Marjorie House Memory Care Community

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

Based on interview and record review, it was determined the facility failed to ensure incidents of abuse, suspected abuse, or injuries of unknown cause were promptly investigated to rule out abuse and neglect and immediately reported to the local Seniors and People with Disabilities (SPD) office when required for 4 of 5 sampled residents (#s 3, 4, 5, and 6). Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 07/2022 with diagnoses including Alzheimer’s disease. In the acuity interview on 01/06/26, Resident 3 was identified as non-verbal, dependent on two caregivers and a Hoyer lift for transfers, and needing full assistance for all ADLs, including meal assistance. The resident’s record, including 10/02/25 service plan, 10/02/25 to 01/05/26 progress notes, alert charting notes, temporary service plan, and incident reports were reviewed. Staff documented the following incidents: * 10/31/25 – Found on floor with redness to left ankle right shin, left cheek, and right knee, a small abrasion on right toe, and “peeled skin” on right knee; and * 11/23/25 – Wounds/scabs on inner right wrist. There was no documented evidence the above injuries of unknown cause had been investigated to rule out abuse or neglect and/or reported to the local SPD office if abuse/neglect could not be ruled out. In an interview on 01/07/26 at 10:00 am, Staff 1 (Administrator) confirmed investigations for the above incidents had not been completed. Survey requested the incidents be reported to the SPD office, and confirmation was provided on 01/08/26, prior to survey exit. The need to ensure incidents or injuries of unknown cause were promptly investigated to rule out abuse and neglect and immediately reported to the local SPD office if abuse and/or neglect could not be ruled out was reviewed on 01/08/26 at 11:35 am with Staff 1 and Staff 2 (Regional Manager). They acknowledged the findings. 2. Resident 4 was admitted to the facility in 03/2022 with diagnoses including vascular dementia and anxiety disorder. In the acuity interview on 01/06/26, Resident 4 was identified as dependent on two caregivers for transfers and needing full assistance for all ADLs, including meal assistance. Review of the resident's record, including the 11/25/25 service plan, 10/05/25 through 01/05/26 progress notes, alert charting notes, temporary service plans, and incident reports was completed. Staff documented the following incidents: * 11/02/25 – Fall out of wheelchair; * 11/06/25 – Left shin bruise; * 11/15/25 – Found on floor; and * 11/18/25 – Left forearm skin tear. The resident was not able to state what happened regarding the above incidents. There was no documented evidence these incidents were investigated to rule out abuse and/or neglect or were reported to the local SPD if abuse and/or neglect could not be ruled out. During an interview on 01/06/26 at 11:05 am, Staff 1 (Administrator) confirmed the above investigations had not been completed. However, she would investigate the 11/02/25 and 11/15/25 incidents, as camera footage was available. The facility reported the injuries of unknown cause occurring on 11/06/25 and 11/18/25 to the local SPD, as abuse and/or neglect could not be ruled out. Confirmation of the investigations was received on 01/08/26, prior to survey exit. The need to investigate all incidents promptly and to report incidents to the local SPD if abuse and/or neglect could not be ruled out was discussed with Staff 1 and Staff 2 (Regional Manager) on 01/08/26 at 11:15 am. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 08/2021 with diagnoses including dementia without behavioral disturbance. Review of the resident's record, including the 10/26/25 service plan, 10/01/25 through 01/02/26 progress notes, alert charting notes, temporary service plans, and incident reports was completed. a. Staff documented the following incidents and injuries of unknown cause: * 11/02/25 – Scratch on right elbow; * 12/04/25 – Resident to Resident altercation; and * 12/20/25 – Bruising/discoloration around both wrists. Observations made of the resident throughout the survey and an interview with Staff 8 (MA) on 01/07/26 at 1:47 pm confirmed the resident was mostly non-verbal. The service plan dated 10/26/25 stated Resident 6 was “mostly non-verbal and will occasionally speak in jumbled, vague language.” There was no documented evidence the incidents were investigated to rule out abuse or suspected abuse and immediately reported to the local office if the investigation could not reasonably conclude the injuries were not the result of abuse. An interview with Staff 1 (Administrator) on 01/07/26 at 1:55 pm confirmed the above incidents had not been investigated or reported to the local SPD office. On 01/07/26, the facility provided documentation that the incidents were reported to the local SPD office. b. Staff documented the following: * 10/26/25 – Resident to resident altercation; and * 12/06/25 – Resident to resident altercation. There was no documented evidence the above incidents were immediately reported to the local SPD office. Confirmation was received on 01/07/26 and 01/08/26 that the above incidents were reported to the local SPD office. The need to investigate all injuries of unknown cause to determine whether or not abuse and/or neglect could be reasonably ruled out, and to report to the local SPD office when needed; and to report all incidents of abuse or suspected abuse to the local SPD office was discussed with Staff 1, Staff 2 (Regional Manager), and Staff 3 (LPN) on 01/08/26 at 10:30 am. They acknowledged the findings.

#1 Example 1: Resident #3 – Staff will continue to follow current care plan and hospice instructions, including hourly checks, daily skin audits during cares by MH care staff, continuing with scoop mattress and fall mat. For Resident #3, incident reports were created and reported to APS for the documented injuries of unknown cause dated 10/31/25 and 11/23/25. Example 2: Resident #4 – Staff will continue to follow current care plan and hospice instructions, including safety checks every 2 hours, daily skin audits during cares. For Resident #4, incident reports were created and reported to APS for the documented injuries of unknown cause dated 11/6/25 and 11/18/25. Administrator investigated documented incidents from 11/2/25 and 11/15/25 and reasonably ruled out abuse by review of video surveillance. Example #3: Resident #6 – Staff will continue to follow current care plan and hospice instructions, including safety checks every 2 hours, and daily skin audits during cares. For Resident #6, incident reports were created and reported to APS for the documented injuries of unknown cause dated 11/2/25 and 12/20/25. The following incident reports for resident to resident altercations were reported to APS for further investigation: 10/26/25, 12/4/25 and 12/6/25. Moving forward, incidents and injuries of unknown cause will be investigated immediately and reported to APS within 24 hours. #2 Staff have received additional training on identifying reportable incidences of abuse, suspected abuse or injuries of unknown cause to ensure that all staff are alert and aware concerning any changes to resident that may be classified as above. Staff have been directed to report immediately all observances, however minimal, to the medication aide who will report to licensed staff and/or administrator. Individual receiving report will immediately complete an incident report and notify LN/Administrator via in person, text or call. Administrative/Nursing Team will thoroughly investigate and if abuse, suspected abuse or injuries of unknown cause cannot be reasonably ruled out, a report will be made to APS within 24 hours. #3 Currently this process is being reviewed daily for the next sixty (60) days. Following the 60 day review period and upon confirmation that the systems in place are adequate, the process will be reviewed weekly at a clinical meeting and as resident needs require. #4 Administrator/designee and nursing team will be responsible for evaluating and ensuring corrections are completed and monitored.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident’s individual ABST evaluation accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 4 sampled residents (#s 2 and 6) whose ABST evaluations were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 07/2024 with diagnoses including vascular dementia, congestive heart failure, and aphasia. Review of the resident’s current service plan, dated 01/06/26, and current ABST evaluation, dated 12/19/25, indicated the following: * Resident 2’s service plan indicated the resident required a two-person transfer in and out of bed and required one-person assistance with all ADLs except eating. In an interview on 01/07/25 at 12:34 pm, Staff 4 (Floor Supervisor/MT) confirmed that Resident 2 had a significant change of condition at the end of 12/2025 and required assistance in all these areas. Resident 2 was observed throughout the survey being wheeled to and from the dining room in a manual wheelchair. * Resident 2’s ABST evaluation did not include the time required to provide transfers, call lights, assist with communication, ambulation, toileting, and grooming. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Administrator) and Staff 2 (Regional Manager) on 01/07/26 at 1:10 pm. They acknowledged the findings. 2. Resident 6 moved into the facility in 08/2021 with diagnoses including dementia without behavioral disturbance. Observations of the resident were made, interviews with the staff were conducted, and the 10/26/25 service plan and Resident 6’s ABST data was reviewed. The following area was not reflective of the resident’s current ADL assistance: * Time spent supervising, cueing or supporting while eating. Meal observations were made of Resident 6 for lunch on 01/06/26 at 11:40 am and 01/07/26 at 11:52 am. Resident 6 was observed sitting in the common area supervised by one staff member for each meal. An interview with Staff 9 (Resident Aide) on 01/06/26 at 1:28 pm confirmed Resident 6 was supervised by one staff member during meals in the common area. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Administrator), Staff 2 (Regional Manager), and Staff 3 (LPN) on 01/08/26 at 10:30 am. They acknowledged the findings.

#1 Example 1: Resident #2 – Prior to passing on 01/22/26, the ABST was updated and completed to reflect accurate care times for the resident and care elements as reflected in the care plan following significant change of condition. ABST areas updated for this resident included but not limited to: time required to provide transfers, call lights, assist with communication, ambulation, toileting and grooming. Example 2: Resident #6 – The ABST was updated and completed to reflect accurate care times for the resident and care elements as reflected in the care plan following significant change of condition. ABST areas updated for this resident included but not limited to: time spent supervising, cueing or supporting while eating. #2 The ABST has been completed in its entirety for all current residents. ABST will be updated each time a resident care plan is updated, a significant change of condition occurs, or a TSP is generated that affects care time and care elements. ABST will be completed at least 24 hours prior to a new move-in to ensure that all care time and care elements are captured accurately in concurrence with the care plan. ABST will also be updated in the event of resident move out or death. Staffing plan will be updated and posted with the current date in concurrence with the updating of the ABST. #3 ABST will be evaluated on a daily basis related to changing resident needs. #4 Administrator/designee will be responsible for seeing that the ABST corrections are completed and monitored.

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

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

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation for each resident was reviewed and updated no less than quarterly at the same time the resident's service plan was updated, before move-in, and whenever there was a significant change of condition for 4 of 6 sampled residents (#s 1, 2, 4, and 6) and multiple unsampled residents. Findings include, but are not limited to: The facility used the Department ABST to document resident care needs and develop its staffing plan. The data in the ABST was reviewed on 01/06/26 at 2:00 pm. The following was identified: a. Resident 1 was admitted to the facility in 11/2025. The resident's service plan was reviewed and updated on 11/11/25. The resident's ABST evaluation was last reviewed on 12/16/25 and was not created prior to resident admit to the facility. b. Resident 2 was admitted to the facility in 07/2024. The resident's service plan was last reviewed and updated on 01/06/26 with a significant change of condition but the resident's ABST evaluation was last reviewed and updated on 12/19/25. The facility failed to update the ABST with a significant change of condition as required. c. Resident 6 was admitted to the facility in 08/2021. The resident's service plan was last reviewed and updated on 10/26/25, but the resident's ABST evaluation was last reviewed and updated on 09/16/22. d. Resident 4 was admitted to the facility in 03/2022; however, the resident was not entered in the facility’s ABST. The date that each resident's ABST evaluation was entered or updated was reviewed. Of the 31 current residents reviewed, 12 resident ABST evaluations had not been reviewed and updated in the last 90 days (quarterly), and five residents had not been entered, including Resident 4. The findings were reviewed with Staff 1 (Administrator) and Staff 2 (Regional Manager) on 01/07/25 at 1:10 pm. They acknowledged the findings.

#1 Example 1: Resident #1 – ABST has been updated to capture accurate care times and care elements for resident as reflected in care plan. Example 2: Resident #2 – ABST was updated to accurately reflect significant change of condition as documented in the care plan. Example 3: Resident #6 – ABST has been updated to capture accurate care times and care elements for resident as reflected in care plan. Example 4: Resident #4 – ABST has been updated to capture accurate care times and care elements for resident as reflected in care plan. All ABST evaluations have been completed and entered for all current residents. #2 The ABST has been completed in its entirety for all current residents. ABST will be updated each time a resident care plan is touched, a significant change of condition occurs, or a TSP is generated that affects care time and care elements. ABST will be completed at least 24 hours prior to a new move-in to ensure that all care time and care elements are captured accurately in concurrence with the care plan. ABST will also be updated in the event of resident move out or death. Staffing plan will be updated and posted with the current date in concurrence with the updating of the ABST. ABST will be reviewed and updated no less than quarterly in conjunction with the updating of the resident care plans, prior to move-in and in the event of a significant change of condition. #3 ABST will be evaluated on a daily basis related to changing resident needs. #4 The Administrator/designee will be responsible for seeing that the ABST corrections are completed and monitored.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was documented in the resident's service plan, restrictive alternatives prior to use were documented, and instruction was provided to caregivers on the correct use of and precautions for the device, for 1 of 1 sampled resident (#2) who had a side rail on his/her bed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 10/2023 with diagnoses including dementia. Observation of the resident's room 01/08/23 revealed a half-length side rail on the left side of the resident's bed. During an interview on 01/09/23, Staff 9 (Resident Aide) stated the resident used the side rail for bed mobility. There was no documented evidence the following required elements were completed: * Documentation of less restrictive alternatives evaluated prior to use of the device; * Instruction provided to staff on the correct use and precautions related to the device; and * Documentation of the side rail in the resident's service plan. The need to ensure the use of a supportive device with potentially restraining qualities included documentation of all required elements and was included in the resident's service plan was discussed with Staff 2 (Administrator) on 01/09/23. He acknowledged the findings.

1. a. Restrictive Device Documentation for Resident 2 will be updated to include less restrictive alternatives evaluated prior to the use of the device. b. Instruction will be provided to staff on the correct use and precautions related to the device. c. Service Plan for Resident 2 will be updated to include the use of the restrictive device. 2. a. Restrictive Device Assessments will be updated to include documentation of less restrictive devices evaluated prior to use of the device. b. Resident Evaluations and Service Plans, including Restrictive Device Assessments, will be combined into a Comprehensive Evaluation and Service Plan to be completed and tracked in Blue Step. c. Staff will receive instruction on the correct use of and precautions related to restrictive devices at time of hire, or upon device implementation, and annually thereafter. 3. a. Comprehensive Evaluation and Service Plans, including Restrictive Devices, will be evaluated every 90 days or less, as resident needs change. b. Staff Instruction regarding restrictive devices will be tracked in Blue Step with annual alerts when instruction is due. 4. a. Comprehensive Evaluation and Service Plans will be reviewed jointly by Administrator and Facility Nurse every 90 days or less, as resident requirements change. Service Plans will be tracked in Blue Step with alerts when routine reviews are due. b. Staff Instruction regarding Restrictive Devices will be tracked in Blue Step and reviewed annually by Administrator and Facility Nurse

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months, conduct fire drills consistently every other month, and to document all required elements for fire drills in accordance with Oregon Fire Code (OFC) requirements. Findings include, but are not limited to: Fire and life safety records were reviewed with Staff 2 (Administrator) and Staff 6 (Maintenance Manager) on 01/09/24 at 11:00 am. The facility provided documentation of two fire drills in the last six months, which occurred on 10/24/23 and 12/28/23. Fire drills were not consistently conducted every other month at different times of day, and written fire drill documentation did not include the evacuation time period needed. There was one documented example of fire and life safety instruction to staff on alternating months, which occurred on 12/15/23. During an interview on 01/09/23, Staff 6 confirmed the fire drills and fire and life safety instruction to staff had not occurred consistently over the last six months. The need to provide fire and life safety instruction to staff on alternate months, to consistently conduct fire drills every other month, and to document all required elements for fire drills as required by the OFC was discussed with Staff 2 and Staff 6. They acknowledged the findings.

1. Staff 2 and Staff 6 will review in detail the Oregon Fire Code specific to fire safety. Staff 2 and Staff 6 will create a calendar moving forward for 2024 scheduling fire drills every other month for all shifts. Staff 2 and Staff 6 will schedule specific education/training for all staff on alternate months. Staff 6 will schedule two trainings to be done by the Fire Marshall's staff for two of the six months that are designated for training/education. Staff 6 will keep consistent and complete documentation regarding all fire drills, including all elements for fire drills as required by the OFC. Documentation will include the evacuation time period needed for each fire drill, for all shifts, conducted every other month. Staff 2 will ensure that all staff are aware of the requirements for assistance during evacuation for each resident by posting evacuation information in the medication room for ease of reference. Staff 2 will oversee and review all documentation on a regular basis, will assist in facilitating all education/training, and will accept responsibility to see that Staff 6 adhers to the schedule of fire drills and/or education/training in accordance with the OAR and OFC. 2. A system of accurate documentation of fire drills and education/training on alternate months will be created in accordance with the OAR and OFC. Staff 6 will be responsible for documentation with Staff 2 oversight monthly. Fire drills will be conducted on alternate months, at varying times of each shift, for all three shifts and documented accordingly. Documentation will include evacuation time period needed for each drill. Staff 2 and Staff 6 will review outcome with managers at the monthly managers' meeting. Education/training will be designed and conducted for 2024 in accordance with the OAR and OFC. All staff will be responsible for knowing the evacuation assistance required for each resident. Evacuation assistance needed for each resident will be included in the individual Resident Care Plans. 3. Staff 2 and Staff 6 will review documentation of fire drills and/or ecucation/training at the beginning of each month. 4.  Staff 2 will be responsible for confirming that all actions/corrections described herein are completed by 3/1/2024. Staff 2 and Staff 6 will be responsible for ongoing compliance moving forward from 3/1/2024.

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.

1. Education on fire drills and training to be set up with Fire Marshall. Fire drills to be schedule every other month and education on life safety on alternate months. 2. Fire drills and education to be scheduled at the beginning of the month and reviewed after they are done  to ensure correct documentation and proper procedures have been followed. 3. On a monthly basis during the first week of each month. 4. Administrator and Maintenance Manager are responsible to for monitoring that fire drills and life safety have been completed.

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 340.

a. Restrictive Device Documentation for Resident 2 will be updated to include less restrictive alternatives evaluated prior to the use of the device. b. Instruction will be provided to staff on the correct use and precautions related to the device. c. Service Plan for Resident 2 will be updated to include the use of the restrictive device. 2. a. Restrictive Device Assessments will be updated to include documentation of less restrictive devices evaluated prior to use of the device. b. Resident Evaluations and Service Plans, including Restrictive Device Assessments, will be combined into a Comprehensive Evaluation and Service Plan to be completed and tracked in Blue Step. c. Staff will receive instruction on the correct use of and precautions related to restrictive devices at time of hire or device implementation and annually thereafter. 3. a. Comprehensive Evaluation and Service Plans, including Restrictive Devices, will be evaluated every 90 days or less, as resident needs change. b. Staff Instruction regarding restrictive devices will be tracked in Blue Step with automated annual alerts when instruction is due. 4. a. Comprehensive Evaluation and Service Plans will be reviewed jointly by Administrator and Facility Nurse every 90 days or less, as resident needs change. Service Plans will be tracked in Blue Step with automated alerts when routine reviews are due. b. Staff Instruction regarding Restrictive Devices will be tracked in Blue Step and reviewed annually by Administrator and Facility Nurse

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 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose records were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4's service plans, assessments, and evaluations were reviewed. There was some information included, but the records lacked documented evidence the facility evaluated the sampled residents activities to include: * 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 that could be used as behavioral interventions, if necessary. On 01/09/24, the need to ensure all residents had individualized activity plans based on the evaluation to engage residents in meaningful activities was discussed with Staff 2 (Administrator) and Staff 3 (RN). They acknowledged the findings.

1. Individualized Activity Plans will be updated for Residents 1, 2, 3, and 4 to include: a. Past and current interests; b. Current abilities and skills; c. Emotional and social needs and patterns; d. Physical abilities and limitations; e. Adaptations necessary for the resident to participate; and f. Activities that could be used as behavioral interventions, if necessary. 2. Resident Evaluations and Service Plans, including Individualized Activity Plans, will be combined into a Comprehensive Evaluation and Service Plan to be completed and tracked in Blue Step. The Individualized Activity Plan portion will be completed by the Life Enrichment Coordinator. 3. Comprehensive Evaluation and Service Plans, including Individualized Activity Plans, will be evaluated every 90 days or less, as resident needs change. 4. Comprehensive Evaluation and Service Plans, Including Individualized Activity Plans, will be reviewed jointly by Administrator and Facility Nurse every 90 days or less, as resident needs change. Comprehensive Evaluation and Service Plans will be tracked by Blue Step with automated alerts when routine reviews are due.

The findings of the re-licensure survey, conducted 01/08/24 through 01/09/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the relicensure survey of 01/09/24, conducted 03/27/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.