Settler's Park Memory Care Community

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to: Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control. Resident 1 was admitted to the MCC in 2013 with diagnoses including incontinence. On 03/10/26 at 9:20 am, the surveyor obtained permission and observed a CG provide ADL care to Resident 1. During the observation, the CG donned gloves, helped the resident onto the toilet, removed the resident’s soiled pants and placed them on the bathroom floor, and wiped urine from the resident’s perineum. Wearing the same soiled gloves, the CG touched the resident's clean clothing, clean incontinence brief, bathroom door handle, sink handles, key/lock to bins in bathroom, wheelchair handles, and a walkie-talkie. After care was completed, the CG removed the soiled gloves and walked to the common bathroom in the hallway to wash her hands. The need to ensure staff consistently used effective universal precautions was discussed with Staff 1 (Executive Director) and Staff 2 (MCC Administrator) on 03/11/26 at 11:00 am. They acknowledged appropriate infection control practices were not implemented.

1. All direct care staff will be assigned an online Oregon Care Partners class on infection control and prevention with a 4.30.2026 due date. An in-person training will be conducted and documented with all direct care staff regarding proper infection control, PPE use and general sanitation protocols when providing personal care to residents. 2. MCA will conduct regular observations of direct care staff including Care Partners and Med Techs to ensure that proper infection prevention protocol and PPE use is being followed. Additional 1:1 training will be provided to direct care staff by MCA as necessary if any deficiencies are noted. 3. MCA will conduct and record obervation of 2 direct care staff including 1 Care Partner and 1 Med Tech on a monthly basis. Results will be discussed during monthly QA meeting with Community Administrator and MCA present. 4. MCA will be responsible for monitoring infection control and ensuring that additional training is provided as needed with assistance from Community Administrator.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept in good repair. Findings include, but are not limited to: Observations of the facility on 03/09/26 and 03/10/26 revealed the following: * Rooms 3, 5, 6, 7, and 10 had scraped doors and/or jambs; * The common bathroom, located near the television room, had several scrapes to the door jamb. The wall adjacent to the toilet had several small holes near the toilet paper holder; * The kitchenette had peeling paint above the sink. The laminate backsplash was coming apart from the wall; and * Room 5 had gouged wall corners near both closets. The bathroom had a scraped door and jamb, discolored caulking and flooring surrounding the toilet, gouged paint and missing drywall near the shower and sink, and cove base coming apart from the wall in several places. The surveyor toured the environment with Staff 1 (Executive Director), Staff 2 (MCC Administrator), Staff 3 (Memory Care Coordinator), and Staff 4 (Maintenance) on 03/11/26 at 10:00 am. They acknowledged the above areas needed to be repaired.

1. With a due date of 4.30.2026, Apartment doors # 3, 5, 6, 7, and 10 will be re-painted. New toilet paper holder will be purchased for common area bathroom and holes will be patched. Damage to Apartment #5 and bathroom including gouged wall, missing drywall by shower, peeling cove base, and discolored caulk will be repaired. Backsplash in Dining area will be repaired. 2. Condition of doorjambs, common areas, apartments etc. will be monitored during regular walk-throughs with Maintenance Director and Community Administrator to evaluate ongoing condition of physical environment. Work orders will be entered by Community Administrator detailing any new damage or issues that need repair. 3. Monthly walk-throughs will be completed to ensure all areas of the community are in good repair. Results will be presented monthly at QA meetings, with issues being addressed through the work-order process as they arise. 4. Maintenance director will monitor and Campus Administrator will ensure completion.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

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 C160 and C513.

Please see each related POC regarding noted violations: (C160 & C513)

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired caregiving staff (#s 6 and 7) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to: Training records, reviewed on 03/10/26, revealed the following: a. Staff 6 (MT/Care Partner) was hired on 09/25/25. There was no documented evidence Staff 6 demonstrated competency in job duties within 30 days of hire and prior to working independently in the following areas: * Providing assistance with ADLs; and * Medication Administration. The surveyor informed Staff 2 (MCC Administrator) that Staff 6 could not administer medications until documented training was completed. She acknowledged and stated documented medication training would be completed for Staff 6 before she administered medications. b. Staff 7 was hired on 01/29/26. There was no documented evidence Staff 7 demonstrated competency in job duties within 30 days of hire and prior to working independently in the following areas: * Providing assistance with ADLs. The need to ensure newly hired staff completed required trainings within 30 days of hire was reviewed with Staff 1 (Executive Director) and Staff 2 on 03/11/26 at 11:00 am. They acknowledged the findings. ?

1. Demonstrated competency evaluation and checklist has been completed with identified staff. Full audit to be conducted by 04.15.26 to identify any missing demonstrated competency evaluations. Competency evaluations to be completed with staff no later than 04.30.2026. 2. System correction moving forward: CPs will not be placed on the floor independently until competency evaluation and checklist is completed. 3. Training system will be evaluated monthly at 1:1 meetings between MCA and Community Administrator. Tracking of checklist to completed by the community's MCA. 4. Community Administrator and MCA to be responsible for ensuring that team members do not work independently without required training checklist. MCA will be responsible to track competency checklist completion, pre-service and annual training.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

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 ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 12/16/25 identified the following: Dishwashing Area: * There was debris observed on top of the warewashing unit; * The glass face over one of the temperature gauges on the warewashing unit was cracked; and * The faucet located in the middle of the three-compartment sink had a constant drip. Front Food Prep Area: * The oven, stove, handles, left side of the oven, and stainless steel backsplash of the stove had brown and black matter and were sticky to the touch; * The industrial can opener had food debris observed on the blade; * There were drips, spills, and debris located on the insides and outsides of the stainless steel cupboards under the steam table; * There were splatters of dried food observed on the cork board; * The fan located to the right of the stove had a layer of dust present and was observed to be on during the meal prep; and * Multiple cutting boards, including the one connected to the steam table, had deep gouges, thus were not cleanable surfaces. Back Food Prep Area: * The light on the ceiling to the left of the entrance was not operable; * The handwashing sink had brown debris around the faucet and in the basin; * The wall under the food prep sink had a circular hole (approximately two inches in diameter) and a rectangular shaped hole (approximately four inches by three inches) observed; * The drain under the food prep sink had black and brown matter observed on the covering; * The industrial sized mixer had dried-on food splatters and areas where the paint was chipping off of the machine; * The vent in the ceiling of the hall had a layer of dust observed; and * There were two wheeled carts with uncovered desserts on the top shelf located in the hall under the dusty vent. Walk-In Refrigerator and Freezer: * Fans located in both units had a layer of dust observed. Front Beverage Area: * The interior of the microwave had a piece of material peeling off of the top and material was pulling off of the door window; * Approximately 14 inches of baseboard was missing under the handwashing sink; * A large, light brown wheeled cart was observed to have a crack in the top shelf, deeming it an uncleanable surface; and * The drain underneath the ice machine had a build-up of black debris observed. Throughout the Kitchen: * Walls were observed to have food drips, splatters, and debris accumulation; * Doors and door frames were observed to be gouged and had missing paint, deeming them uncleanable surfaces; * There were brown and black particles observed inside the ceiling light coverings; * The light fixtures that were located close to ceiling vents had a layer of dust observed; * There was dark matter build-up where the floor and equipment met; * Baseboards had an accumulation of black build-up; and * There was black build-up on the flooring under and around the feet of table legs. The kitchen was toured with Staff 1 (Community Administrator) and Staff 2 (Dining Services Director) on 12/16/25. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1, Staff 2, and Staff 3 (Memory Care Administrator) on 12/16/25 at 1:16 pm. They acknowledged the findings.

1. For areas identified in the deficiency, the areas with splatters, spills, debris and drips were cleaned immediately, including fans. Corkboards and damaged cart were removed immediately. A replacement mixer was already purchased, and the old mixer will be removed. A device was purchased to eliminate grooves on cutting boards. Maintenance dept. will address door frames, ceiling lights, holes in walls, dripping faucet, baseboard. 2. All areas noted in the deficiency regarding cleaning will be added to a cleaning schedule in the kitchen and kitchen staff will be trained on their cleaning responsibilities. 3. Dining Services Director will evaluate kitchen cleaning/repair needs weekly. Community Admin and Dining Services Director will evaluate needs monthly as part of ongoing quality assurance program. 4. Dining Services Director and Community Administrator will be responsible for monitoring.

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 observation 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

see C 240

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 facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the change of ownership survey, conducted 08/26/24 through 08/29/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope and number of citations. Refer to deficiencies in the report.

1. MC Administrator has enrolled in NurseLearn for Administrators. MC Administrator will also complete 2 hour Oregon Care partners "Foundations of Older Adult Care" course by 9.30.24. 2. Weekly meetings with Settler's Park Assisted Living/Campus Administrator and MC Administrator to review identified areas outlined throughout the report. 3. Bi-weekly review with Settler's Park Assisted Living/Campus Administrator, Regional Wellness Director, and Regional Director of Operations to evaluate until substantial compliance is achieved. 4. Settler's Park Assisted Living/Campus Administrator and Regional Director of Operations.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents related to the MCC entry door for 1 of 1 sampled resident (#2) who was an elopement risk. Findings include, but are not limited to: Resident 2 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status and was identified in the acuity interview as having multiple elopement attempts. The resident's 06/29/24 service plan, temporary service plans (TSPs), incident reports, and 06/29/24 through 08/26/24 observation notes and 24-hour communication reports were reviewed. Observations were made, and staff and the resident were interviewed. The following was identified: * On 08/26/24 when this surveyor entered the MCC unit, the MCC entrance door was observed to take 18-20 seconds to close. * On 08/26/24 at 3:10 pm, Staff 16 (Care Partner) confirmed the MCC door’s delayed closure, and stated staff had been trained to wait by the door until it closed whenever Resident 2 was observed near the door. The resident’s record identified exit-seeking behavior with multiple elopement attempts and that Resident 2 had incidents of leaving the locked and secure MCC unit through the MCC entrance door behind someone else entering or exiting the MCC unit. On 08/28/24, Staff 1 (Memory Care Administrator) and Staff 2 (Assisted Living Administrator) stated they were aware the MCC entrance door’s delayed closure, and that Resident 2 had been found outside of the locked and secure MCC unit because of this. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety, or welfare of residents related to the MCC entry door was discussed with Staff 1, Staff 2, Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. Bid will be obtained to repair or replace the secured code accessible door that separates Memory Care from the rest of the facility to ensure that the door closes in a reasonable amount of time. 2. Door will either be repaired or replaced. 3. Secured Door closing time will be monitored through monthly walk-throughs to ensure compliance. 4. Campus Administrator and Maintenance Director to ensure that corrections are made and to monitor future function of locks on doors.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

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 promptly investigate incidents to rule out abuse and report incidents to the local Seniors and People with Disabilities (SPD) office, if abuse or neglect could not be ruled out, for 2 of 2 sampled residents (#s 1 and 2) with resident-to-resident altercations or unwitnessed injury falls. Findings include, but are not limited to: 1. Resident 1 was admitted to the MCC in 09/2022 with diagnoses including dementia and was identified in the acuity interview as a high fall risk. Resident 1's observation notes, dated 05/26/24 through 08/26/24, were reviewed and the following was identified: * Unwitnessed fall with “hip strain, right contusion of the left shoulder, acute bilateral ankle pain.” During an interview at 2:45 pm on 08/27/24, Staff 3 (Wellness Director/RN) confirmed no investigation had been completed for the unwitnessed fall. The facility was asked to report the unwitnessed injury fall to the local SPD office prior to survey exit. Confirmation was received on 08/29/24. The need to investigate injuries of unknown cause immediately and report the incident to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings. 2. Resident 2 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status. The resident was identified to have physical and verbal aggression towards other residents and was an elopement risk. The resident’s observation notes, temporary service plans, incident reports, and 24-hour communication reports dated 06/29/24 through 08/26/24, were reviewed, and facility staff were interviewed. The following was identified: a. There was no documented evidence the facility completed an investigation with all required components for the following incidents: * 07/13/24 –Resident 2 was observed to stand in another resident’s doorway and when approached, the resident stated “[Resident 2] grabbed [his/her] shirt and was shaking [him/her] angrily”; * 07/23/24 – Unwitnessed injury fall; * 08/13/24 – An unsampled resident reported to staff that “[Resident 2] grabbed [his/her] arm” and “it hurt”; and * 08/21/24 – Staff reported that Resident 2 attempted to “force” his/her way into another resident’s apartment. b. There was no documented evidence the facility reported the incident on 08/21/24 to local SPD. On 08/27/24 at 3:48 pm, Staff 1 (Memory Care Administrator) and Staff 2 (Assisted Living Administrator) confirmed no investigation had been completed for any of the above events and the event on 08/21/24 was not reported to local SPD. The facility was asked to report the resident-to-resident altercation to the local SPD office prior to survey exit. Confirmation was received on 08/29/24. The need to investigate incidents of abuse or suspected abuse and injuries of unknown cause immediately and report the incident to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 1, Staff 2, Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. The two identified incidents that could potentially result in abuse or neglect findings were reported to APS as requested: the 8.13.24 fall for Resident #1 was reported on 8.27.24; the 8.21.24 resident to resident was reported on 8.30.24. Documentation of submission to APS of other reports was provided: Incident on 7.13 was reported on 7.13; Incident on 7.23 was reported on 7.23; Incident on 8.13 was reported on 8.14. 2. System is that staff are to complete IR in ECP; Administrator and RNs will review all incident reports at daily clinical meeting. Administrator will be responsible for documenting in each IR that no evidence of abuse or neglect was found. Administrator will be responsible for reporting to APS immediately (within 24 hours) when the IR shows any unexplained injury, any incident wherein abuse or neglect could not be ruled out, or any potential crime. 3. This system will be evaluated weekly x4 then monthly at CQI meetings to ensure that all IRs are appropriately managed and reported. 4. RNs and Administrator will be responsible daily to review incidents and any needed reports. Administrator will be responsible to oversee that reports are completed in a timely manner.

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 411-054-0034 (1-6) Resident Move-in and Eval: 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 include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) 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) 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).(b) 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.(c) 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.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) 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.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) 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.(o) 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.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status. The resident's move-in evaluation documentation dated 06/27/24 and 06/29/24 was reviewed and lacked the following required elements: * Customary routines including sleeping, eating, and bathing; * Interests, hobbies, social, and leisure activities; * Mental health, including treatment and effective non-drug interventions; * Pain including pharmaceutical and nonpharmaceutical interventions and how a person expresses pain or discomfort; and * Nutritional habits, fluid preferences, and weight if indicated. The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

1. Growth and Wellness plans for residents #1 & 2 and were unable to be corrected as Resident #1 is deceased and Resident #2 has been re-located to a higher level of care. 2. Policy training will be conducted with RNs and Administrator on 9.20.24. RN to complete initial evaluation. Administrator to complete secondary review to ensure that all requried elements are captured. Facility has updated move-in evaluation form to include missing information as indicated by SOD. 3. System will be reviewed with each new move-in and at monthly CQI Meetings. 4. Administrator or designee will be responsible to ensure all elements of move-in evalauations are complete.

OAR 411-054-0034 (1-6) Resident Move-in and Eval: 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 include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) 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) 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).(b) 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.(c) 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.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) 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.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) 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.(o) 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.

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.(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 move- in 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 reflective of residents' current care needs and preferences, provided clear direction regarding the delivery of services, and/or were implemented for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status. The resident's current service plan, dated 06/29/24, and temporary service plans dated 06/29/24 through 08/26/24, were reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear instruction to staff, and/or was not implemented in the following areas: * Personal hygiene and grooming; * Oral care; * Bathing as needed every day, verbal prompting and cueing; * Laundry assistance needed; * Nighttime preparation and care; * Elopement interventions including the door in-between the MC and AL medication rooms to remain closed; * Pain management including how the resident expressed pain; and * Behavior management including clear instruction to staff and 1:1 direct care to manage behaviors. The need to ensure service plans were reflective of resident needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings. 2. Resident 1 was admitted to the MCC in 09/2022 with diagnoses including dementia and depression. The resident’s service plan, dated 06/28/24, and 05/21/24 through 08/26/24 observation notes and temporary service plans (TSPs) were reviewed, observations of the resident were made, and interviews were conducted. The service plan was not reflective and/or did not provide clear direction regarding the delivery of services in the following areas: * Assistive devices including walker and wheelchair; * Ambulation status; * Transfer status; * Dentition status; * Shower assistance; * Meal reminders; * Presence of catheter; * Dressing assistance; * Pain; and * Behavior interventions. The need to ensure service plans were reflective of the resident’s needs and preferences and provided clear direction regarding the delivery of services was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. Service Plans of Residents #1&2 were unable to be corrected and updated as these residents no longer reside in the community. 2. Live in-person service plan training will be provided for RNs and Administrators utilizing regional resources on 9.20.24. Full audit of all service plans to be completed by 10.28.24 in order to ensure that all missing information mentioned in SOD is included and updated. 3. Service plans will be re-evaluated by Administrator and RN at 90 day evaluations. 4. Administrator and RN to be responsible to ensure that all necessary information is included in service plans.

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.(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 move- in 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 observation, interview and record review, it was determined the facility failed to ensure actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift with weekly progress noted until the condition resolved for 2 of 2 sampled residents (#s 1 and 2) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the MCC in 09/2022 with diagnoses including dementia and depression. The resident’s service plan, dated 06/28/24, 05/21/24 through 08/26/24 observation notes and temporary service plans (TSPs), and “MC Monthly VS [vital signs] and Weights Monitoring” logs, dated April 2024 through August 2024, were reviewed. The following was identified: a. There was no documented evidence the facility determined and documented actions or interventions for the following short-term changes of condition: * 06/2024 – Nine-pound weight loss in one month; * 06/02/24 – Chafing and redness to buttocks; * 07/03/24 – “Red spots” in brief; and * 07/08/24 – Loose stools and pain. b. There was no documented evidence resident-specific instructions or interventions were communicated to staff on each shift for the following changes of condition: * 05/21/24 – Foley catheter placement; * 06/2024 – Nine-pound weight loss in one month; * 06/20/24 – Chafing and redness to buttocks; * 07/02/24 – Foul odor in catheter bag; * 07/03/24 – “Red spots” in brief; * 07/08/24 – Loose stools and pain; * 07/11/24 – IV placement for antibiotics; * 08/01/24 – “Open” blister on right shin and blister on left shin; * 08/09/24 – Witnessed fall; * 08/24/24 – Unwitnessed fall; and * 08/25/24 – Unwitnessed fall. c. There was no documented evidence of weekly progress noted to resolution for the following short-term changes of condition: * 06/2024 – Nine-pound weight loss in one month; * 06/20/24 – Chafing and redness to buttocks; * 07/03/24 – “Red spots” in brief; * 07/05/24 – Urinary tract infection; * 08/01/24 – “Open” blister on right shin and blister on left shin; and * 08/09/24 – Witnessed fall. The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift, and weekly progress was noted until resolution for short term changes of condition was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings. 2. Resident 2 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status. The resident's 06/29/24 service plan, temporary service plans (TSPs), incident reports, current physician orders, and 06/29/24 through 08/26/24 observation notes and 24-hour communication reports were reviewed. Observations were made, and staff and the resident were interviewed. The following was identified: There was no documented evidence resident-specific actions or interventions were determined for short-term changes of condition, the actions or interventions were communicated on all shifts, and/or changes were monitored through resolution, with progress noted at least weekly, for the following: * 07/01/24 – Exit-seeking, elopement risk, verbally aggressive behavior; * 07/01/24 – Emergency room and medication change; * 07/04/24 – Skin on top of right foot redness; * 07/10/24 – Behavioral disturbances and communication with doctor; * 07/12/24 – Document behaviors each shift; * 07/13/24 – Resident-to-resident altercation; * 07/13/24 – Medication change; * 07/14/24 – Resident attempted to exit memory care unit through the MC main entrance; * 07/16/24 – Resident was found outside of the locked and secure MC unit in the assisted living facility; * 07/17/24 – Medication change; * 07/19/24 – Medication change; * 07/23/24 – Unwitnessed injury fall; * 07/24/24 – Medication change; * 07/28/24 – Multiple attempts to elope through memory care entrance; * 07/30/24 – Extra dose of medication given; * 08/01/24 – Medication change; * 08/02/24 – Indecent exposure; * 08/13/24 – Resident-to-resident altercation; * 08/14/24 – Medication change; * 08/18/24 – Resident "forced" the main MC door open; * 08/20/24 – Resident "forced" the main MC door open and “was able to get out”; * 08/21/24 – Resident to resident altercation; and * 08/23/24 – Psychotropic medication held due to signs of sedation. The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and the changes of condition were monitored weekly through resolution was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

1. Change of condition safety plans for residents 1&2 are unable to be implemented as Resident #1 is deceased and Resident #2 was re-located to a higher level of care. 2. a. Change of Condition class through Oregon Care Partners to be taken by RNs and Administrator by 10.15.24. b. Moving forward, the system will be to review potential COCs in clinical meetings 3-4 days a week starting 9.23.24 with RNs and Administrator as available. c. RNs will be responsible for resolving COCs. 3. COCs will be monitored for TSPs and resolutions weekly x4 weeks, and then monthly at CQI meetings. 4. Administrator and RNs will monitor system to ensure that TSPs are initiated and resolutions are timely. BOM will monitor 10.15.24 completion of Oregon Care Partners class.

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 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a timely assessment that documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (#1) who experienced a significant change of condition. Findings include, but are not limited to: Resident 1 was admitted to the facility with diagnoses including dementia. The resident’s 05/21/24 through 08/26/24 observation notes were reviewed, observations of the resident were made, and interviews with staff were conducted. The following was identified: Review of observation notes indicated the resident had an indwelling Foley catheter placed on 05/21/24. The resident was observed with the catheter in place at 9:45 am on 08/27/24. The new catheter constituted a significant change of condition for which an RN assessment was required. During an interview at 2:20 pm on 08/27/24, Staff 3 (Wellness Director/RN) stated there was no RN assessment completed which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure a timely RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. Resident #1 no longer resides in the community. 2. RN and Administrator to take Change of Condition class through Oregon Care Partners to be completed by 10.15.2024. RN will make weekly notes and implement interventions for all change of condition identified within the community. RNs and Administrators will meet daily Monday-Friday as available to identify any clinical needs for change of condition. 3. Change of Condition needs will be monitored weekly x4 then monthly at CQI meetings going forward. 4. Administrator and RNs will be responsible to ensure change of condition charting and assessments are complete.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions for PRN medications were included on the MAR for 1 of 1 sampled resident (#1) who had PRN pain medications. Findings include, but are not limited to: Resident 1 was admitted to the facility with diagnoses including dementia. The resident's 08/01/24 to 08/26/24 MAR and current physician orders were reviewed and revealed the following: The following prescribed and administered PRN medications lacked resident-specific parameters or instructions for unlicensed staff, including which medication to administer first, second, or third: * Acetaminophen (for pain); * Phenazopyridine (for pain); and * Tramadol (for pain). The need to ensure PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. Residents #1&2 med lists were unable to be corrected as they no longer reside in the facility. 2. Full audit of all resident med lists has been completed to ensure that each physician's order is trancribed completely and correctly to the MAR. Audit to ensure that all resident specific instructions and perameters, including which to administer first, second or third for prn medications are present and correct. Moving forward, the system will be a three person check, with RN to complete final check of all new orders to ensure accuracy and to ensure that resident specific instructions and perameters (including which medication to administer first, second or third) are included. Staff to be further trained on resident specific instructions for prn medications by RN and Administrator on 9.27.24. 3. Med list audit of each new order to be pulled weekly x4 then monthly x3 then quarterly thereafter. 4. RN to be responsible that audits are completed. Administrator to be responsible that ongoing semi-monthly staff training meetings cover this topic quarterly.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

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 PRN psychotropic medications were administered only after documented, nonpharmacological interventions were tried with ineffective results for 2 of 2 sampled residents (#s 1 and 2) who had orders for PRN psychotropic medications. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 06/2024 with diagnoses including dementia and altered mental status. The resident's 08/01/24 to 08/26/24 MAR, observation notes dated 06/29/24 through 08/26/24, and current physician orders were reviewed. The following was identified: The resident had an order for lorazepam, one tablet by mouth every eight hours as needed for anxiety. The MAR indicated staff administered the PRN medication on two occasions from 08/01/24 to 08/26/24. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the medication. On 08/28/24 at 9:41 am, Staff 16 (MT) confirmed staff would administer the resident’s PRN lorazepam before attempting a non-drug intervention. The need to ensure documentation that staff administered PRN psychotropic medications only after attempting nonpharmacological interventions with ineffective results was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings. 2. Resident 1 was admitted to the MCC in 09/2022 with diagnoses including dementia. The resident’s 08/01/24 through 08/26/24 MAR, observation notes dated 05/21/24 through 08/26/24, and current physician orders were reviewed. The following was identified: The resident had an order for hydroxyzine, one tablet by mouth four times daily as needed for anxiety. The MAR indicated staff administered the medication on five occasions between 08/01/24 and 08/26/24. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the medication. The need to ensure documentation that staff administered PRN psychotropic medications only after attempting nonpharmacological interventions with ineffective results was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. Resident #1& #2 PRN psychotropic orders were unable to be reviewed and corrected as Resident #1 is deceased and Resident #2 has been re-located to a higher level of care. 2. Audit of all PRN psychotropic meds has been completed by RN to ensure that all interventions are written into orders. Staff training regarding interventions for PRN psychotropic meds to be conducted by RN and Administrator on 9.27.24. 3. With full audit completed, moving forward all psychotropic medications to be reviewed monthly with CQI meetings. Quarterly pharmacy review to ensure that interventions are in place, accurate and up to date. 4. RNs and Administrator responsible for monthly audits.

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 411-054-0037 (1)(2)(a)(c) Acuity Based Staffing Tool: Development (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department?s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (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. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident?s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule.

Based on observation, interview, and record review, it was determined the facility failed to accurately capture care time and care elements that staff were providing to each resident in their acuity-based staffing tool (ABST) for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia. The resident's ABST, last updated 05/21/24, current service plan dated 06/28/24, and temporary service plans dated 05/21/24 to 08/26/24 were reviewed. The following was identified: The resident's ABST failed to capture adequate staff time for the following resident needs: * Non-drug interventions for behaviors; * Cueing or redirecting due to cognitive impairment or dementia; * Escorting to meals; * Transferring in or out of a bed or a chair including need for two staff; and * Dressing and undressing. The need to ensure care time and care elements that staff provided to residents were accurately captured on the ABST was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/2024 with diagnoses including dementia and altered mental status. The resident's ABST, last updated 08/05/24, current service plan dated 06/29/24, and temporary service plans and observation notes dated 06/29/24 to 08/26/24 were reviewed. The following was identified: The resident's ABST failed to capture adequate staff time for the following resident needs: * Personal hygiene such as shaving and mouth care; * Monitoring physical conditions and symptoms; * Leisure activities; * Non-drug interventions for behaviors; * Providing treatments; * Bathing; and * Dressing and undressing. The need to ensure care time and care elements that staff provided to residents were accurately captured on the ABST was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. ABST has been audited and updated with current care plans of all residents. Resident #1&2 were unable to be updated as they no longer reside in the facility. 2. ABST documentation will be reviewed with each care plan quarterly, or any time there is a COC. 3. This will be reviewed weekly x4 weeks then monthly with CQI meetings. 4. Administrator and Memory Care Coordinator to monitor in order to ensure that ABST is complete and accurate.

OAR 411-054-0037 (1)(2)(a)(c) Acuity Based Staffing Tool: Development (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department?s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (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. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident?s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule.

OAR 411-054-0037 (4)(5)(6)(a-b)(C) Acuity Based Staffing Tool: Frequency of 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 develop and maintain an updated posted staffing plan based on the results of an acuity-based staffing tool (ABST) and failed to consistently staff to meet or exceed the staffing plan 24 hours a day, seven days a week. Findings include, but are not limited to: The facility’s ABST was reviewed with Staff 1 (Memory Care Administrator) and Staff 2 (Administrator) at 11:00 am on 08/28/24. The following was identified: a. A facility staffing plan was posted in the MCC; however, Staff 1 stated the posted staffing plan was outdated and from the prior owner of the facility. b. The staffing plan determined by the facility’s ABST was as follows: * Day shift – Five direct care staff; * Evening Shift – Four direct care staff; and * Night Shift – Two direct care staff. Review of the 08/01/24 through 08/26/24 facility schedule indicated the facility was consistently staffing the MCC as follows: * Day shift – Three direct care staff; * Evening shift – Three direct care staff; and * Night shift – Two direct care staff. Staff 1 confirmed at 11:00 am on 08/28/24 the facility was not staffing to the levels determined by the ABST. The need to use an ABST to develop and routinely update the facility’s posted staffing plan and to consistently staff to meet or exceed the staffing plan was discussed with Staff 1, Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. ABST has been audited and updated with current care plans of all residents. Staffing plan has been corrected and updated to match ABST staffing hours. 2. ABST documentation will be reviewed with each care plan held quarterly or any time there is a COC. 3. ABST will be reviewed weekly x4 then monthly with CQI meetings. 4. Administrator and Memory Care Coordinators will be responsible to monitor that ABST is complete and correct.

OAR 411-054-0037 (4)(5)(6)(a-b)(C) Acuity Based Staffing Tool: Frequency of 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 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire and to keep a written record of fire safety training, including content of the training sessions and the residents attending as required by the Oregon Fire Code (OFC). Findings include, but are not limited to: On 08/27/24, Staff 5 (Maintenance Director) was asked to explain the facility's process and to provide documentation for instructing residents in fire and life safety procedures upon admission and annually. Staff 5 stated there was no system or documentation in place since the facility changed ownership in 02/2024. The need to instruct residents in fire and life safety procedures within 24 hours of admission and re-instruct at least annually, and to keep a written record of the content of the training sessions and the residents attending was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. Annual Fire and Life Safety Training for Residents will be provided for all residents by 10.28.24. 2. Fire and Life Safety Training will be provided within 24 hours of move-in. Annual training will be provided in co-ordination with 90 evaluations. 3. Resident training will be monitored quarterly at CQI meetings. 4. Maintenance director to work with clinical team to provide trainings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure the interior was maintained in clean and good repair. Findings include, but are not limited to: The facility was toured on 08/26/24 at 3:08 pm. The following was identified: * Facility-wide, there was a buildup of dust, dirt, splashes, stains, and black scuffs on the walls, doors, door frames, vents, ledges, and baseboards; * The chairs in the dining room had gouges of wood missing from the frames and stains on the fabric; * The couch in the television room had peeling vinyl on the seat and arms, rendering it uncleanable; * Several light fixtures in the halls and common areas were not functioning; * The dining room and television room flooring was scratched and gouged; and * The baseboard and the door frame in the bathroom of Room 7 was missing, exposing unfinished wall material. The building was toured with Staff 1 (Memory Care Administrator) and Staff 5 (Maintenance Director) on 08/28/24 and the areas needing cleaning and repair were reviewed. They acknowledged the findings.

1. Baseboards have been cleaned and housekeeping team will attempt to clean dark marks from walls, doors and baseboards, with a painting plan to be completed by 10.28.24 to address what could not be cleaned off. Bids to be obtained to replace stained and gouged dining chairs; bids obtained to replace couches with peeling vinyl and stained upholstry. Bids to be obtained to repair or replace dining and tv room flooring; baseboard and door frame of Room 7 will be repaired prior to moving in a new resident. Light fixtures are failed ballasts connected to emergency generator and will be repaired through the planned lighting cap-ex project. 2. Cleaning of baseboards and doors will be placed onto the task list for the housekeeping team. 3. Monthly walk-throughs will be completed to ensure all areas of the community are in good repair. Results will be presented monthly at CQI meetings, with issues being addressed as they arise. 3. Maintenance director will monitor and Campus Administrator will ensure completion.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to no locking mechanism on shared bathroom doors for residents who shared a room and were not bedbound. Findings include, but are not limited to: During the acuity interview on 08/26/24 at 2:09 pm, six unsampled residents were identified as sharing a room, including one shared bathroom. On 08/27/24 at 9:21 am, Staff 11 (MT) stated none of the resident rooms had a locking mechanism for the shared bathroom door, including those rooms with two residents. Observations of resident units on 08/27/24 confirmed the shared bathrooms lacked a locking mechanism to ensure privacy in resident units. On 08/28/24 at 11:00 pm, Staff 1 (Memory Care Administrator) and Staff 3 (Assisted Living Administrator) confirmed none of the resident rooms had a locking mechanism for the shared bathroom door and multiple rooms had the capacity to be shared. The need to ensure privacy and dignity related to shared resident units and the capacity to lock bathrooms was discussed with Staff 1, Staff 2, Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

1. Bids are being obtained to replace or update current bathroom pocket doors with appropriate locks. 2. Doors will be replaced or updated with appropriate locks. 3. Doorlocks will be monitored through monthly walk-throughs to ensure compliance. 4. Campus Administrator and Maintenance Director to ensure that corrections are made and to monitor future function of locks on doors.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual.

Based on observation and interview, it was determined the facility failed to ensure the outdoor courtyard was physically accessible to all residents. Findings include, but are not limited to: On 08/26/24 at 3:51 pm, the memory care was identified to have three doors that provided access to the courtyard. The threshold in each doorway had a transition to ground level ranging from one half inch to two inches that created inaccessibility for residents who wanted to access the courtyard independently. On 08/28/24 at 9:34 am, Staff 2 (Assisted Living Administrator) and Staff 11 (MT) stated there were several residents who ambulated independently with the use of an assistive device and who were unable and/or had difficulty accessing the courtyard due to the thresholds. The need to ensure residents had physical accessibility to the courtyard was discussed with Staff 1 (Memory Care Administrator), Staff 2, Staff 3 (Wellness Director/RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. Bids will be obtained to replace or repair exisiting doors and thresholds. 2. Doors will be replaced; Thresholds will be replaced. If the thresholds cannot be lowered to meet requirements stated in SOD, cement walkway will be leveled out. 3. Door safety and threshold accessibility will be monitored with monthy facility walk-throughs and inspections to ensure accessibility. 4. Campus Administrator and Maintenance Director will ensure that repairs are completed and monitored. Any concerns will be brought to the monthly CQI meeting.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their room. Findings include, but are not limited to: Resident 2’s care plan, dated 06/29/24, listed the resident’s ability to use a key independently as “not applicable”. On 08/27/24 at 9:21 am, Staff 11 (MT) stated there were a few residents who had keys and were able to lock and unlock their room independently. On 08/28/24 at 11:00 am, Staff 1 (Memory Care Administrator) and Staff 2 (Assisted Living Administrator) confirmed residents were not issued a key to their room unless requested and were able to use independently. The need to ensure residents were provided a key to their room was discussed with Staff 1, Staff 2, Staff 3 (Wellness Director/RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

1. Each Memory Care resident has been evaluated for their ability and interest in using a key. 2. Keys will be provided to each resident and/or their POA/Guardian by 9.19.24; this will be noted in a TSP and then added to each resident's care plan at their next 90 day evaluation. 3. Residents shall be evaluated for their ability and interest in using a key at each 90 evaluation. 4. Administrator to ensure that each resident has access to their apartment key.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

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 C150, C160, C231, C361, C363, C422, and C513.

Please see each related POC regarding noted violations: (C150, C160, C231, C361, C363, C422, C513)

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 12 and 15) completed all preservice orientation training and 2 of 2 newly hired staff (#s 12 and 15) demonstrated satisfactory performance in any duty they were assigned within the first 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 2 (Assisted Living Administrator) at 9:45 am on 08/28/24. The following was identified: a. There was no documented evidence Staff 12 (MT), hired 02/26/24, and Staff 15 (Care Partner), hired 05/23/24, completed required preservice orientation training prior to beginning job duties in one or more of the following: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Infectious disease prevention; * Home and community-based services; and * Preservice dementia training. b. There was no documented evidence Staff 12 and Staff 15 demonstrated satisfactory performance in assigned job duties within 30 days of hire in one or more of the following areas: * Role of service plans; * Providing assistance with ADLs; * Changes associated with normal aging; * Identifying, documentation, and reporting changes of condition; * Conditions that require assessment, treatment, observation, and reporting; * General food safety, serving, and sanitation; and * Medication and treatment administration. At 9:45 am on 08/28/24, survey requested Staff 12 complete medication and treatment administration demonstration prior to administering medications and treatments, and confirmation was received prior to survey exit. The need to ensure staff completed all preservice orientation training prior to beginning job duties and staff demonstrated competency in any duty they were assigned within the first 30 days of hire was discussed with Staff 1 (Memory Care Administrator), Staff 2, Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. Pre-Service Orientation trainings to be provided to identified staff. Demonstrated competency to be completed with identified staff. Full audit to be conducted by 10.15.24 to identify any missing pre-service training or missing demonstrated competency evaluations. Pre-service training and competency evaluations to be completed by all staff no later than 10.28.24. 2. System correction going forward: Staff will not begin floor training until all pre-service training is completed. Administrator and RCC will ensure PCAs do not work the floor independently until competency checklist and additional 30 day training is completed. 3. Initial audit will be completed by the BOM. Monthly tracking will be completed by the BOM with RCC support. Training will be monitored quarterly at CQI meetings. 4. BOM and RCC will monitor pre-service training, competency checklists and additional 30 day training progress. Administrator to be responsible to ensure that team members do not work independently without required training.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

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 C252, C260, C270, C280, C310, and C330.

Please see Plan of Correction regarding noted violations: (C252, C260, C270, C280, C310, C330)

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 observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's care plan for 2 of 2 residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to: Residents 1 and 2's current service plans were reviewed during survey. Each of the service plans lacked information and staff instruction related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24 at 1:18 pm. They acknowledged the findings.

1. Nutrition and Hydration Service Plans of Residents #1&2 were unable to be corrected and updated as these residents no longer reside in the community. 2. Live in-person service plan training will be provided for RNs and Administrators utilizing regional resources on 9.20.24. Full audit of all Nutrition and Hydration Service plans to be completed by 10.28.24 in order to ensure that all missing information mentioned in SOD is included and updated. 3. Service plans will be re-evaluated by Administrator and RN at 90 day evaluations. 4. Administrator and RN to be responsible to ensure that all necessary information is included in service plans.

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 each resident was evaluated for activities and to develop an individualized activity plan based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose evaluations and service plans were reviewed. The most recent evaluations and current service plans were reviewed for Residents 1 and 2. The following was identified: * There was no documented evidence an activity evaluation or individualized activity plan had been completed for either resident. During an interview at 3:35 pm on 08/27/24, Staff 6 (Memory Care Coordinator) confirmed the facility had not completed an activity evaluation or activity plan for either sampled resident. The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. Activities Service Plans of Residents #1&2 were unable to be corrected and updated as these residents no longer reside in the community. 2. Live in-person service plan training will be provided for RNs and Administrators utilizing regional resources on 9.20.24. Full audit of all Activities Service plans to be completed by 10.28.24 in order to ensure that all missing information mentioned in SOD is included and updated. 3. Service plans will be re-evaluated by Administrator and RN at 90 day evaluations. 4. Administrator and RN to be responsible to ensure that all necessary information is included in service plans.

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 411-057-0170(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 ensure residents were not locked out of their rooms at any time for multiple sampled and unsampled residents. Findings include, but are not limited to: During the change of ownership survey, conducted from 08/26/24 to 08/29/24, observations of resident rooms revealed multiple rooms were locked from the outside, preventing residents from entering their rooms without assistance from staff. Multiple unsampled residents and sampled residents’ family members were observed approaching staff and/or waiting to be let into their respective rooms. During an interview on 08/27/24 at 10:30 am, Staff 1 (Memory Care Administrator) stated resident room doors were locked because of one resident who wandered and tried to enter other residents’ rooms. The need to ensure residents were not locked outside of their rooms at any time was discussed with Staff 1, Staff 2 (Assisted Living Administrator), Staff 3 (Wellness Director/RN), Staff 4 (RN), and Staff 8 (Regional RN) on 08/29/24. They acknowledged the findings.

1. Each Memory care resident has been evaluated for their ability and interest in using an apartment key. Facility will utilize interventions other than locking doors. 2. Keys will be provided to each resident and/or their POA/Guardian by 9.19.24. At each new Move-in a key will be provided to the resident and/or their POA. 3. TSPs will be written for the initial key evaluations and care plan will be updated with the next 90 day evaluation. 4. Administrator to ensure that key evaluations are included with each 90 day evaluation.

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, interview, and record review, 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 facilities kitchen, food storage areas, food preparation, and food service on 07/12/22 revealed: * Splatters, spills, debris, and drips noted: - Surfaces an underneath storage shelves, cabinets, and drawers throughout the kitchen; - Metal storage shelves throughout the kitchen and walk in refrigerator; - Walls throughout the kitchen; - Floors and drains; - The vents, outer surface, and underneath the ice machine; - The dishwashing area walls, floors, and equipment; - Both sides and the interior of the range, grill, and oven; - The range hood; - Food storage bins; - Behind and underneath appliances; - The surface and underneath the tray line steam table; - The plate warmer; - Food preparation counters; - Interior of the microwave; - The stand mixers; - Garbage cans and lids; - The mop bucket storage area; and - A radio on the counter by the stand mixer. * The walk in freezer had a leak creating a build up of ice build from the ceiling to the floor. * Food was stored on the floor of the freezer. * Multiple dented cans of food were noted in they dry storage area; * Bagged food items were stored on the floor of the dry storage area; and * A Styrofoam cup was left in a bag of rice. * Dust and debris noted on cages of three fans blowing onto the tray line, preparation areas, and into the dish washing area. * Undated food items and food items with dates older than seven days were noted in the refrigerators. * The back entrance to the kitchen was left open allowing the entrance of flies and pests. * The wiping cloth sanitizer bucket was not monitored to ensure the sanitizer was dispensing at the correct parts per million. * Staff were observed to not change gloves between tasks or sanitize hand upon entering the kitchen.   * Staff in the kitchen did not have hair restrained; and * Caregiving staff assisting with meal service and delivery were not using aprons. A box of frozen Halibut fillets was observed to be left on the kitchen counter at 8:45 am. It was still on the counter at 9:15 am. Dietary staff stated it was to be used for lunch, and they were waiting to get the number of fillets needed. The need to thaw items on the lowest shelf in the refrigerator or under cold running water was explained. Staff acknowledged the information. The Halibut was not moved to the refrigerator or under cold running water. Staff 1 (Executive Director) was requested to intervene. The fillets were still frozen. b. Observations of the Memory Care food storage area on 07/12/22 revealed: * Spills, splatters and debris in the reach-in refrigerator; * The refrigerator lacked a thermometer; and * Cupboards, drawers, and handles were sticky to the touch with spills and splatters. The Surveyor and Staff 1 toured the kitchens, and the areas in need of cleaning and repair were reviewed. He acknowledged the findings.

1. For the areas identified in the deficiency, the areas with splatters, spills, debris and drips were cleaned immediately including fans. In addition, all food is properly stored, labeled and all cans with dents were destroyed. The repair for the walk freezer has been scheduled. Aprons have been purchased and staff will be in-serviced on proper infection control, sanitation and safe handling of frozen and defrosted food. 2.All areas noted in the deficiency will be added to the cleaning schedule in the kitchen. Dining Service director will review cans weekly for damage and remove cans with damage Safe handling of foods, sanitation and infection control will be added to our monthly in-service meeting for all staff. 3. It will be reviewed monthy in the sanitation audit 4. The Dining Service Director and Exeutive Director will be responsible.

Based on observation, interview, and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the facilities kitchen, food storage areas, food preparation, and food service on 10/03/22 revealed: * Splatters, spills, debris, and drips noted: - Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen; - Metal storage shelves throughout the kitchen and walk in refrigerator; - Racks in walk in refrigerator; - Cart used for food delivery; - Walls throughout the kitchen; - Flooring throughout the kitchen; - Drains; - The outer surface and underneath the ice machine; - Behind and beside the range; - Interior of the microwave; - The stand mixers; and - Garbage cans and lids; * The walk in freezer had a leak creating a build up of ice from the ceiling to the floor. * Dented can noted in they dry storage area; * A scoop left in the bin of sugar. * Dust and debris noted on cage of fan blowing into the dish washing area. * Undated food items noted in the refrigerator. * Staff were observed to not change gloves between clean and dirty tasks or sanitize hands upon entering the kitchen.   * Staff in the kitchen did not have hair and beards restrained. * The reach in refrigerator in the MCC unit did not have a thermometer. The Surveyor and Staff 2 (Dietary Manager) toured the kitchen, and the areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director). They acknowledged the findings.

1. For the areas identified in the deficiency, the areas with splatters, spills, debris, dust, and drips were cleaned immediately. In addition, all food is properly stored and labeled, utensil properly stored and all cans with dents were destroyed: The repair for the walk in freezer has been completed and excess ice removed; All kitchen staff have hair and beard restrained and covered. 2. All areas noted in the deficiency will be added to the cleaning schedule in the kitchen. Dining Service director will review cans weekly for damage and remove cans with damage. Safe handling of foods, sanitation and infection control will be added to our monthly in-service meeting for all staff. 3. It will be reviewed weekly and monthly in the sanitation audit. 4. The dining Service Director and Executive Director will be responsible.

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.

1. For the ares identified in the deficiency: all splatters,spills, debris and drips were cleaned immediately.See C240 2..All areas noted in the deficiency will be added to the cleaning schedule in the kitchen. Safe handling of foods, sanitation and infection control will be added to our monthly in-service meeting for all staff. 3. It will be reviewed monthy in the sanitation audit 4. The Dining Service Director and Exeutive Director will be responsible.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C240.

1. Refer to C240 and C 455

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

1. The plan of correction noted in C240 will be immediately implemented. See C240 2. the violations and plan will be audited weekly for compliance. 3. Weekly and Monthly 4. Dining Service Director and Executive Director.

The findings of the kitchen inspection, conducted 07/12/22, 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 first revisit to the kitchen inspection of 07/12/22, conducted 10/03/22, 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 second revisit to the kitchen inspection of 07/12/22, conducted 12/13/22, 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.