Chateau Gardens Memory Care Community

Based on interview and record review, it was determined the facility failed to promptly investigate incidents to rule out abuse, or immediately report abuse and suspected abuse to the local SPD (Seniors and People with Disabilities) office for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 10/2021 with diagnoses including vascular dementia and generalized anxiety.

a. The resident’s 02/05/25 to 05/02/25 progress notes identified the following incidents of abuse:

* 03/01/25 – The resident “exhibited aggressive behaviors” and called three other residents names.

* 03/09/25 – The resident “has been aggressive” and swearing at other residents.

* 03/16/25 – “[Resident] had a pretty bad behavior day... [s/he was seen] rubbing another residents [sic] thigh…”

* 04/29/25 – “[Resident]…started calling [another resident] names which upset [him/her].

In an interview on 05/06/25, Staff 1 (ED) stated she was not aware of these incidents of abuse and that they had not been reported to the local SPD.

On 05/07/25 Staff 1 provided documentation of investigations for these incidents of abuse and a copy of the self-report to the local SPD office.

b. During the entrance interview on 05/05/25, it was reported Resident 1 “kissed and groped” Resident 3.

There was no documentation of this incident in Resident 1’s and Resident 3’s records.

In an interview on 05/06/25 Staff 2 (RCC) reported she was aware of this incident but did not know if it had been reported.

The facility was unable to provide documentation of this incident of abuse being reported to the local SPD. On 05/07/25 Staff 1 provided documentation of an investigation and self-report to SPD, completed 05/06/25.

The facility’s failure to immediately report all incidents of abuse to the local SPD office was discussed with Staff 1 and Staff 2 on 05/07/25. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 04/01/25 care plan, 04/02/25 through 05/03/25 progress notes, “Temporary Service Plans,” incident investigations and physician communications were completed.

The resident required total staff assistance for meal intake and two staff assistance for all ADL care. The resident was not able to consistently make needs known and would no longer initiate any care needs. The resident’s cognition and physical condition had declined significantly over the last several weeks.

Review of the resident's records showed the following:

* An incident investigation, dated 04/05/25, indicated the resident experienced an unwitnessed fall and sustained a head injury and a skin tear to the right elbow. The resident could not say what occurred.

The fall with injury was not reported to the local SPD office.

* An incident investigation, dated 04/07/25, indicated the resident experienced an unwitnessed fall and sustained a laceration and a dislocation to fingers on the left hand. The resident could not offer any information.

The fall with injury was not reported to the local SPD office.

In interviews between 05/05/25 and 05/07/25, Staff 1 (ED) and Staff 2 (RCC) indicated the incidents were not reported at the time of the injuries.

A confirmation that the falls with injuries were reported to the local SPD office was provided to the survey team prior to exit.

The need to ensure incidents were reported to the local SPD office when required was discussed with Staff 1 and Staff 2 on 05/07/25. The staff acknowledged the findings.

3. Resident 4 was admitted to the facility in 03/2025 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 03/12/25 care plan, 03/12/25 through 05/01/25 progress notes, “Temporary Service Plans,” incident investigations and physician communications were completed.

The resident required staff assistance for all ADL care. The resident was not able to consistently make needs known and required frequent cueing and redirection toward needed tasks.

Review of the resident's records showed the following:

* An incident investigation, dated 03/16/25, indicated the resident had an altercation with his/her roommate (Resident 5). Resident 4 was hit in the head with a cane and sustained a head injury. The incident investigation was incomplete. The altercation was not reported to the local SPD office.

* A progress note, dated 03/18/25, indicated the resident had an altercation with another resident. Resident 4 touched the other resident’s genitals. The resident-to-resident altercation was not investigated. The altercation was not reported to the local SPD office.

* A progress note, dated 03/19/25, indicated the resident had an altercation with another resident. Resident 4 touched the other resident’s thigh. The resident-to-resident altercation was not investigated. The altercation was not reported to the local SPD office.

* A progress note, dated 03/19/25, indicated an unsampled resident’s family reported that their family member (a resident) stated Resident 4 entered his/her apartment and attempted to touch the resident. Resident 4 was kicked at by the unsampled resident and made to leave. The resident-to-resident altercation was not investigated. The altercation was not reported to the local SPD office.

* A progress note, dated 03/22/25, indicated the resident had experienced an unwitnessed fall and sustained a skin tear. The fall with injury was not investigated nor reported to the local SPD office.

* A progress note, dated 03/23/25, indicated the resident had an altercation with an unsampled resident. Resident 4 grabbed the unsampled resident’s walker and would not let go. Staff were eventually able to get the resident to release the walker. The resident-to-resident altercation was not investigated or reported to the local SPD.

* A progress note, dated 03/28/25, indicated Resident 4 entered another resident’s apartment. The progress note did not provide information on any interaction with the resident who resided in the apartment or any touching that may have occurred. The resident-to-resident altercation was not investigated or reported to the local SPD office.

* A progress note, dated 04/07/25, indicated the resident was found with an injury of unknown cause, a bruise found on the resident’s left arm. The resident could not offer any information on what occurred. The injury of unknown cause was not investigated or reported to the local SPD office.

In interviews between 05/05/25 and 05/07/25, Staff 1 (ED) indicated she was not yet working at the facility and could not say why the incidents were not investigated or properly reported.

A confirmation that the incidents were reported to the local SPD office was provided to the survey team prior to exit.

The need to ensure incidents were investigated promptly to rule out abuse and neglect and reported to the local SPD office when required, was discussed with Staff 1 and Staff 2 on 05/07/25. The staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were completed prior to the resident being admitted to the facility for 2 of 2 sampled residents (#s 2 and 5) whose move-in evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia.

The resident's new move-in evaluation was completed on 03/25/25. The following elements were not addressed or had conflicting information in the move-in evaluation:

* Customary routines related to eating and bathing;
* Interests, hobbies, social and leisure activities;
* Memory, confusion and decision making abilities;
* Personality, including how the person copes with change or challenging situations;
* Speech;
* Pronouns and gender identity;
* How does the person express pain;
* Nutrition habits, fluid preferences and weight if indicated;
* Fall risk or history;
* Alcohol and drug use; and
* Environmental factors that impact the resident’s behaviors.

The need to complete move-in evaluations prior to a resident being admitted to the facility and to address all required elements was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia.

The resident's new move in evaluation was undated and unsigned. The following elements were not addressed or had conflicting information on the move-in evaluation:

* Customary routines related to sleeping, eating and bathing;
* Interests, hobbies, social and leisure activities;
* List of current diagnoses;
* List of medications and PRN use;
* Visits to health practitioner(s), ER, hospital or NF in the past year;
* Behavioral problems;
* Memory, confusion and decision making abilities;
* Speech;
* Personal hygiene;
* Transfers and assistive devices;
* Ability to manage medications;
* Ability to use call system;
* Transportation;
* Pronouns and gender identity;
* How does the person express pain;
* Nutrition habits, fluid preferences and weight if indicated;
* Fall risk or history;
* Alcohol and drug use;
* Emergency evacuation ability;
* History of dehydration;
* Recent losses;
* Elopement risk or history;
* Alcohol and drug use; and
* Environmental factors that impact the resident’s behaviors.

The need to complete move-in evaluations prior to a resident being admitted to the facility and to address all required elements was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN.
(a) The facility must determine whether a potential resident meets the facility's admission requirements.
(b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability.
(c) Each resident record must, before move-in and when updated, include the following information:
(A) Legal name for billing purposes.
(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding:
(i) Name.
(ii) Pronouns.
(iii) Gender identity.
(C) Prior living arrangements;
(D) Emergency contacts;
(E) Service plan involvement - resident, family, and social supports;
(F) Financial and other legal relationships, if applicable, including, but not limited to:
(i) Advance directives;
(ii) Guardianship; (iii) Conservatorship; and
(iv) Power of attorney.
(G) Primary language;
(H) Community connections; and
(I) Health and social service providers.

(2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.
(a) Resident evaluations must be:
(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and
(B) Performed at least quarterly, to correspond with the quarterly service plan updates.
(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.
(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.
(E) Documented, dated, and indicate who was involved in the evaluation process.
(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.

(3) EVALUATION REQUIREMENTS AT MOVE-IN.
(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.
(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.
(c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs.
(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.
(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.

(4) QUARTERLY EVALUATION REQUIREMENTS.
(a) Resident evaluations must be performed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.
(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.

(5) The resident evaluation must address the following elements:
(a) For service planning purposes, if indicated by the resident,
(A) Name.
(B) Pronouns.
(C) Gender identity.
(b) Resident routines and preferences including:
(A) Customary routines, such as those related to sleeping, eating, and bathing;
(B) Interests, hobbies, and social and leisure activities;
(C) Spiritual and cultural preferences and traditions; and
(D) Additional elements as listed in 411-054-0027(2).
(c) Physical health status including:
(A) List of current diagnoses;
(B) List of medications and PRN use;
(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and
(D) Vital signs if indicated by diagnoses, health problems, or medications.
(d) Mental health issues including:
(A) Presence of depression, thought disorders, or behavioral or mood problems;
(B) History of treatment; and (C) Effective non-drug interventions.
(e) Cognition, including:
(A) Memory;
(B) Orientation;
(C) Confusion; and
(D) Decision-making abilities.
(f) Personality, including how the person copes with change or challenging situations.
(g) Communication and sensory abilities including:
(A) Hearing;
(B) Vision;
(C) Speech;
(D) Use of assistive devices; and
(E) Ability to understand and be understood.
(h) Activities of daily living including:
(A) Toileting, bowel, and bladder management;
(B) Dressing, grooming, bathing, and personal hygiene;
(C) Mobility - ambulation, transfers, and assistive devices; and
(D) Eating, dental status, and assistive devices.
(i) Independent activities of daily living including:
(A) Ability to manage medications; (B) Ability to use call system;
(C) Housework and laundry; and
(D) Transportation.
(j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.
(k) Skin condition.
(l) Nutrition habits, fluid preferences, and weight if indicated.
(m) List of treatments - type, frequency, and level of assistance needed.
(n) Indicators of nursing needs, including potential for delegated nursing tasks.
(o) Review of risk indicators including:
(A) Fall risk or history;
(B) Emergency evacuation ability;
(C) Complex medication regimen;
(D) History of dehydration or unexplained weight loss or gain;
(E) Recent losses;
(F) Unsuccessful prior placements;
(G) Elopement risk or history;
(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and
(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.
(p) Environmental factors that impact the resident's behavior including, but not limited to:
(A) Noise.
(B) Lighting.
(C) Room temperature.
(6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.

Stat. Auth.: ORS 410.070, 441.122, 443.450
Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff, were consistently implemented by staff and readily available for staff review for 4 of 4 sampled residents (#s 1, 2, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the care plan, dated 04/01/25, showed the care plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas:

* Safety interventions including low bed, fall mats and side rail use;
* Meal assistance;
* Safety checks;
* Fluid placement and keeping over bed table in reach;
* Dressing, hygiene and grooming assistance;
* Transfers, incontinent care and skin care;
* Catheter care; and
* Bed mobility and position changes.

The need to ensure resident care plans were reflective of current care needs, were consistently implemented, provided clear direction to staff and were available for care staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in 08/2020 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the care plan, dated 03/27/25, showed the care plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas:

* Safety checks;
* Nighttime checks;
* Dressing, hygiene and grooming assistance;
* Toileting and incontinent care; and
* Proper footwear.

The care plan binder did not contain all resident care plans for staff review. Eight care plans were not located in the binder including Resident 4’s care plan. The other available information was locked in the medication room.

The need to ensure resident care plans were reflective of current care needs, were consistently implemented, provided clear direction to staff and were available for care staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

3. Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the care plan, dated 03/12/25, showed the care plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas:

* 1- versus 2- staff assistance, fall interventions and safety checks;
* Dressing, hygiene and grooming assistance;
* Excessive call light use;
* Meal assistance and cueing;
* Nonskid footwear and gait belt use;
* Sexual behaviors, wandering and grabbing other residents/belongings; and
* Toileting, bathing and incontinent care.

The care plan binder did not contain all resident care plans for staff review. Eight care plans were not located in the binder including Resident 5’s care plan. The other available information was locked in the medication room.

The need to ensure resident care plans were reflective of current care needs, were consistently implemented, provided clear direction to staff and were available for care staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

4. Resident 1 moved into the facility in 10/2021 with diagnoses including vascular dementia and generalized anxiety disorder. The resident’s care plan dated 03/27/25 was reviewed, observations were made, and interviews were conducted.

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

* Romantic relationship with another resident; and
* Safety checks.

The need to ensure care plans were reflective of the residents’ needs and provided clear instruction to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident following a short-term change of condition, communicate determined interventions to staff on each shift, monitor the effectiveness of the interventions consistent with the evaluated needs of the resident, and/or monitor and document weekly progress until the condition resolved for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) who experienced falls, had changes of condition, or who required monitoring. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 10/2021 with diagnoses including vascular dementia and generalized anxiety disorder.

The resident’s progress notes dated 02/05/25 through 05/05/25, and care plan dated 03/27/25 were reviewed, observations were made, and interviews with staff were conducted.

a. During the entrance interview on 05/05/25 Resident 1 was identified as having “kissed and groped” Resident 3.

There was no documented evidence the facility had determined interventions for this incident, had communicated interventions to staff, and had monitored the situation until resolution according to the needs of Residents 1 and 3.

In an interview on 05/06/25 Staff 1 (ED) reported that she was unaware of the incident of and acknowledged that the facility had not determined interventions and monitored Residents 1 and 3.

b. During the entrance interview on 05/05/25 Resident 1 was identified as having a special friendship with an unsampled resident and had been observed recently with his/her arm around the unsampled resident.

Throughout the survey Resident 1 was observed having meals with the unsampled resident at a table for two. A photo of the two residents together was hung outside Resident 1’s apartment, and multiple staff reported that the residents were “boyfriend and girlfriend.”

There was no documented evidence the facility had developed appropriate interventions for this relationship and were monitoring for ongoing evidence of consent.

Staff 1 reported in an interview on 05/07/25 that she had observed Resident 1 and the unsampled resident holding hands. She acknowledged that the facility was not monitoring the two residents according to their needs.

The need to ensure the facility determined and documented what actions or interventions were needed for a resident and monitored the resident and documented on the progress of the condition at least weekly until resolved following a change of condition was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia.

The resident's 04/01/25 care plan, 04/02/25 through 05/03/25 progress notes, incident investigations and physician communications were reviewed.

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

* Medication changes;
* Urinary tract infection and antibiotic use;
* Injury and non-injury falls;
* Skin injuries;
* Seizure activity;
* Emergency room visits; and
* Vomiting.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

4. Resident 4 was admitted to the facility in 08/2020 with diagnoses including dementia.

The resident's 03/27/25 care plan, 02/05/25 through 03/18/25 progress notes, incident investigations and physician communications were reviewed. Additional progress notes were requested after 03/18/25, and no additional notes were provided.

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

* Resident-to-resident altercation.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

5. Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia.

The resident's 03/12/25 care plan, 03/12/25 through 05/01/25 progress notes, incident investigations and physician communications were reviewed.

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

* Medication changes;
* Skin injuries and a head wound;
* Resident-to-resident altercations;
* Aggressive behaviors, hitting glass, throwing items;
* Sexual behaviors; and
* Falls and placing self on the floor.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed by a physician or other legally recognized practitioner for 1 of 3 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to:

Resident 1 moved into the community in 10/2021 with diagnoses including vascular dementia and generalized anxiety disorder.

During the entrance interview on 05/05/25, Resident 1 was identified as receiving palliative care services which included regular visits from a nurse practitioner.

An “Outside Agency Documentation” sheet dated 02/20/25 documented a signed order from the nurse practitioner: “Please repeat blood pressure. If after lisinopril SBP >150 and [sic] notify me.”

Review of the resident’s vital records log identified 18 days between 02/21/25 and 03/20/25 that Resident 1’s blood pressure was not rechecked.

The need to ensure physician or legally recognized practitioner orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to an order for medication and treatment administration for 1 of 1 sampled resident (# 5) who was reviewed with documented refusals. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia.

The resident's 04/01/25 through 05/05/25 MAR and signed physician orders dated 03/11/25 were reviewed.

The following medications were documented as refused between 04/01/25 and 05/05/25:

* Calmoseptine (skin cream), was refused on 41 occasions;
* Propranolol (blood pressure medication used out of class for anxiety/agitation for this resident), was refused on 14 occasions;
* Fluticasone (nasal spray), was refused on 13 occasions; and
* Eliquis (blood thinner), was refused on nine occasions.

There was no documented evidence the prescriber was notified after each refusal for the above medications/treatments.

The need to notify the physician or other practitioner of resident medication refusals was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

(j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and included resident-specific parameters and instructions for PRN medications for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 10/2021 with diagnoses including vascular dementia and generalized anxiety disorder.

Review of Resident 1's 04/01/25 through 05/05/25 MAR and physician orders identified the following:

The following PRN medications for pain lacked resident-specific parameters to direct unlicensed staff, including sequential order of use:

* Acetaminophen 325 mg tab tablet (for pain/fever); and

* Hydrocodone-APAP 5-325 mg tablet (for pain).

Between 04/01/25 and 04 /18/25, the resident was administered acetaminophen on four occasions.

The need to ensure MARs were accurate, including providing resident-specific parameters for PRN medications and medication notes, was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia.

Review of the resident's 04/01/25 through 05/05/25 MARs, 04/02/25 through 05/03/25 progress notes and physician communications and 4/08/25 signed physician orders showed the following:

* Acetaminophen 325 mg tablets, take two tablets every six hours PRN (for pain);
* Acetaminophen 500 mg tablet, take one tablet three times a day PRN (for pain); and
* Morphine 20 mg/ml, take 0.5 ml every hour PRN (for pain).

There were no resident specific parameters to direct unlicensed staff which medication to give first and in what order the other medications were to be administered.

The need to ensure medication administration records were complete and included resident specific parameters for PRN use was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 3 of 3 sampled residents (#s 1, 2 and 5) who were prescribed PRN medications to address behaviors. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia.

Review of the resident's 04/01/25 through 05/05/25 MARs, 04/02/25 through 05/03/25 progress notes and 4/08/25 signed physician orders showed the resident had the following order:

* Lorazepam 1.0 mg tablet, give one tablet every four hours PRN for anxiety.

The instructions for staff indicated the resident had anxiety with transfers. However, the resident was bed bound and no longer transferred out of the bed. There were no other resident-specific instructions for staff on what the resident’s anxiety looked like or what they should be watching for.

The lorazepam PRN dose was not administered between 04/01/25 and 05/05/25.

The need to ensure resident-specific information on how the resident expressed anxiety/agitation was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 03/2025 with diagnoses including dementia.

Review of the resident's 04/01/25 through 05/05/25 MARs, 03/12/25 through 05/01/25 progress notes and 03/11/25 signed physician orders showed the following:

* Lorazepam 0.5 mg tablet, give one tablet twice daily PRN every four hours for anxiety.

The medication was given three times between 04/01/25 and 05/05/25.

The MAR lacked resident-specific information for staff on how the resident’s anxiety was expressed and what the staff should watch for. Additionally, there were no resident-specific interventions for staff to attempt prior to administration of the medication.

The need to ensure resident-specific information on how the resident expressed anxiety/agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

3. Resident 1 moved into the facility in 10/2021 with diagnoses including vascular dementia and generalized anxiety disorder.

The resident had orders for lorazepam 0.5 mg tablet for generalized anxiety disorder – take ½ tablet by mouth once daily as needed.

The facility failed to ensure there were specific parameters for staff describing how Resident 1 expressed anxiety.

The need to ensure there were resident-specific descriptions for all PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on observation, interview and record review it was determined the facility failed to ensure devices with restraining qualities were assessed by an RN, OT or PT to determine safety of the device, the risks and benefits for the resident and if the least restrictive option was utilized for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

Resident 2 was admitted to the facility in 04/2025 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's care plan dated 04/01/25 showed the resident had two half side rails on his/her bed. The resident was observed to use the rails to help roll and partially hold his/her position during care.

The resident was able to express minimal information regarding the device. The resident’s cognition was impaired, and s/he required full assistance from staff for all ADL care including feeding of meals and two-person assistance for bed mobility, incontinent care and dressing.

Review of the resident's record showed no documented assessment or evaluation of the side rails. The resident’s care plan did not provide information to staff related to either device, safety/maintenance items to watch for or how to use the device with the resident.

The need for a PT, RN or OT to complete an assessment of any device with restraining qualities and to include all required documentation was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. The staff acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure that 3 of 3 newly hired direct care staff (#s 7, 9 and 10) demonstrated competency in the use of abdominal thrust and first aid within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 05/06/25. There was no documented evidence that Staff 7 (MT), hired 02/24/25, Staff 9 (MT/CG), hired 03/03/25, and Staff 10 (CG), hired 02/15/25, had completed competencies in first aid and abdominal thrust. On 05/07/25 Staff 6 (Business Office Manager) confirmed the lack of documentation of first aid and abdominal thrust training for Staff 7, Staff 9 and Staff 10.

The need to ensure direct care staff had demonstrated competency in first aid and abdominal thrust within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff

(5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF.
(a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned.
(b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to:
(A) The role of service plans in providing individualized resident care.
(B) Providing assistance with the activities of daily living.
(C) Changes associated with normal aging.
(D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition.
(E) Conditions that require assessment, treatment, observation and reporting.
(F) General food safety, serving and sanitation.
(G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised.

(9) ADDITIONAL REQUIREMENTS. Staff:
(a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services.
(b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required.
(c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed.

(10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule.
(a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code on alternate months. Findings include, but are not limited to:

Fire and life safety records between 12/2024 and 05/2025 were reviewed and showed:

a. Two fire drills were documented as completed in the last six months.

b. Fire drills were not conducted on alternating months with fire life safety training.

c. Drills were not conducted on alternating shifts to include all three shifts.

d. Fire drill documentation was missing the following components:

* Location of simulated fire;

* Escape route used;

* Evacuation time period needed;

* Number of occupants evacuated; and

* Evidence alternate routes were used.

The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from life safety training was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 05/05/25 and 05/06/25. The staff acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

(1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to:

Fire and life safety records were reviewed and discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 05/05/25.

There was no documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission and again at least annually.

The need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and again annually was discussed with Staff 1 and Staff 4. The staff acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces and surrounding pathways were maintained in good repair. Findings include, but are not limited to:

Observations of fac ility pathways and patio areas on 05/05/25 identified the following:

* Multiple drop-offs of 2 to 3 inches were noted in the courtyard, along pathways and outside exterior doorways; and

* Cracked, lifting and/or broken sidewalk pieces were noted in the courtyard.

The need to ensure pathways around the facility were in good repair with no potential tripping hazards were shown to and discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 05/05/25 and 05/06/25. The staff acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior

(3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:

Observations of the facility between 05/05/25 and 05/07/25 showed the following areas in need of cleaning or repair:

* Common area bathrooms were found to have missing and/or discolored sealant at the shower edge and the flooring. Several laminate boards were pulling apart at the seams creating gaps in the flooring. Transition strips at the doorways of the bathrooms were pulling away from floor edges and/or had pieces missing;

* Lights throughout the hallways, television room and dining room had debris and/or dead bugs in the covers;

*Round hanging lights in the entryway and dining room had dust accumulation and/or were discolored;

* Wall chips and missing plaster were noted behind the nurse’s station;

* A large crack between the outside door in the television room and wall was noted on the left-hand side;

* Dining room blinds were covered with dust and debris. Windowsills had dirt, debris and dead insects present;

* Flooring in the sunroom, television room, hallways and dining room had long scuffs, scratches and/or gouges. The television room and two short halls of the facility had chips, dings and large chunks of flooring missing. The transition areas at the doorways in the hallway were bubbled, raised and/or cracked;

* The divider wall in Room 22 was scraped, dinged and had a loose chunk of board hanging down towards the floor;

* Tables and chairs in the dining room, sunroom and television room had dings, scrapes, food spills and debris on arms, legs and/or fabric backs;

* Two armchairs in the entryway had dark stains on the arms and lower portions of the chairs. A vinyl love seat in the entryway had worn fabric spots on the arms with an exposed fabric layer;

* Two recliners in the tv room had stains and/or splatters, and one of the chairs had a large tear on the footrest with exposed foam;

* A small, carpeted area in the television room was stained, frayed and missing large pieces of transition edge covering; and

* The flooring in Room 8 and 9A had several sections that were pulling apart at the seams, creating gaps and/or small chips to the flooring.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 05/06/25. She acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

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

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to:

During the survey from 05/05/25 through 05/07/25, observations and interviews with residents and staff confirmed not all residents had keys to their units.

In interview on 05/05/25, Staff 1 (ED) indicated residents who wanted a key and could use a key were given one. They did not routinely give every resident a key to their units.

The need to ensure all residents were provided keys to their units was discussed with Staff 1 on 05/05/25. She acknowledged the findings.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access

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

This Rule is not met as evidenced by:

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

Refer to C 231, C 372, C 420, C 422, C 510, and C 513.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 7, 9, 10, and 18) completed all pre-service orientation requirements before performing any job duties, 3 of newly-hired direct care staff (#s 7, 9, and 10) completed pre-service training before independently providing personal care services and demonstrated competencies within 30 days of hire for all tasks assigned in the provision of resident services. Findings include, but are not limited to:

Staff training records reviewed on 05/06/25 at 3:00 pm identified the following:

1. Staff 7 (MT), Staff 9 (CG), Staff 10 (MT/CG), and Staff 18 (Housekeeping), hired on 02/24/25, 02/15/25, 03/03/25 and 04/18/25, respectively, lacked documented evidence of completing pre-service orientation before performing any job duties as follows:

a. Staff 7, 9, and 18 lacked abuse reporting requirements.

b. Staff 10 completed fire safety and emergency procedures on 05/06/25.

c. Staff 9 and 10 did not have signed job descriptions, and Staff 7 and Staff 18 signed their job descriptions on 05/06/25.

d. Staff 9 lacked approved infectious disease prevention training, Home and Community Based Services (HCBS) training, and approved LGBTQIA2s+ training.

2. There was no documented evidence Staff 9 completed pre-service dementia training.

3. Staff 7, 9, and 10 lacked documented evidence of completing additional pre-service training prior to independently providing personal care as follows:

a. Staff 7, 9 and 10 lacked:

* Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lighting, room, temperature, noise, etc.);

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require ongoing assessment; and

* Use of supportive devices with restraining qualities in memory care communities.

b. Staff 9 lacked how to provide personal care to a resident with dementia, including an orientation to the resident’s service plan.

4. Staff 7, Staff 9, and Staff 10 lacked documentation of demonstrated competency in any duty to which they were assigned.

The need to ensure all required training was completed within the specified time frames was discussed with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 252, C 260, C 270, C 303, C 305, C 310, C 330 and C 340.

OAR 411-057-0160(2b) Compliance with Rules Health Care

(b) Health care services provided in accordance with the licensing rules of the facility.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' care plans, for 2 of 3 sampled residents (#s 2 and 5). Findings include, but are not limited to:

Residents 2 and 5's current care plans were reviewed during survey. Each of the care plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to develop individualized care plans addressing residents' nutrition and hydration was discussed with Staff 1 (ED) and Staff 2 (RCC). The staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to develop an individualized activity plan based on an activity evaluation for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose activity plans were reviewed. Findings include, but are not limited to:

Activity documents were reviewed with Staff 3 (Activities Director) on 05/06/25. Residents 1, 2, 3, 4, and 5 each had a “Then & Now” document and an “Individualized Activity Plans” document. The two documents together contained all the required components for an activity evaluation.

There was no individualized activity plan developed for each resident based on their activity evaluation which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.

The need to develop individualized activity plans which were based on the activity evaluation was discussed with Staff 3 on 05/06/25, and with Staff 1 (ED) and Staff 2 (RCC) on 05/07/25. They acknowledged the findings.

OAR 411-057-0160(2d) Activities

(d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure that fencing was no less than six feet in height, constructed to reduce the risk of elopement and that furniture was of sufficient weight to prevent injury or aid in elopement. Findings include, but are not limited to:

A tour of the facility's MCC courtyard on 05/05/25 showed multiple sections of chain link fence in the courtyard and in two unsecured breezeways that were less than six feet in height. The shortest sections were approximately five feet four inches, up to five feet nine inches in height.

The two unsecured breezeways had multiple plastic milk crates, chairs and/or cinder blocks stacked against or next to the chain link fences. These items posed an elopement risk as it gave residents items to stand on to aide in climbing the fence.

The fencing sections that were less than six feet in height and the items stacked next to the fence were shown to and discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 05/05/25. Staff 4 removed the stacked items. The staff acknowledged the findings.

OAR 411-057-0170(6) Secure Outdoor Recreation Area

(6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy.

This Rule is not met as evidenced by:

Based on observation and interviews, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to:

Observation of the kitchen on 12/31/24 at 10:45 am through 1:00 pm revealed the following deficiencies:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Flooring/walls and ceiling in freezer room;
* Flooring in corners, edges, between and under equipment in main kitchen area;
* Floors and walls in dry storage;
* Walls, floors, ceiling, and vents;
* Drains throughout kitchen;
* Industrial can opener and housing;
* Interiors of cupboards/cabinets and drawers;
* Interior of reach in cooler;
* Range top, grill, and interior of ovens;
* Steam wells and knobs;
* Grill and oven knobs;
* Floor between oven and side tables with food debris;
* Walls throughout kitchen and food storage areas;
* Area behind and under 3 compartment sink;
* Minor equipment (blender/food processor);
* Metal racks;
* Open metal shelving;
* Plastic bins/containers storing food;
* Coffee makers;
* Utility carts;
* Fan blades and cages;
* Metal racks in reach in cooler;
* Hand washing skink and surrounding area;

b. The following areas were found in need of repair:

* Cabinets under hand washing sink with visible damage;
* Section of caulking behind sinks with black matter buildup;
* Vents and fire sprinklers with heavy dust/dirt buildup;
* Multiple light fixtures in kitchen and dry storage not operational making dark and unsafe conditions.
* Holes around electrical conduit by hood and fire suppression system allowing potential entry way to insects and pests.
* Facility dishwasher had broken and been removed more than two months prior and had not been replaced or repaired.

b. Facility did not have a commercial dishwasher. It was removed in October. Facility was utilizing the 3 compartment sink method to clean and sanitize dishes. Staff 1(Facility Designee) was not aware a commercial dishwasher was required for facilities with census capacity of 17 or more. Staff 1 acknowledged facility had a census capacity of 22 residents.

c. Handwashing sink was directly by a food prep or service area and did not have a splash guard to prevent possible contamination of food or area by hand washing.

d. Multiple food items observed stored in reach in coolers without open dates.

e. Scoops were found stored in multiple bulk food items/bins potentially contaminating food products;

f. Seven days of menus were not readily available as required. Staff 2 stated usually week of menus was posted out side of kitchen. Staff 2 stated the printer was broken. Staff 1 indicated the menu system license had expired.

f. Food contact surfaces of utensils and to go containers and disposable plates/bowls were found stored uncovered and open to potential contamination.

Surveyor toured kitchen areas with Staff 2 (Dining Services Manager) and they acknowledged the identified areas. At 12:30 pm surveyor reviewed items with staff 1 (Facility designee) and they acknowledge areas needing correction.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

This Rule is not met as evidenced by:

Based on observation and interview, it was determined that the facility failed to have a commercial dishwasher when census capacity is 17 or greater.

During the annual kitchen survey on 12/31/24, it was observed that the facility did not have a commercial dishwasher. Staff 2 (Food Service Director) was interviewed at approximately 11:00am and indicated the dishwasher had been removed in October. Staff 2 verified they were using the Three compartment sink method for cleaning and sanitizing of dishes. Staff 2 had indicated they had inquired several times as to when another dishwasher would be installed and had not been made aware when or if one would be replaced. At approximately 12:45 Staff 1 (facility administration designee) was informed of the need for a commercial dishwasher for facilities with 17 or more capacity. Staff 1 verified capacity was 17 or more and that they did not currently have a commercial dishwasher. They were unaware of a rule that required one. Staff 1 did indicate that the facility had attempted to get one from a sister facility but it did not fit.

OAR 411-054-0200 (7)(e) Kitchen and Food Storage

(e) KITCHEN AND FOOD STORAGE. Kitchen facilities and equipment in residential care facilities with a capacity of 16 or fewer may be of residential type except as required by the building codes. Residential care facilities licensed for a capacity of more than 16, must comply with OAR 333-150-0000 (Food Sanitation Rules). The following are required:
(A) Dry storage space, not subject to freezing, for a minimum one-week supply of staple foods.
(B) Refrigeration and freezer space at proper temperature to store a minimum two days' supply of perishable foods.
(C) Storage for all dishware, utensils, and cooking utensils used by residents must meet OAR 333-150-0000 (Food Sanitation Rules).
(D) In facilities licensed to serve 16 or fewer residents, a dishwasher must be provided (may be residential type) with a minimum final rinse temperature of 140 degrees Fahrenheit (160 degrees recommended), unless a chemical disinfectant is used in lieu of the otherwise required water temperature. In facilities of 17 or more capacity, a commercial dishwasher is required meeting OAR 333-150-0000 (Food Sanitation Rules).
(E) In residential care facilities with a capacity of 16 or fewer, a two compartment sink or separate food preparation sink and hand wash lavatory must be provided. In residential care facilities with 17 or more capacity, a triple pot wash sink (unless all pots are sanitized in the dishwasher), a food prep sink, and separate hand wash lavatory must be provided.
(F) Food preparation and serving areas must have smooth and cleanable counters.
(G) Stove and oven equipment for cooking and baking needs.
(H) Storage in the food preparation area for garbage must be enclosed and separate from food storage.
(I) Storage for a mop and other cleaning tools and supplies used for dietary areas must be separate from those used in toilet rooms, resident rooms, and other support areas. In residential care facilities with a capacity of 17 or more, a separate janitor closet or alcove must be provided with a floor or service sink and storage for cleaning tools and supplies.
(J) Storage must be available for cookbooks, diet planning information, and records.
(K) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.

This Rule is not met as evidenced by:

Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on interview and document review, it was confirmed that the facility failed to develop and implement a written policy that prohibits the falsification of records. Findings include, but not limited to:A review of medication incident report dated 12/26/23 for Resident 1 indicated the following:· Corrective actions taken following med error reported " Counseling performed, Physician Contacted, Review of the 8 rights of medication assistance with return demonstration. "During interviews on 04/03/24, Staff 3 (MT/RCC) stated the previous RCC did mark on the incident report that staff was counseled which is incorrect. Staff 5 (MT/RA) stated "I made a med error and the documents said I was counseled and talked to, but I never was" . S/he stated that staff member who documented that was no longer working at the facility.The findings were reviewed with and acknowledged by Staff 3 on 04/03/24 and with Staff 1 (ED) on 04/04/24.It was confirmed the facility failed to develop and implement a written policy that prohibits the falsification of records.Plan of correction: Previous RCC no longer is working at the facility. ED will ensure that the new RCC is trained on accurate documentation and will be documenting any follow up conversations or trainings given to staff. ED will follow up with all parties involved before signing off on incident reports.

Based on interview and record review, conducted during a site visit on 04/03/24, it was confirmed the facility failed to ensure service plans were updated quarterly for 2 of 3 sampled residents (#2, 4, and 5), whose service plans were reviewed. Findings include, but are not limited to:A review of Resident 2's service plan dated 12/17/23 and Resident 5's service plan dated 12/21/23 indicated the facility had not updated the residents service plan quarterly.During an interview, Staff 1 (ED) confirmed the facility had been behind on resident service plans and stated s/he had been working on getting them updated. The findings were reviewed with and acknowledged by Staff 1 on 04/04/24.It was confirmed the facility failed to ensure service plans were updated quarterly.Verbal plan of correction: ED and RCC have already been working on getting all of the service plans updated that are out of date.

Based on interview and record review, conducted during a site visit on 04/03/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#3). Findings include, but not limited to:Compliance Specialist (CS) reviewed Resident 3's March 2024 MAR and physician orders which indicated the following:· Order dated 03/21/23 for Hydroxyzine Pamoate 25 MG Capsule to be given one capsule by mouth twice daily for itching· MAR shows resident did not receive his/her Hydroxyzine scheduled for 8 pm on 03/24/24· Order dated 03/31/23 for Melatonin Soft Gel 10 MG Capsule to be given 1 capsule by mouth every day at bedtime for insomnia· MAR shows between 03/02/24-03/20/24 resident did not receive his/her Melatonin on twelve different dates due to "awaiting med from pharmacy"During an interview, Staff 1 (MT/RCC) stated the power did go out for a few days, however, they had printed MARs and the correct orders were added or updated on the paper MAR. Staff 5 (MT/RA) stated medications are not always re-ordered timely.The findings were reviewed with and acknowledged by Staff 3 on 04/03/24.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: ED has been working with each MT doing 1:1 training, re-doing competencies, going over the medication rights, checking the MAR and documentation. There will be a MT meeting this month to go over policy and procedures.Based on interview and record review, conducted during a site visit on 04/03/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but not limited to:Compliance Specialist (CS) reviewed Resident 1's December 2023 MAR, progress notes, and physician orders which indicated the following:· Order dated 03/30/23 for Clonazepan 1 MG Tablet to be given one tablet by mouth twice daily for anxiety· Progress note and incident report dated 12/26/23 stated resident was given his/her PRN Lorazepam on 12/24/23 and 12/25/23 instead of scheduled ClonazepanDuring an interview, Staff 3 (MT/RCC) stated the incident did occur and the MT should have matched the bubble pack to the MAR.The findings were reviewed with and acknowledged by Staff 3 on 04/03/24.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: ED has been working with each MT doing 1:1 training, Re-doing competencies, going over the medication rights, checking the MAR and documentation. There will be a MT meeting this month to go over policy and procedures.Based on interview and record review, conducted during a site visit on 04/03/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 2 of 2 sampled residents (#1's and 4). Findings include, but are not limited to:Compliance Specialist (CS) reviewed Resident 1's January 2024 MAR, progress notes, and physician orders which indicated the following:· Order dated 03/30/23 for Clonazepam 1 MG Tablet to be given one tablet by mouth twice daily for anxiety· Progress notes and incident report dated 01/22/24 reported resident missed his/her 7:30am Clonazepam Compliance Specialist (CS) reviewed Resident 4's January 2024 MAR, progress notes, and physician orders which indicated the following:· Order dated 08/17/23 for Lorazepam 1 MG Tablet to be given one tablet by mouth three times daily for anxiety· Progress notes and incident report dated 01/08/24 reported resident missed his/her 2pm Lorazepam· MAR indicated from 01/19/24-01/22/24 resident did not receive his/her Lorazepam due to "awaiting med from pharmacy"During an interview, Staff 3 (MT/RCC) stated the incident did occur.The findings were reviewed with and acknowledged by Staff 3 on 04/03/24.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: ED has been working with each MT doing 1:1 training, Re-doing competencies, going over the medication rights, checking the MAR and documentation. There will be a MT meeting this month to go over policy and procedures.

Based on interview and record review, conducted during a site visit on 04/03/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:In review of the facility's ABST and resident roster on 04/03/24, it was determined all 17 residents were entered into the ABST. The tool contained all 22 required ADLs and generated a 24-hour staffing plan. There were 7 residents on the ABST that had not been updated at least quarterly with the oldest date being 11/14/23.In an interview on 04/05/24, Staff 1 (ED) stated the previous RCC had not been keeping the ABST updated.On 04/05/24, findings were reviewed with and acknowledged by Staff 1.The facility failed to fully implement and update an ABST.

Based on interview and record review, it was confirmed the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing for 3 of 3 sampled staff (#'s 3, 4, and 5). Findings include, but are not limited to:Compliance Specialist (CS) reviewed completed MT training and Medication Aide Training procedures for Staff 3 (MT), Staff 4 (MT), and Staff 5 (MT) which indicated the following:· Staff 3's completed MT Skills checklist was dated 03/01/24, however, was working as the MT on the February 2024 staff schedule.· Staff 4 did not have a completed MT Skills checklist and was working as MT.· Staff 5's completed MT Skills checklist was dated 03/26/24, however, was scheduled as the MT alone in March 2024 prior to completing the training.During an interview on 04/05/24, Staff 1 (ED) stated s/he could not find completed training documents for some staff. S/he also stated they had found some that hadn't been completed by the previous RCC.The findings were reviewed with and acknowledged by Staff 1 on 04/05/24.It was determined the facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing.Plan of correction: ED is working to make sure that all staff have completed their required trainings and document them. They will make sure that MTs have the trainings completed before their next shifts.

The findings of the on-site investigation, conducted 01/03/2024, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

The findings of the on-site investigation, conducted 01/03/2024, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

The findings of the on-site investigation, conducted 01/03/2024, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

The findings of the on-site investigation, conducted 9/14/23 through 9/14/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

The findings of the on-site investigation, conducted 9/14/23 through 9/14/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

The findings of the on-site investigation, conducted 09/14/23 through 09/14/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

The findings of the on-site investigation, conducted 9/14/23 through 9/14/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Based on interview and record review, conducted during a site visit on 09/14/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: Resident 1's February 2023 Medication Administration Record (MAR) and progress notes, indicated the following:* fixed order for Novolog 100 u/ml flexpen 13 units 3x daily before meals. Hold scheduled insulin if BG level at mealtime is less than 120.* order Novolog 100 u/ml flexpen 0-11 sliding scale <100-no insulin, 101-150- 6 units, 151-200- 7 units, 201-250- 8 units, 251-300- 9 units, 301-350- 10 units, BS>350 give- 11 units. Give in addition to fixed units*Resident 1 missed his/her 2:00 pm dose of Lactulose 10gm/15ml SOLN on 02/19/23 with a noted exception of "awaiting med from pharmacy"; *Progress note on 2/24/23 at 3:19 pm indicated on 02/23/23, Resident 1 was ordered to recieved an additional 6 units of Insulin Novalog 100U/ML per sliding scale order (101-150= 6 units) for CBG of 105 at 5:00 pm. Staff gave the base 13 units and did not give the additional 6 units; and*On 02/09/23 and 02/10/23, there was no evidence of the 11:30 am CBG, or units given for Insulin Novalog 100U/ML Flex pen. * On 02/21/23 at 4:30 pm CBG was 99 and 13 units were given. Order was to hold if less than 120.* On 02/24/23 at 4:30 pm CBG was 171 and only 13 units were given.* On 02/18/23 and 02/24/23, there was no evidence of the 11:30 am CBG, or units given for Insulin Novalog 100U/ML Flex pen. Resident 2's February 2023 MAR and progress notes indicated Resident 2 missed his/her 8:00 pm dose of Melatonin 5mg Tab due to med not being available.During an interview, Staff 1 (ED) stated most medications are on cycle fill. S/he also stated that they had been doing a lot of re-training on medication administration since s/he started in August 2023.The findings were reviewed with and acknowledged by Staff 1 on 09/14/23.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: Staff received in-service training last week on Wednesday (Sept 6th) and the RN, ED, MT lead, and RCC will be having a "boot camp" for the med techs. Training will be provided on ordering/re-ordering medications and the 3-check system. A lead MT was hired, there have been increased MT meetings, and the RCC will start auditing the MAR and pulling missed med reviews next week to ensure medications are being administered as ordered.

The findings of the on-site investigation, conducted on 09/14/23 , are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Based on interview and record review, conducted during a site visit on 09/14/23, it was confirmed the facility failed to ensure the completeness, accuracy, and preservation of resident records for 5 of 7 sampled residents (#s 1, 2, 3, 4, and 5) whose records were reviewed. Findings include, but are not limited to: Compliance Specialist reviewed Resident 1, 2, 3, 4, and 5s' August 2023 Medication Administration Records (MARs), progress notes, doctor's orders, and the facility's alert charting log and incident reports. Documents indicated Residents1, 2, 3, 4, and 5s' all had missed medication on 08/22/23 as indicated by their progress note, incident report, or alert charting log; however, documentation on the MAR reported that the medications were given. During separate interviews, Staff 1 (ED) stated s/he did their own investigation of the incidents on 08/22/23. S/he stated, "they were given and documented, but they were not popped on the right day". Staff 1 stated that s/he had not documented his/her investigation or findings. S/he also stated that they had been doing a lot of retraining on medication administration since s/he started in August 2023. Staff 4 (CG) stated s/he had two med errors at the same time. S/he stated they "signed it out on the MAR and forgot to pop it " so they are "no longer passing meds". The findings were reviewed with and acknowledged by Staff 1 on 09/14/23.It was confirmed the facility failed to ensure the completeness, accuracy, and preservation of resident records.Verbal plan of correction: Staff received in-service training last week on Wednesday (Sept 6th) and the RN, ED, MT lead, and RCC will be having a "boot camp" for the med techs. Training will be provided on documentation, ordering/re-ordering medications, and the 3-check system. A lead MT was hired, there have been increased MT meetings, and the RCC will start auditing the MAR and pulling missed med reviews next week to ensure medications are being administered as ordered.

Based on interview and record review, conducted during a site visit on 09/14/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 5 of 7 sampled residents (#s 1, 2, 3, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to: Compliance Specialist reviewed Residents 1, 2, 3, 4, and 5s' August 2023 Medication Administration Record (MAR), progress notes, doctor's orders, and the facility's alert charting log and incident reports. The following discrepancies were found:a. Resident 1's records indicated:· Alert charting log reported "missed meds" for 08/22/23; · MAR showed medications as given on 08/22/23; and · Progress note dated 08/24/23 at 2:09 am reported Resident on alert charting for "missed meds" on 08/22/23.b. Resident 2's records indicated:· Alert charting log reported "missed meds" for 08/22/23;· Medication incident report dated 8/22/23 reported that resident did not receive 8 am medications;· MAR showed medications as given on 08/22/23; and· Progress note dated 08/26/23 at 1:54 am reported resident on alert charting for "missed medication 8/22".c. Resident 3's records indicated:· Alert charting log reported "missed med" 08/22/23;· MAR showed medications as given on 08/22/23; and· Progress note dated 8/24/23 at 9:32 am reported resident on alert charting for "missed medication".d. Resident 4's records indicated:· Alert charting log reported "missed med" 08/22/23;· MAR showed medications as given on 08/22/23; and · Progress note dated 8/26/23 at 2:11 am reported resident on alert charting for "missed medication".e. Resident 5's records indicated:· Medication incident report, dated 08/22/23, reported resident did not receive their 8 am medications; · There were no entries in the progress notes regarding alert charting for missed med· MAR showed medications as given on 08/22/23;* MAR indicated Resident 5 did not recieve their 12 pm dose of Cephalexin 500 mg capsule due to waiting on med from pharmacy; and· MAR indicated on 08/12/23, 08/13/23, and 08/14/23 Resident 5 did not recieve their Trazadone HCL 50 mg tablet due to awaiting med from pharmacy or Doctor needs to be called for refill. During separate interviews, Staff 1 (ED) stated s/he did their own investigation of the incidents on 08/22/23. S/he stated, "they were given and documented, but they were not popped on the right day". Staff 1 stated s/he had not document his/her investigation or findings. S/he also stated that they had been doing a lot of re-training on medication administration since s/he started in August 2023. Staff 4 (CG) stated s/he had two med errors at the same time. S/he stated they "signed it out on the MAR and forgot to pop it" so s/he was "no longer passing meds" .The findings were reviewed with and acknowledged by Staff 1 on 09/14/23.It was confirmed the facility failed to carry out medication and treatment orders as prescribed.Verbal plan of correction: Staff received in-service training last week on Wednesday (Sept 6th) and the RN, ED, MT lead, and RCC will be having a " boot camp " for the med techs. Training will be provided on ordering/re-ordering medications and the 3-check system. A lead MT was hired, there have been increased MT meetings, and the RCC will start auditing the MAR and pulling missed med reviews next week to ensure medications are being administered as ordered.

The findings of the kitchen inspection, conducted 6/30/23-7/3/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first re-visit to the kitchen inspection of 06/30/23, conducted 10/5/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the second re-visit to the kitchen inspection of 06/30/23, conducted 01/11/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observation of the kitchen on 6/30/23 at 10:30 am through 12:30 pm revealed the following deficiencies:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* Flooring in freezer room;* Flooring in corners, edges, between and under equipment;* Interior of Ice machine;* Ceiling, vents and fire sprinklers;* Drains throughout kitchen;* Industrial can opener and housing;* Interior of microwave;* Interiors of cupboards/cabinets and drawers;* Interior of resident refrigerator;* Interior of freezer;* Range top, grill, and interior of ovens;* Grill and oven knobs;* Floor between oven and side tables with food debris;* Ceiling above ovens:* Walls throughout kitchen and food storage areas;* Area behind and under dishwasher; and* Hand washing sink and surrounding area. b. The following areas were found in need of repair:* Cabinets under 3 compartment sink with damaged/rotting wood;* Wood cabinets throughout kitchen with areas needing repaired or painted;* Section of caulking behind sinks with black matter buildup;* Wood pallet under ice machine causing un-cleanable area.* Vents and fire sprinklers with heavy dust/dirt buildup;* Cabinet areas stained or cracked or chipped; and* Door thresholds with damaged/exposed wood.c. Cutting boards were observed heavily stained and scored. Spatulas also found chipped and stained.d. Facility did not have test strips available to validate concentration of sanitizer used for surface sanitation buckets and 3 compartment sinks, or dish machine. e. Dish machine was not registering any chemical to sanitize dishes. Surveyor tested dish machine with chlorine and quat test strips. Neither one registered any concentration. Per staff 2 (Dinning Service Manager) the chemical for machine was chlorine. S/He validated there were no strips on hand and was shown test strips and validated no chemical sanitizer was registering. Staff 2 indicated the facility would utilize a 3 sink method until dish machine representative could service the machine.f. Kitchen staff preparing and/or serving food did not have hair and/or facial hair effectively restrained as required. g. Hand washing sink was directly by a food prep or service area and did not have a splash guard to prevent possible contamination of food or area by hand washing. h. Dish washing racks were observed stored on the floor. i. Scoops were found stored in multiple bulk food items/bins.Surveyor reviewed above areas with Staff 2 (Dining Services Manager) and s/he acknowledged the identified areas. On 7/3/23 at 12:00 pm the surveyor reviewed the areas in need of cleaning, repair and poor practices with Staff 1 (Administrator). S/he acknowledged the areas.
Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observation of the kitchen on 10/5 at 11:30 am through 12:30 pm revealed the following:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* Flooring in freezer room;* Flooring in corners, edges, between and under equipment;* Ceiling, vents and fire sprinklers;* Drains throughout kitchen;* Industrial can opener and housing;* Interior of microwave;* Interiors of cupboards/cabinets and drawers;* Interior of resident refrigerator;* Interior of freezer;* Range top, grill and interior of ovens;* Grill and oven knobs;* Walls throughout kitchen and food storage areas;b. The following areas were found in need of repair:* Vents and fire sprinklers with heavy dust/dirt buildup;c. Multiple items in reach in refrigerator were not dated and/or labeled as required.d. Food contact equipment were not stored correctly to prevent potential contamination during storage. Forks/ knives/spoons were stored with food contact surfaces up and exposed to possible contaminants.e. A container of half and half was found past the manufactures use by date. f. Kitchen staff were observed preparing and/or serving food without their hair and/or facial hair effectively restrained as required. g. Hand washing sink was observed directly by a food prep/service area, where clean dishes (silverware and plates) were stored and no splash guard present to prevent possible contamination of food/area/equipment by hand washing. h. Dish washing racks were observed stored on the floor. i. Scoops were found stored in multiple bulk food items/bins.The surveyor reviewed the above areas with Staff 1 (Administrator) and s/he acknowledged the identified findings.

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

Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.
Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

The findings of the re-licensure survey conducted 04/04/22 through 04/05/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the initial survey of 04/05/22, conducted 09/20/22 through 09/22/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second revisit to the re-licensure survey of 04/22/22, conducted from 03/13/23 through 03/14/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 1 and 2) who were recently admitted to the facility. Findings include, but are not limited to:Move-in evaluations for Residents 1 and 2 were reviewed during the survey. The evaluations lacked the following required components: *Personality: including how the person copes with change or challenging situations;*Environmental factors that impact the residents behavior: noise, lighting, room temperature; and*Effective non-drug interventions for behaviors.On 04/05/22 the need to ensure new move in evaluations addressed all required elements was discussed with Staff 1 (Administrator) and Staff 3 (Community Liaison/MA). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:Current service plans for Residents 1 and 2 were reviewed during the survey. There was no documented evidence that a Service Planning Team reviewed and participated in the development of the service plans. On 04/05/22 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 3 (Community Liaison/MA). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents with changes of condition were evaluated and resident-specific instructions or interventions were determined, documented and monitored for effectiveness at least weekly through condition resolution for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in February 2022 with a diagnoses including dementia and macular degeneration.The resident's records including progress notes dated 02/16/22 through 04/24/22, incident reports, service plans and interim service plans were reviewed during survey and indicated the following:The resident's service plan dated 03/21/22 indicated the resident had a history of falls, had "very poor vision", was not oriented to persons, place or time, had poor memory and judgement and s/he was unable to use the call light. Resident 2 required assistance with all ADLs and one to two person assist for transfers. The service plan instructed staff to complete safety checks every hour, ensure the bed and chair alarms were in place at all times and to make sure a pathway was clear of clutter and spills or items on the apartment floor that could pose a trip hazard.The resident experienced four falls, both injury and non-injury, between 02/16/22 and 04/04/22. There was no evidence an interim service plan or other documentation was recorded to show the facility had determined resident specific interventions, evaluated current interventions for effectiveness and determined the need to implement additional interventions when the resident experienced the following falls:*02/20/22 at 1:35 pm: The resident was found sitting behind his/her walker by the Administrators office. There was redness to the lumbar back and coccyx area. *02/20/22 at 3:15 pm: An incident report revealed the resident was found on the floor of his/her apartment. No injury was noted. *02/21/22: Staff responded to the resident's alarm sounding and found the resident on the floor. The resident was transferred to the hospital and had sustained a hip fracture.*03/28/22: Staff observed resident fall to the floor while trying to get up from the wheelchair. No injury was noted.On 04/04/22 Staff 3 (Community Liaison/MA) reported there were no interim service plans for the above falls.The need to ensure residents with changes of condition were evaluated and resident-specific instructions or interventions were determined, documented and monitored for effectiveness at least weekly through condition resolution was discussed with Staff 1 (Administrator) and Staff 3 on 04/05/22. They acknowledged the findings.
2. Resident 1 was admitted to the memory care community in 02/2022 with diagnoses including congestive heart failure, dementia, hypertension and diabetes.Review of Resident 1's service plan, dated 02/28/22, progress notes, temporary service plans and incident reports indicated the resident experienced multiple short-term changes. The records lacked evidence that resident-specific interventions were implemented or monitored for effectiveness, or that conditions were monitored, at least weekly, to resolution in the following areas:*New admission to facility;*Fall with injury;*New admission to Hospice;*New bed alarm (for safety); and*New orders for Haldol (for agitation) and PRN oxygen (for shortness of breath).On 04/05/22 the need to ensure resident specific interventions were developed and monitored for effectiveness was discussed with Staff 1 (Administrator) and Staff 3 (Community Liaison/MA). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to determine and document what actions and interventions were needed for residents when they experienced short-term changes of condition, communicate them to staff on all shifts, and monitor the changes at least weekly for 2 of 4 sampled residents (#s 3 and 6) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 11/2019 with diagnoses including Alzheimer's Disease. Review of the resident's current service plan, 08/25/22 through 09/20/22 temporary service plans and progress notes revealed the resident fell on 08/29/22 and 09/06/22. There was no documented evidence the facility determined and documented what actions and interventions were needed for the resident and communicated them to staff on all shifts after the falls. The need to communicate the needs of the resident to staff on all shifts was discussed with Staff 1 (Administrator), Staff 3 (Community Liaison/MA), and Staff 4 (RCC). They acknowledged the findings. 2. Resident 6 was admitted to the facility in 08/2022 with diagnoses including Alzheimer's Disease. Review of the resident's current service plan, 08/25/22 through 09/20/22 temporary service plans and progress notes, revealed the resident experienced the following short-term changes of condition which were not monitored through resolution: a. A progress note dated 08/24/22 indicated the resident "smashed" his/her finger in the door of his/her daughter's car while out of the facility. Monitoring of the finger was discontinued on 08/31/22, though documentation in progress notes on that date indicated the resident's finger was still bruised. b. A progress note dated 08/27/22 stated Resident 6 fell out of bed and complained of left-sided rib pain. The resident was sent to the emergency department of the local hospital and diagnosed with a rib contusion. Monitoring of the resident for the rib contusion was discontinued on 08/31/22. Multiple progress notes between that date and 09/15/22 stated the resident still complained of rib pain. During an interview on 09/22/22, the resident confirmed s/he still had rib pain. The need to monitor short-term changes of condition through resolution was discussed with Staff 1 (Administrator), Staff 3 (Community Liaison/MA), and Staff 4 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 3 of 3 sampled residents (#s 5, 6 and 7) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.During interviews with Staff 1 (Administrator) and Staff 4 (RCC) on 09/21/22 at 9:15 am and 9:25 am respectively, they stated the facility had been without a RN since the middle of August, 2022. Staff 4 (RCC) identified Residents 5, 6 and 7 were administered insulin injections daily by non-licensed staff.Review of the 09/01/22 through 09/20/22 MARs for each of the residents revealed Staff 3 (MA/Community Liaison), Staff 9 (MA/Resident Assistant), and Staff 12 (MA/Resident Assistant), had administered insulin to the residents on multiple occasions.Review of the delegation documentation revealed Staff 3, 9, and 12 had been delegated to administer insulin to Residents 5 and 7 by the previous RN, but did not have current delegations. There was no documented evidence any staff had been delegated to administer insulin to Resident 6. Staff 1 and 4 confirmed this during an interview at 11:54 am on 09/21/22. At that time, the facility was directed to ensure staff were delegated to administer insulin to Resident 6 prior to any future administrations of the medication. At 3:48 pm, Staff 1 apprised the survey team, that Staff 2 (the previous RN) would return to her position that day to initiate delegation of Staff 12 for the administration of insulin to Resident 6 and would update delegations for the other staff in a timely manner. During an interview with Staff 1, 2, 3 and 4 at 5:00 pm on 09/21/22, Staff 2 stated she had initiated the delegation of Staff 12 for the administration of insulin to Resident 6. Staff 1 and 2 provided a written plan stating residents would only be administered insulin by delegated staff and all delegations would be updated timely. The need to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules for residents who received insulin injections by unlicensed facility staff was discussed with Staff 1, 2, 3 and 4 on multiple occasions throughout the day on 09/21/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 6 and 7) whose facility records were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 08/2022 with diagnoses including insulin-dependent diabetes. Review of the resident's 08/16/22 physician orders and 09/01/22 through 09/20/22 MAR revealed the following: a. Resident 6 had a physician order for Humalog (insulin) which stated, "Inject 0-11 units subcutaneously as directed per sliding scale, total daily dose max 35 units." The MAR reflected the medication was scheduled TID, though the physician had not indicated the frequency the medication was to be administered. There was no documentation the facility had clarified the order. There was no documentation on the MAR how many units of insulin staff administered for each administration of the medication. b. Toujeo (insulin) was ordered by the physician to be administered subcutaneously every morning. The facility held the medication 09/02/22, 09/05/22, 09/08/22, and 09/11/22 secondary to low blood glucose levels, though no instructions to do so were indicated by the physician. The need to follow physician orders as written and clarify orders when needed was discussed with Staff 1 (Administrator), Staff 3 ( MA/Community Liaison) and Staff 4 (RCC) on 09/21/22. They acknowledged the findings. The facility provided documentation a fax had been sent to the physician for clarification related to the frequency for administration of the Humalog prior to exit. 2. Resident 7 was admitted to the facility in 01/2021 with diagnoses including insulin-dependent diabetes. Review of the Resident's 08/19/22 physician orders and 09/01/22 through 09/20/22 MAR revealed the following: Resident 7 had a physician order for staff to administer 4 units of Humalog (insulin) PRN to the resident subcutaneously when the resident's blood glucose levels exceeded 300 and to recheck the resident's blood glucose one hour after administration of the medication. The resident experienced blood glucose levels greater than 300 seven times between 09/01/22 through 09/20/22. There was no documented evidence the facility administered the PRN insulin on four of the occasions and no documentation the resident's blood glucose levels had been re-checked after administration of the medication. The need to follow MD orders as written was discussed with Staff 1 (Administrator), Staff 3 (MA/Community Liaison) and Staff 4 (RCC) on 09/22/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. Findings include, but are not limited to:Fire drill and fire and life safety records were reviewed for October 2021 through March 2022. The following deficiencies were identified:* There was no documented evidence the facility was conducting fire drills every other month on alternating shifts for the memory care community;* There was no documented evidence the facility was providing fire and life safety training on alternating months for staff; and* The conducted evacuation/drill documentation did not contain information on the escape route used, problems encountered, evacuation time period needed, the number of occupants evacuated, or evidence that alternate routes were used during fire drills. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) and Staff 6 (Maintenance Director) on 04/04/22. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drill documentation reflected all required components. This is a repeat citation. Findings include, but are not limited to:The 09/01/22 fire drill record, reviewed on 09/20/22, failed to include documentation the time the drill was conducted, the escape route used, and any problems encountered. The need to ensure file drill records included documentation of all required components was discussed with Staff 1 (Administrator), Staff 3 (Community Liaison/MA), Staff 4 (RCC), and Staff 6 (Maintenance Director) on 09/22/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C270, C420, C510, C513, Z163, Z164

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. Findings include, but are not limited to:Observations of the secure courtyard on 04/04/22 showed there were multiple drop-offs of 2-3 inches along sitting areas in the courtyard and a drop off of approximately 5 inches off the sidewalk in front of the west wing exit door to the courtyard.The need to ensure pathways in the resident courtyard did not have potential safety hazards was discussed with Staff 1 (Administrator) and Staff 6 (Maintenance Director) on 04/05/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. This is a repeat citation. Findings include, but are not limited to:During a tour of the secured courtyard on 09/20/22, multiple drop-offs of 2-5 inches were noted along the concrete pathway edges. The need to ensure pathways in the resident courtyard did not have potential safety hazards was discussed with Staff 1 (MC Administrator) and Staff 6 (Maintenance Director) on 9/20/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:During a tour of the facility on 04/04/22 with Staff 6 (Maintenance Director) the following areas were found in need of cleaning or repair:* Multiple walls in the dining room had scrapes or gouges and/or splatters/drips;* There were broken slats on two of the the blinds in the dining room windows;* Three areas of linoleum in the dining room had square and triangular pieces missing;* The service table in the dining room had missing laminate on one edge, exposing bare wood surface;* Cove base in the dining room was being secured to one wall with black tape, approximately six feet in length; * Multiple door frames throughout the facility had chips, gouges and/or scrapes; * Multiple walls throughout the facility had scrapes or gouges;* Hand rails were worn and scraped, showing bare wood surfaces throughout the facility;* Overhead light fixtures in the hallways had debris and dead insects;* Two overhead light fixtures were cracked or broken;* Linen closet door had a large cracked/broken area;* Restroom number three had a large area of warped and chipped linoleum on the floor;* Restroom number two had areas on the walls around the sink chipped and worn without paint and there were areas missing stain protection on the wood mount of the grab bar above the toilet;* All bathrooms had dirt and/or debris on the floors, sinks, toilets and showers; and* Beige chairs in the sun room had gray and black colored stains.The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) and Staff 6 on 04/05/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. This is a repeat citation. Findings include, but are not limited to:During a tour of the facility with Staff 1 (Administrator) and Staff 6 (Maintenance Director) on 09/20/22, the following areas were found in need of cleaning or repair:* Multiple walls and door frames in the dining room and bathrooms had smudges, gouges and chipped paint;* Overhead light fixtures throughout the building had debris and dead insects;* Multiple overhead light fixtures were cracked or broken or missing covers;* Floors throughout the building had a build-up of dirt and debris; and* The beige chairs in the sun room had gray and black colored stains.The need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 6 on 09/22/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:Observations on 04/04/22 showed that the two exit doors leading out to the secured courtyard did not have an operational alarm or other acceptable system to alert staff when residents exited the building. The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Administrator) and Staff 6 (Maintenance Director) on 04/05/22. They acknowledged the findings.

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 420, C 510, C 513 and C 555.
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 C420, C510 and C513.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 252, C 262 and C 270.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C270, C282 and C303.

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:Resident 1 was admitted to the memory care community in 02/2022 with diagnoses including congestive heart failure, dementia, hypertension and diabetes.Resident 2 was admitted to the MCC in 02/2022 with diagnoses including dementia and macular degeneration.Resident 1's service plan, dated 02/28/22 and Resident 2's service plan, dated 03/21/22 were reviewed during the survey. In both cases, the service plans lacked documentation of individualized nutrition and hydration plans for the residents.On 04/05/22 the need to develop individualized nutrition and hydration plans was discussed with Staff 1 (Administrator) and Staff 3 (Community Liaison/MA). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 2 of 2 sampled residents (#s 3 and 4) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 3 and 4's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions 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 (Administrator), Staff 3 (Community Liaison /MA) and Staff 4 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to develop individualized activity plans based on activity evaluations, and reflective of each resident's current needs and preferences for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:Current evaluations and service plans for Residents 1 and 2 were reviewed during the survey. The records lacked evidence that individualized activity plans were developed, based on an activity evaluation, for meaningful activities that promoted the physical and emotional well-being of each resident, were person-directed and available during the resident's waking hours.Both Resident 1 and 2's evaluations failed to address the following required elements:-Past and current interests;-Current abilities and skills;-Emotional and social needs and patterns;-Physical abilities and limitations;-Adaptations necessary for the resident to participate; and-Activities for behavior interventions.On 04/05/22 the need to develop individualized activity plans that were reflective of each resident's current status and available during resident's waking hours was discussed with Staff 1 (Administrator) and Staff 3 (Community Liaison/MA). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 2 sampled residents (#s 3 and 4) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 3 and 4's service plans were reviewed. There was no documented evidence activity plans had been developed for the residents based on their activity evaluations. The need to ensure activity evaluations were thorough and activity plans developed for each resident was discussed with Staff 1 (Administrator), Staff 3 (Community Liaison), and Staff 4 (RCC). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to not aid in elopement. Findings include, but are not limited to:A tour of the facility courtyard on 04/04/22 with Staff 1 (Administrator) and Staff 6 (Maintenance Director) was completed and identified the following: Multiple metal patio chairs, one metal dining size table and three benches, were not of sufficient weight. The need to ensure outdoor furniture was of sufficient weight and design to not aid in elopement was discussed with Staff 1 and Staff 6. They staff acknowledged the findings. Staff 1 also stated the patio furniture would be removed.