conducted 11/02/22, are documented in this report. It was determined the facility was 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 the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 11/15/21 and 11/17/21, the facility's three kitchens, located in Cottages A, B and C, were observed to need cleaning and repair in the following areas: a. Food spills, splatters, debris, dirt, dust, and black matter was observed on or underneath the following: * Metal countertops and shelving units; * Plastic storage bins; * Storage shelves in the dry food storage area; * Flooring underneath metal shelving, stoves, and sinks; * Doors; and * Ceiling vents. b. The following areas needed repair: * Doors, door frames and storage shelves had areas of chipped paint, gouges, and cracks; and *Overhead lighting fixtures were cracked in Cottages B and C. The areas that required cleaning and repair were discussed with Staff 2 (RN) and Staff 3 (Regional Operations Specialist) and observed with Staff 11 (Cook) on 11/17/21. They acknowledged the findings.

1. The kitchens will receive a deep clean. Lighting fixtures will be replaced and chipped paint, gouges, and cracks will be repaired. 2. The Dining Services Director and Executive Director will receive additional training on Kitchen Cleaning Schedule Policy and Procedure. 3. The Dining Services Director will review weekly per the Quality Assurance Review Schedule - Dining Services. 4. The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations included all required elements for 1 of 1 sampled resident (#5). Findings include, but are not limited to: Resident 5 was admitted in 08/2021 with diagnoses including arthritis. Review of the resident's new move-in evaluation, dated 08/27/21, revealed it failed to include the following required elements: * Interests, hobbies, social and leisure activities; * History of treatment and effective non-drug interventions related to mental health; * Personality, including how the person copes with change or challenging situations; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. The need to ensure new move-in evaluations included all required elements was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Operations Specialist) on 11/17/21. They acknowledged the findings.

1. The Resident Evaluation Tool has been reviewed and updated as needed to include all elements required per the Resident Move-In and Eval: Res Evaluation. 2. The Executive Director, Wellness Director(s) and Wellness Nurse will receive additional training on the Move-In Evaluation Tool.     3.  The Executive Director will review this area with each move-in. 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 ensure service plans were reflective of residents' current status and failed to provide clear instruction to staff for the provision of care for 2 of 3 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2019, with diagnoses including Alzheimer's Disease. Review of Resident 2's service plan, dated 10/22/21, interviews with staff, and observations of the resident revealed the service plan was not reflective of the following: * Two-person transfers; * Use of wheelchair for mobility; * Assistance for bed mobility; and * Knee brace. The need to ensure service plans were reflective of the resident's current status was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (Operations Specialist) on 11/17/21. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 05/2021 with diagnoses including vascular dementia and multifocal leukoencephalopathy. The resident's record, including the most recent service plan (dated 07/27/21), quarterly evaluations dated 08/06/21 and 10/08/21, change of condition evaluation dated 11/09/21, and outside provider notes from 08/20/21 through 09/15/21, were reviewed, observations were made, staff and the resident's private caregiver were interviewed. A review of Resident 4's 07/27/21 service plan revealed it was not reflective of the resident's current status and care needs or did not provide clear instructions to staff in the following areas: * Hospice status; * Catheter flushes; * Use of protective footwear; and * Feeding. There were no interim service plans related to those areas provided for the resident. The need for service plans to be reflective of residents' current status and care needs and to provide clear direction to staff regarding the provision of care was discussed with Staff 1 (Executive Director) and Staff 3 (Operations Specialist) on 11/18/21. They acknowledged the findings.

1.  The Service Plan for resident #2 and resident #4 were updated to reflect the residents current status and care needs and to provide clear direction to staff. 2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Service Plan Policy. 3. The service plan schedule will be reviewed weekly per the Quality Assurance - Health Services Review Schedule. 4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure residents were monitored based on their evaluated needs and short-term changes of condition were monitored to resolution for 2 of 3 sampled residents (#s 2 and 4) who experience short-term changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2019, with diagnoses including Alzheimer's Disease. Review of Resident 2's current service plan, interim service plans, 08/20/21 through 11/14/21 progress notes, fall investigations, and RN assessments revealed the following: Resident 2 experienced 18 falls between 10/01/21 and 11/11/21. The facility failed to consistently document what fall prevention interventions were in place at the time of the falls and failed to monitor the effectiveness of the interventions. The need to monitor the effectiveness of fall prevention interventions was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (Operations Specialist) on 11/17/21. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 05/2021 with diagnoses including vascular dementia and multifocal leukoencephalopathy. The resident's record most recent service plan dated 07/27/21, progress notes from 08/17/21 through 11/15/21, and evaluations were reviewed, observations were made, and staff and the resident's private caregiver were interviewed. Progress notes identified multiple short-term changes of condition: *08/25/21, 09/21/21, 10/06/21, and 10/25/21: the resident started an antibiotic; and *11/09/21, the resident returned from the hospital. Although the documentation indicated those short-term changes of condition were monitored, there was no documented evidence they were resolved. The need to monitor short-term changes of condition through resolution was discussed with Staff 1 (Executive Director) and Staff 3 (Operations Specialist) on 11/18/21. They acknowledged the findings.

1. The facility has documented the review of effectiveness for fall prevention interventions on resident #2 and has documented the resolution of short term changes of condition for resident #4. 2.  The Executive Director and Wellness Nurse will receive additional training on the Change of Condition Policy and Procedure. 3.  The Wellness Nurse will review this area weekly per the Quality Assurance - Clinical Review Schedule. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#3) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: During the acuity interview on 11/15/21, Resident 3 was identified as receiving insulin injections by unlicensed facility staff. A review of Resident 3's delegation records on 11/17/21 identified the following: a. Resident assessments did not consistently include the following: * How it was determined his/her condition was stable and predictable; and * A rationale for how frequently s/he would be re-assessed. b. Initial delegation documentation for Staff 13 (MT) and Staff 17 (MT) lacked the following: * A rationale the task could be safely delegated to the caregiver; * How it was determined the caregiver was competent to safely perform the task; * A rationale for the frequency the resident would be re-assessed; * A rationale for the frequency the caregiver would be re-evaluated; and * An indication the RN took responsibility for delegation tasks and ensured supervision would occur for as long as the RN was supervising performance. c. Re-delegation documentation for Staff 13 and Staff 17 lacked the following: * An assessment of the resident which included how it was determined the resident remained stable and predictable; * Documentation of how it was determined the caregiver remained capable and willing to safely perform the task; and * A rationale for how frequently the caregiver would be re-evaluated. d. Staff 13 and Staff 17 were initially delegated by Staff 2 (RN) on 03/09/21 and 03/08/21, respectively. Documentation indicated they would be re-assessed in 180 days /6 months. Records revealed the RN re-evaluated Staff 13 on 06/03/21 and Staff 17 on 06/07/21. OSBN Division 47 states re-delegation must be "within at least 60 days from the initial date of delegation." In an interview on 11/18/21, the RN indicated she worked at the facility previously, had delegated those two MTs in the past and was familiar with their abilities, and didn't think she needed to re-evaluate them as frequently as staff she had not worked with before. Delegation records and the need to ensure delegation of special tasks of nursing care were documented in accordance with OSBN Division 47 were reviewed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (Operations Specialist) on 11/18/21. They acknowledged the findings.

1. All current delegation records will be reviewed to ensure appropriate documentation including review schedules. 2. The Executive Director and Wellness Nurse will receive additional training on Delegation rules per the OSBN Division 47 rules. 3. The Wellness Nurse will review this area weekly per the Quality Assurance - Clinical Review Schedule. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure physician orders were followed as written for 1 of 5 sampled residents (#3) whose MARs and physician orders were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 11/2019 with diagnoses including diabetes. The resident's clinical record was reviewed, including 10/01/21 through 11/15/21 MARs, physician orders, and a medication error report for 10/12/21, and staff were interviewed. The following was identified: a. During the acuity interview on 11/15/21, Staff 2 (RN) reported the resident had recently been sent to the emergency department because of a medication error. * Resident 3 was prescribed the following: * Humalog 100U/ML (insulin), 9 units subcutaneously every morning with breakfast; *Humalog 100U/ML, on a sliding scale with each meal, based on CBG; and *Tresiba Flextouch 100U/ML (insulin), 25 units subcutaneously every morning. On 10/12/21 the resident received 27 units of Humalog instead of the scheduled 27 units of Tresiba. The 27 units of Humalog was in addition to the scheduled 9 units the resident received that morning. * The resident's blood sugar level dropped as low as 63, which was documented in a progress note on 10/12/21 and the resident was transported to the emergency department for observation. * Resident 3 returned to the facility from the emergency department on 10/12/21 in the afternoon. Records indicated the medication error was immediately reported by the MT, was self-reported to the local Adult Protective Services office the same day, and there was no further outcome for the resident. In an interview on 11/16/21, the RN reported she had provided extra training to the medication technician responsible for the error. b. The resident was prescribed Humalog 100U/ML with each meal, based on his/her CBG, on the following sliding scale: - 0-150 = 0 units - 151-175 = 1 unit; - 176-200 = 2 units; - 201-225 = 3 units; - 226-250 = 4 units; - 251-275 = 5 units; - 276-300 = 6 units; - 301-325 = 7 units; - 326-350 = 8 units; - 351-375 = 9 units; - 376-400 = 10 units; - 401-425 = 11 units; - 426-450 = 12 units; - 451-476 = 13 units; - 476-500 = 14 units; and - 501-525 = 15 units. The MARs indicated the following errors occurred: * 10/19/21, 7:30 am: CBG 179; 11 units were administered instead of two (2) units. * 10/24/21, 11:30 am: CBG 195; one (1) unit was administered instead of  two (2) units. * 10/27/21, 11:30 am: CBG 174; two (2) units were administered instead of one (1) unit. * 11/04/21, 11:30 am: CBG 200; three (3) units were administered instead of two (2) units. In an interview on 11/16/21, Staff 1 (Executive Director) and Staff 2 indicated they were unaware of the errors. On 11/17/21 Staff 2 indicated she had provided additional training to the medication technicians responsible for the errors. The need for physician orders to be followed as written was discussed with Staff 1 and Staff 3 (Operations Specialist) on 11/18/21. They acknowledged the findings and reported additional training would be provided to all medication technicians.

1. The Medication Administration Record for resident #3 was audited with additional training provided to the Med-Tech regarding following sliding scale insulin orders. 2. The Med-Tech's will receive additional training on resident specific parameters regarding sliding scale insulin. 3. The Wellness Director and/or Wellness Nurse will complete MAR audits weekly per the Quality Assurance Review Schedule - Health Services. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternate months from fire drills and to ensure a written fire drill record was maintained and included all required components in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records for May 2020 through October 2021 were reviewed during survey. a. There was no documented evidence the facility provided fire and life safety instruction to staff on alternate months from fire drills. b. The following required components were not consistently documented in fire drill records: * The escape route used; and * Problems encountered and comments relating to residents who resisted or failed to participate in the drills. The need to ensure fire and life safety instruction was provided to staff on alternate months from fire drills and to ensure fire drill records included all required components was discussed with Staff 1 (ED), Staff 3 (Regional Operations Specialist), and Staff 21 (Maintenance Director) on 11/17/21. They acknowledged the findings.

1. The community will complete fire drills life safety instruction at least every other month. 2. The Executive Director and Mainteance Director will receive additional training on the Fire Life Safety Training & Drill Flow Chart and the Fire Drill Checklist. 3. The Maintenance Director will review monthly per the Quality Assurance - Maintenance Review Schedule. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to provide evidence that alternating evacuation routes were used during fire drills and residents received annual fire and life safety instruction. Findings include, but are not limited to: Review of fire and life safety records for May 2020 through October 2021 revealed the facility lacked documented evidence of the following: * Alternate exit routes used during fire drills; and * Annual fire and life safety instruction for residents that included 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. The need to ensure alternate exit routes were used during fire drills and fire and life safety instruction was provided to residents at least annually was discussed with Staff 1 (ED), Staff 3 (Regional Operations Specialist), and Staff 21 (Maintenance Director) on 11/17/21. They acknowledged the findings.

1. All assisted care resident records will be reviewed to ensure completion of the new resident safety orientation checklist has been completed. 2. The Executive Director and Mainteance Director will receive additional training on the New Resident Safety Orientation Checklist and the Fire Life Safety Training & Drill Flowchart. 3. The Maintenance Director will review with each new move-in and annually per the New Resident Checklist and Quality Assurance - Maintenance Review Schedule. 4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to: A tour of the facility on 11/15/21 and 11/16/21 revealed the following areas were in need of cleaning  and repair: * Carpets in common areas in all cottages had diffuse stains; * Multiple resident carpets viewed from the hallway in Cottage C were stained; * Laundry rooms in all three cottages had an accumulation of dirt, smudges, and trash on the floors; drips on walls behind and at bases of hoppers; holes in drywall; chipped paint on walls and doors; and the laminate counter in Cottage A was cracked; * Doors and walls throughout the three cottages had chipped paint; * Multiple coffee tables had exposed wood on the tops; * Multiple benches had scrapes and exposed wood on the legs; and * The caulking at the base of Cottage B, Room 8's toilet and shower was cracked. The environment was toured with Staff 1 (Executive Director) and Staff 21 (Maintenance Director) on 11/17/21. They acknowledged the findings.

1. An internal building inspection will be completed with identified concerns addressed by cleaning or repairing the items. 2. The Executive Director and Maintenance Director will receive additional training on the Quarterly Building Inspection. 3. The Maintenance Director will review the areas monthly and then meet with the Executive Director and review quarterly per the Quality Assurance - Maintenance Review Schedule. 4. The Executive Director will ensure the corrections are completed and monitored.

Based on observation and interview, the facility failed to ensure  fireplace doors did not exceed 120 degrees Fahrenheit.  Findings include, but are not limited to: The environment was toured on 11/17/21 with Staff 1 (Executive Director) and Staff 21 (Maintenance Director). At the time of the tour, the glass doors of the fireplace located in a common resident area in Cottage C measured 122 degrees Fahrenheit with the surveyor's thermometer. The glass doors of the fireplace in the lobby of Cottage B measured 121 degrees on the same date. Staff 21 turned the fireplaces off at that time. Staff 1 stated she would direct staff not to use the fireplaces in any of the cottages until she was able to obtain screens that kept the temperature at a safe level. The need to ensure fireplace doors did not exceed 120 degrees Fahrenheit was discussed with Staff 1 and Staff 21 during the tour on 11/17/21.  They acknowledged the findings.

1. Fireplace screens have been placed in the front of fireplaces in the lobby of each cottage. 2. The Executive Director and Maintenance Director will receive additional training on the Quarterly Building Inspection - Fireplaces. 3. The Maintenance Director will take the temperature monthly and then meet with the Executive Director and review quarterly per the Quality Assurance - Maintenance Review Schedule. 4. The Executive Director will ensure the corrections are completed and monitored.

Based on 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, C420, C422, C513 and C540.

Refer to C240, C420, C422, C513, and C540.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 veteran staff (#s 5 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 11/17/21 and revealed the following: * Staff 5 (CG) and Staff 13 (MT) were hired 04/17/19 and 10/31/18, respectively. There was no documented evidence either 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 3 (Operations Specialist) on 11/18/21. They acknowledged the findings.

1. All employee records will be reviewed to ensure 16 hours of annual in-service training with a minimum of 6 hours related to dementia care have been completed. 2. The Executive Director and Business Office Director will receive additional training on annual in-service requirements. 3. The Business Office Director will review monthly per the Quality Assurance - Business Office 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 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, C270, C282 and C303.

Refer to C252, C260, C270, C282, and C303.

The findings of the re-licensure survey conducted 11/15/21 through 11/18/21 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 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 11/18/21, conducted 03/02/22, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.