Maple Valley Memory Care

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

Based on observation, interview, and record review, it was determined the facility failed to determine actions or interventions needed, communicate actions or interventions to staff on all shifts, and monitor changes through resolution with at least weekly documentation for 2 of 2 sampled residents (#s 1 and 2) reviewed with short-term changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 02/2025 with diagnoses which included Alzheimer’s disease and schizoaffective disorder. The resident’s clinical record, including progress notes from 09/19/25 through 11/17/25 were reviewed, observations were made, and staff were interviewed during the survey. a. A review of the resident’s clinical record indicated the resident experienced the following: * 11/02/25-non-injury fall; * 11/03/25-non-injury fall; * 11/07/25-two falls with injuries, abrasion to right toe and abrasions to both knees; * 11/08/25-fall with abrasion to forehead; and * 11/14/25-fall with abrasion to right knee. There was no documented evidence the facility determined, documented, and communicated to staff what actions or interventions were needed and failed to document weekly progress of the resident’s mobility and injuries until the conditions resolved. On 11/18/25 at 12:15 pm, Staff 3 (Memory Care Coordinator/LPN) acknowledged there were no actions and/or interventions communicated to staff regarding Resident 2’s falls. b. A review of the resident’s clinical record indicated the following medication changes: * 10/14/25 - Discontinue lamotrigine 100mg (anti-seizure medication); * 10/28/25 - New medication methadone 2.5mg (for pain); * 11/04/25 - Increase methadone to 5mg (for pain); increase duloxetine from 30mg to 60mg (for mood stabilization); and new medication haloperidol 1mg (for mood stabilization); * 11/06/25 - Increase haloperidol to 2mg (for mood stabilization); * 11/08/25 - New medication, valproic acid 250mg/ml (for hallucinations/agitation); and * 11/11/25 – New PRN medication, triamcinolone cream (to treat skin conditions). There was no documented evidence these short-term changes of condition were monitored, with progress noted at least weekly, to resolution. On 11/18/25 at 1:20 pm, Staff 2 (Resident Services Coordinator/RN) and Staff 3 (Memory Care Coordinator/LPN) confirmed the identified changes of condition for medications, and they acknowledged the lack of documented monitoring through resolution. The need to ensure the facility determined and documented what actions or interventions were needed for changes of condition, communicated the actions or interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (ED), Staff 2, and Staff 4 (Behavioral Support Specialist) on 11/19/25. They acknowledged the findings. No additional documentation was provided. 2. Resident 1 was admitted to the facility in 06/2024 with diagnoses including late onset Alzheimer’s disease and dementia. The resident’s 08/21/25 through 11/05/25 progress notes, temporary service plans (TSPs), and interim service plans (ISPs) were reviewed, and staff were interviewed. The following was identified: * 08/21/25 – Memantine 10 mg tab (for dementia); give half (5 mg) twice daily for seven days then discontinue; * 09/11/25 – Discontinue erythromycin 5 mg (an antibiotic), memantine 10 mg twice daily (for Alzheimer’s disease), and sertraline 100 mg (an anti-depressant); * 09/12/25 – Start new medications, including acetaminophen 325 mg (for pain), bisacodyl suppository (for constipation), bupropion (an anti-depressant), cetirizine (for allergies), haloperidol (an anti-psychotic), lorazepam (for anxiety or agitation), mirtazapine (a mood stabilizer), morphine (for pain), paroxetine (a mood stabilizer), polyethylene glycol (for constipation), risperidone (a mood stabilizer), and senna (for constipation). Discontinue as-needed acetaminophen, “alum and mag” (an antacid), Milk of Magnesia (for constipation), and nystatin (an antifungal medication); and * 10/06/25 – Discontinue bupropion (an anti-depressant). There was no documented monitoring of these short-term changes of condition through resolution. In an interview on 11/19/25 at 12:55 pm, Staff 3 (Memory Care Coordinator/LPN) stated she was not sure why some TSPs/ISPs got resolved and some didn’t. She stated she was trying to figure out a system that would ensure all short-term changes of condition were monitored through resolution. The need to monitor short-term changes of condition through resolution, with at least weekly progress documented, was discussed with Staff 1 (ED), Staff 2 (Resident Services Coordinator/RN), and Staff 4 (Behavioral Support Specialist) on 11/19/25 at 2:30 pm. They acknowledged the findings.

1) Residents presenting with any short term change or incidents will be doccumented with a TSP or ISP. TSP and ISP will be individualized to fit individual residents needs. Resident's status will be documented in progress notes until resolved and removed off of alert charting. 2) Resident TSP and ISP will be individualized to fit each residents needs and reviewed by Resident Service Coordinator until resolved. Care staff and Med techs will review and sign ISP or TSP at beginning of each shift. 3)TSP and ISP sign off sheets will be audited weekly by Resident Service Coordinator. Weekly and until resolved and closed out 4) Resident Service Coordinator, Executive Director

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 2) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 2 was admitted to the facility in 02/2025 with diagnoses which included Alzheimer’s disease and schizoaffective disorder. The resident's 11/01/25 through 11/17/25 MARs and physician orders were reviewed. The following was identified: The resident had an order for morphine (narcotic analgesic) 20 mg/ml every hour as needed for pain. * The 11/01/25 through 11/17/25 MAR revealed the resident was administered the PRN narcotic on nine on occasions. * The Controlled Substance Distribution log contained 13 entries for 11/2025. Four of the 13 entries in the controlled substance log were not reflected on the MAR. * The number of milliliters remaining noted in the Controlled Substance Distribution log matched the number of milliliters remaining in the corresponding medication bottle. Inconsistencies between the MAR and Controlled Substance Disposition Log were reviewed with Staff 3 (Memory Care Coordinator/LPN) on 11/19/25 at 9:30 am. She reviewed the documentation and acknowledged the discrepancy. The need to ensure a system was in place for tracking controlled substances was discussed with Staff 1 (ED), Staff 2 (Resident Services Coordinator/RN), and Staff 4 (Behavioral Support Specialist) on 11/19/25. They acknowledged the findings.

1) MAR's and Narc book will be audited by Facility RN weekly. All Medication Aids will be retrained and will take an Oregon Care Partners Course, Medication Administration Training for Unlicensed Medication Technicians. 2) Medication Aids will be trained through Oregon Care Partners. MAR's and Narc book will be audited routinly. 3)Mar's and Narc book will be audited by Facility RN weekly and by RDO monthly. 4)Resident Service Director/RN, Regional Director of Operations, Executive Director

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

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.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired direct care staff (#s 9, 10, and 11) demonstrated competency in first aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 11/18/2025, and the following was identified: There was no documented evidence that Staff 9 (MT/CG), hired 08/04/25, Staff 10 (CG), hired 08/06/25, and Staff 11 (CG), hired 09/18/25, had demonstrated competency in first aid and abdominal thrust within 30 days of hire. The need to ensure staff demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 2 (Resident Services Coordinator/RN), and Staff 4 (Behavioral Support Specialist) on 11/19/25 at 2:30 pm. They acknowledged the findings.

New hire packets will be update for compliance with required training. Caregiver check off sheet will be audited prior to staff working with residents. Staff files will be audited qurterly for staff training compliance. Staff noted during survey have been trained on First Aid and Abdominal Thrust. 2) Caregiver worker check off sheets completed 3) Prior to Caregivers completing initial training, Staff files will be audited qurterly for staff training compliance. 4) Maple Valley Office Assistant, Executive Director

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.

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

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C372.

Refer to C 372

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

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

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C270 and C302.

Refer to C 270 and C302

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

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 05/16/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: * Dust build up on window sill (screened window open), next to clean cutting boards; * Paper lined tray containing bottles of syrup next to microwave, had dried spills and food debris; * Tray containing chemical solution jugs for dishwashing machine on the floor under the three compartment sinks was heavily soiled with black/brown matter; * Dried on drips and spills on sides of stove/grill; * Hood vents above stove/grill had build up of grease/dust; * Wall behind stove/grill had grease drips; and * Flooring throughout the kitchen had build up of black/brown matter. The areas in need of cleaning were observed and discussed with Staff 1 (Dietary Manager/Cook) and discussed with Staff 2 (Executive Director) and Staff 3 (Regional Director of Operations) on 05/16/24. The finding were acknowledged.

1) Dirty items of deficiency have been deep cleaned and resolved. 2) Deep cleaning of the kitchen has been added to the routine maintenance program twice a month. Window sill, hood vents, Clean wall behind stove and flooring has been added to routine maintenance program. Window sill, condiment/coffee tray, chemical tray and side of stove/grill/oven will be cleaned daily and added to the daily cleaning check list 3) Weekly 4) Dietary Manager, Director of Environmental Services, Executive Director

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

Refer to C240.

The findings of the kitchen inspection, conducted 05/16/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.

The findings of the first re-visit to the kitchen inspection of 05/16/24, conducted on 07/25/24, are documented in this report. The facility was found in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review, conducted during a site visit on 05/15/24 and 05/16/24, it was determined the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. Findings include, but are not limited to: Staff 1 (Executive Director) provided a "Suspected Abuse or Unexplained Injury Reporting" form regarding an incident that occurred on 05/22/23 for Resident 2. A review of Central Access Management (CAM) revealed APS was not notified of the incident until 05/25/23. Staff 1 provided a "Suspected Abuse or Unexplained Injury Reporting" form regarding an incident that occurred on 04/09/24 for an unsampled resident. A review of CAMs revealed Adult Protective Services (APS) was not notified of the incident until 04/22/24. Staff 1 provided a "Suspected Abuse or Unexplained Injury Reporting" form regarding an incident that occurred on 05/10/24 for Resident 1. A review of CAMs revealed APS was not notified of the incident until 05/15/24. During an interview , Staff 1 stated they reported incidents to APS after conducting their internal investigations. The findings were reviewed with Staff 1 and Staff 2 on 05/16/24. The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse. Verbal Plan of Correction: Management will report incidents moving forward within 24 hrs before or concurrently with internal investigations.

Based on interview and record review, conducted during a site visit on 5/15/24 and 5/16/24, it was confirmed the facility failed to include a written description in service plans of who shall provide the services and what, when, how, and how often the services shall be provided for 2 of 3 sampled residents (#s 1 and 3). Findings include but are not limited to: A review of Resident 1's service plan, dated 04/29/24, indicated the following: * Resident 1 was incontinent and required 2 two-staff members to assist with brief changes and peri care. * The service plan did not include how often resident was to receive incontinence assistance. A review of Resident 3's service plan, dated 03/26/24, indicated the following: * Resident 3 was incontinent and required 2 two-staff members to assist with escort to and from toilet, brief changes, and peri care. * The service plan did not include how often resident was to receive incontinence and toileting assistance. The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 (RN). The facility failed to include a written description in service plans of who shall provide the services and what, when, how, and how often the services shall be provided. Verbal Plan of Correction: Within two weeks, management will update resident service plans to reflect details of frequency (i.e. toileting and hydration).

Based on record review and interview, conducted during a site visit on 05/15/24 and 05/16/24, it was determined the facility failed to fully implement and update an acuity-based staffing tool. Findings include, but are not limited to: In an interview on 05/16/24, Staff 1 (Executive Director) stated the following: * The facility is using the ODHS tool; * Staff 1 updates the tool upon admission, within 30 days, quarterly, and with changes of conditions. On 05/16/24, a review of the facility's ABST "Export All Data" report revealed profiles had not be updated within the last quarter for Resident 4, Resident 5, and Resident 6. In an interview 05/16/24, Staff 1 and Staff 2 (RN) confirmed these three residents' profiles had not been updated within the last quarter. The facility's posed staffing plan showed the facility used Universal Workers (UW) and indicated the following: * Day: five UWs; * Eve: five UWs; and * Night: three UWs. A review of the facilty's Staffing Schedule for May 2024 indicated the facility consistently scheduled to their posted staffing plan. Observations of day and evening shift staffing showed the facility was staffing to the levels required by the facility's ABST. Observations of residents did not reveal any missed needs. The findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 05/16/24. The facility failed to fully implement and update an acuity-based staffing tool.

Based on observation, interview, and record review, conducted during a site visit on 05/15/24 and 05/16/24, it was confirmed  the facility failed to ensure an individualized nurtrition and hydration plan was developed for 3 of 3 sampled residents (#s1, 2, and 3). Findings include but are not limited to: A review of Resident 1's service plan, dated 03/25/24, indicated the following: *Resident is independent with eating tasks; *Staff to prepare and serve all snacks; *There was no frequency specified related to snack and hydration; and *There were no resident-specific details regarding preferences for drinks or snacks. A review of Resident 2's service plan, dated 04/30/24, indicated the following: *Resident can eat on his/her own but needs staff assistance at times; *Staff are to encourage food consumption and fluids; *There was no frequency specified related to snack and hydration; and *There were no resident-specific details regarding preferences for drinks or snacks. A review of Resident 3's service plan, dated 03/29/24, indicated the following: *Resident is independent with eating tasks; *Staff to prepare and serve all snacks; *There was no frequency specified related to snack and hydration; and *There were no resident-specific details regarding preferences for drinks or snacks. On 05/15/24 and 05/16/24, the following were observed: *A hydration cart was in the dining room; *Residents were all served the same drink; and *Residents were given the same snacks. The findings were reviewed with an acknowledged by Staff 1 (Executive Director) and Staff 2 (RN) on 05/16/24. The facility failed to ensure an individualized nurtrition and hydration plan was developed and included in the service plan. Verbal Plan of Correction: Management will be providing education on the implementation of resident-specific snack and hydration programs within two weeks.

Based on interview, observation, and record review, conducted during a site visit on 05/15/24 and 05/16/24, it was confirmed the facility failed to provide a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large. Findings include, but are not limited to: A review of the facility's activity schedule, dated 05/15/24, indicated the following: * "Hammer Paint Craft;" * "Hammer Away Day;" * Morning stretch; * Group Karaoke; * Daily Chronicles; * Bingo; and * An animated movie. On 05/15/24, the Compliance Specialists did not observe any of the scheduled activities occurred. A review of the facility's activity schedule, dated 05/16/24, indicated the following: * "What's all the Racket Day!" * Daily Chronicles; * Racketball; * Wheel of Fortune; and * An animated movie. During observation on 05/16/24 at 1:18 pm, only bingo was observed to occur with four residents in attendance. No other activities were observed. In an interview on 05/16/24, Staff 4 (Activities Director ) stated s/he used a company-provided activity website to create the facility's activity calendar and did not include residents' individualized activity plans. The findings were reviewed with an acknowledged by Staff 1 (Executive Director) and Staff 2 (RN) on 05/16/24. The facility failed to provide a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large. Verbal Plan of Correction: Within three weeks, management will train activities person in using the resident evaluations which will transfer into the service plan to then provide an activities program that is based on resident-specific interests.

The findings of the on-site investigation, conducted 05/15/24 to 05/16/24, 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 living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:             Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

3. Resident 2 was admitted to the facility in 04/2022 with diagnoses including dementia. The resident's 04/29/22 through 08/08/22 progress notes, physician communications, incident reports, and weight records were reviewed. The resident experienced multiple changes of condition without documented monitoring until resolution and/or resident-specific directions to staff in the following areas: * 04/29/22 Fall with facial hematoma; * 06/01/22 Significant weight loss of 11.4 pounds, or 8% of total body weight in one-and-a-half months; * 06/12/22 Fall with reddened facial area and right arm pain; * 06/18/22 Ingestion of another resident's psychotropic medications; *  07/08/22 Severe weight loss of 17.2 pounds, or 13.6% of total body weight in two-and-a-half months; * 07/08/22 Non-injury fall ; * 07/09/22 Decreased, then discontinued psychotropic medication; and * 07/12/22 Fall with abrasion to forehead. There was no documented monitoring of the resident's condition at least weekly through resolution, to include effectiveness of interventions. The facility failed to provide resident-specific direction to staff, and there was no evidence the RN was notified of the significant weight loss on 06/01/22. The need to monitor short-term changes to resolution with clear direction to staff, and to notify the facility RN of significant changes of condition, was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (Regional Director of Operations) on 08/09/22. The staff acknowledged the findings. 4. Resident 3 was admitted to the facility in 12/2019 with diagnoses including dementia. The resident's 05/13/22 through 08/08/22 progress notes and physician communications were reviewed. The resident experienced the following short-term change of condition without documented monitoring until resolution or specific direction to staff: * On 06/02/22 progress notes indicated Resident 3 was on alert for "possible hand- foot mouth disease". There was no evaluation, clear direction to staff, or monitoring of the resident's condition at least weekly through resolution. The need to monitor short-term changes to resolution, with clear direction to staff, was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (Regional Director of Operations) on 08/09/22. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate changes of condition, determine and implement interventions needed, provide resident-specific instructions to staff, monitor the conditions at least weekly to resolution, notify the RN of any significant changes, and/or evaluate the effectiveness of the interventions for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2016 with diagnoses including dementia, acute agitation, and diabetes. The resident's service plan, dated 06/03/22, progress notes dated 05/10/22 through 08/08/22, temporary service plans, and incident reports were reviewed. The resident experienced multiple changes of condition without documentation of interventions developed, specific signs/symptoms to observe, and/or clear directions to staff in the following areas: * 05/25/22 ER visit for "increased confusion, extremely swollen feet, and pale color"; * 05/31/22 Fall with transport to ER; * 06/03/22 Admission to hospice; and * Multiple medication changes. On 08/10/22 the need to evaluate changes of condition, develop interventions, provide resident-specific directions to staff, and monitor the conditions to resolution was discussed with Staff 1 (ED) and Staff 3 (LPN). They acknowledged the findings. 2. Resident 4 was admitted to the MCC in 09/2020 with diagnoses including hypothyroidism, encephalitis, and hallucinations. The residents progress notes, dated 05/10/22 through 08/08/22, MAR, dated 07/01/22, and temporary service plans were reviewed. Resident 4 experienced multiple changes of condition without documentation of monitoring until resolution, specific signs/symptoms to observe, and/or clear directions to staff in the following areas: * 05/13/22 Episode of aggressive, agitated behavior; * 07/08/22 Skin issue - soreness in perineal area; and * Multiple medication changes. On 08/10/22 the need to evaluate changes of condition, develop interventions, provide resident-specific directions to staff, and monitor the conditions to resolution was discussed with Staff 1 (ED) and Staff 3 (LPN). They acknowledged the findings.

1) Residents presenting with any short term change or incidents will be doccumented with a TSP or ISP. TSP and ISP will be individualized to fit individual residents needs. Resident's status will be documented in progress notes until resolved. 2) Resident TSP and ISP will be individualized to fit each residents needs and reviewed by RSC until resolved. 3)Weekly until resolved 4) RSC, ED

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed following significant, then severe, weight loss for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: Resident 2 was admitted to the facility in 04/2022 with diagnoses including dementia. The resident was observed during survey eating independently for short periods of time, then pacing up and down the halls for long periods of the day. The meal monitor record from 08/01/22 through 08/08/22 showed an average meal intake of 100%. Staff interviewed reported that Resident 2 was difficult to keep at the table for meals due to constant pacing, but did well with finger foods given to him/her to eat while walking. This intervention was not reflected on the service plan. A review of the resident's 05/03/22 through 08/08/22 progress notes, 04/2022 through 08/01/22 weight records, physician communications, and 07/01/22 through 08/08/22 MAR identified the following: * From 04/13/2022 to 06/01/22, Resident 2 lost 11.4 pounds, from 146.2 pounds to 134.8 pounds, a decrease of 8.4% in his/her total body weight. This constituted a significant weight loss. There was no documented evidence the staff who documented the weight information had referred the weight loss to the RN for follow-up. The resident began receiving protein shakes three times a day on 05/11/22. * Between 04/13/22 and 07/01/22, the resident lost a total of 17.4 pounds, from 146.2 pounds to 128.6 pounds, a decrease of 13.6% of his/her total body weight, which constituted a severe weight loss. Meal monitoring was initiated on 07/09/22. Staff 2 (LPN) documented on 07/22/22 that due to the resident's decline, recent falls, and severe weight loss, hospice care would recommended. The facility RN was notified. Resident 2's weight was 129 pounds on 08/01/22. On 08/03/22 the RN documented the resident was admitted to hospice services due to overall decline, falls, and weight loss. There were no documented RN significant change of condition assessments of the resident's weight losses, including findings, resident status, and interventions made as a result of the assessment. The facility RN was not available for interview during the survey. The need for a significant change of condition assessment, which included findings, resident status, and interventions made as a result of the assessment, to be completed by an RN in a timely manner was discussed with Staff 1 (ED), Staff 2, and Staff 3 (Regional Director of Operations) on 08/09/22. They acknowledged the findings.

1) Significant Change of Condition will be reviewed and reported by staff to Resident Service Coordinator, RSC will review and report to RN, RN will complete COC assesment. 2)Significant Change of Condition form will be created by RN and reviewed by RSC 3)Weekly for COC 4) RN, RSC, ED

Based on interview and record review, it was determined the facility failed to ensure outside service providers left written documentation in the facility for on-site services provided to residents and failed to coordinate care with outside providers to ensure continuity of care, for 3 of 3 sampled residents (#s 1, 2, and 3) who received outside services. Findings include, but are not limited to: During the acuity interview, Residents 1, 2, and 3 were identified as currently receiving hospice services. Facility records lacked documented evidence of any visits by outside service providers. In interviews on 08/09/22, Staff 1 (ED) and Staff 2 (LPN) stated the facility had not been keeping written records of outside provider visits. On 08/10/22 the need to ensure outside service providers left written documentation of all visits, and to implement any recommendations made by the providers was discussed with Staff 1, Staff 2 and Staff 3 (Regional Director of Operations). They acknowledged the findings.

1) A list will be kept on which residents will be reciving home health and Hospice services. Home Health agency and Hospice will need to check in with med tech or nurse and sign in on a separate log daily, who they are seeing and what they are being seen for. Home health agency and Hospice will then have to fill out an outsider provider form and turn it into Med tech prior to leaving the community. 2) The med tech will check sign in log and cross refrence outside provider forms prior to the end of shift daily. 3) weekly 4) resident service coordinator and ED

Based on interview and record review, it was determined the facility failed to notify the physician or practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#4) who had documented medication refusals. Findings include, but are not limited to: Resident 4 was admitted to the memory care community in 09/2020, with diagnoses including heart failure and hypertension. Resident 4's MAR, dated 07/01/22 through 07/31/22 was reviewed. The MAR listed two occasions, 07/08/22 and 07/27/22, when Resident 4 refused blood pressures, which was ordered to precede metoprolol administration (for hypertension). This constituted a medication refusal, which required the facility to notify the resident's physician.   There was no documented evidence the facility notified Resident 4's physician of the refusals. In an interview on 08/10/22, Staff 2 (LPN) stated the facility did not have a system for physician notification following medication refusals. On 08/10/22, the need to ensure a resident's physician or practitioner was contacted following medication refusals was discussed with Staff 1 (ED), Staff 2, and Staff 3 (Regional Director of Operations). They acknowledged the findings. No further information was provided.

1) Medication refusals and medication peramator refusal will be doccumented on MAR's then recorded on medication refusal forms and faxed to PCP 2) Education for medication techs on proper procedure for medication refusals, medication parameter refusals and when to notify PCP and creation of medication refusal form 3) Weekly 4) RSC

Based on interview and record review, it was determined the facility failed to ensure documented, non-pharmacological interventions had been tried, with ineffective results, prior to administering PRN psychotropic medications and to ensure complete documentation of all PRN administrations for 1 of 1 sampled resident (#4) who was administered a PRN psychotropic.  Findings include, but are not limited to: Resident 4 was admitted to the memory care community in 09/2020 with diagnoses including hypothyroidism, encephalitis, and hallucinations. Resident 4's MAR, dated 07/01/22 through 07/31/22, indicated the resident was administered PRN clonazepam (for severe agitation) 38 times in July. The medication "pass notes" showed all doses listed, but multiple entries lacked documentation of the following: * Non-drug interventions tried, prior to PRN administration; * Effectiveness of the medication; * Time of follow-up evaluation; and/or * Initials of the entry's author. On 08/10/22 the need to ensure non-pharmacological interventions were tried with ineffective results, prior to administration of PRN psychotropic medications, and complete documentation of all such administrations was discussed with Staff 1 (ED) and Staff 3 (Regional Director of Operations). They acknowledged the findings.

Interventions will be listed for all PRN psychotropic medication including those ordered for end of life when reasen for use is not end of life comfort care. Interventions will be listed on MAR's and careplans and doccumented on MAR's 2) All psychotropic and end of life care medications will be reviewed for interventions 3)weekly 4)Resident Service Coordinator and ED

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to: There was no documented evidence the facility was using an ABST which would determine a staffing plan to meet the 24-hour scheduled and unscheduled needs of residents. On 08/08/22, Staff 1 (ED) reported the facility had not implemented the ABST, as they had not added all the resident information needed. Staff 1 stated he would follow-up to ensure the ABST was implemented as required.

DHS ABST will be used until PCC staffing tool will be implimented. 2) Use of DHS ABST untill PCC staffing tool is used. 3)With move in, quarterly, Change of condition, and move out 4) Resident Service Coordinator and ED

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff  (#s 7, 9, and 11) completed abdominal thrust and First Aid training within 30 days of hire. Findings include, but are not limited to: A review of staff training records with Staff 1 (ED) on 08/10/22 revealed the following: There was no documented evidence Staff 7 (Universal Worker), Staff 9 (Universal Worker), or Staff 11 (Universal Worker), hired 06/29/22, 06/13/22, and 05/17/22, respectively, had completed the required training in First Aid and abdominal thrust. The need for staff to complete all required training within the appropriate time frame was discussed with Staff 1 and Staff 3 (Regional Director of Operations) on 08/10/22. They acknowledged the findings.

New hire packets will be update for compliance with required training. Universal worker checkoff sheet will be audited prior to staff working with residents. 2) Universal worker checkoff sheets completed 3) Prior to universal worker completing initial training 4) Residential Care Coordinator, ED

Based on interview and record review, it was determined the facility failed to conduct fire drills and to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of facility records on 08/09/22 identified the following deficiencies: * There was no documented evidence fire drills were conducted every other month, as required; and * There was no documented evidence fire and life safety instruction was provided to staff on alternating months. On 08/10/22 the need to conduct regular fire drills and to provide fire and life safety instruction to staff in accordance with the OFC, was discussed with Staff 1 (ED) and Staff 3 (Regional Director of Operations). They acknowledged the findings.

Education and training on how to complete fire drills and fire training provided by Fire Marshal. Fire drills will be conducted every other month and fire education on opposite months 2)Drills and traning recorded and reviewed. 3) Monthly. 4) Maintenance and ED

Based on observation and interview, it was determined the facility failed to ensure the building was maintained in good repair.  Findings include, but are not limited to:   During an environmental tour of the building's interior, on 08/08/22 at 10:20 am, the following deficiencies were observed: * Paint chipping on window sills in dining room; * Gouges and scrapes on multiple wood door frames; * Chipping and missing plaster on numerous walls; and * Baseboards worn, discolored, and separated from walls in several places. On 08/10/22 the need to maintain the facility in good repair was discussed with Staff 1 (ED) and Staff 5 (Environmental Services Director). They acknowledged the findings.

Maintenance will conduct a monthly apartment and building check list and make repairs accordingly. 2) Apartment and building repair check list and routine maintinance log will be created and kept. 3) Weekly and monthly 4) Weekly by Maintenance monthly by ED

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 361, C 372, C 420, and C 513.

Refer to C 361, C 372, C 420, C 513

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff (# 7) completed all required pre-service orientation prior to performing any job duties and 3 of 3 staff (#s 7, 9,  and 11) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 08/09/22 and 08/10/22 with Staff 1 (ED). 1. There was no documented evidence Staff 7 (Universal Worker), hired 06/29/22, completed the required pre-service orientation topics prior to performing any job duties. During review of Staff 7's pre-service orientation, it was identified she had completed her ADL competency training on 07/18/22, which was two days prior to completion of the pre-service orientation dated 07/20/22. 2. There was no documented evidence Staff 7, Staff 9 (Universal Worker), hired 06/13/22, and Staff 11 (Universal Worker), hired 05/17/22, demonstrated competency in all assigned job duties within 30 days of hire in the following areas: * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; * Conditions that require assessment, treatment, observation, and reporting; and * General food safety, serving, and sanitation. The need to ensure staff completed all required training within the specified time frames was discussed with Staff 1 and Staff 3 (Regional Director of Operations) on 08/10/22. They acknowledged the findings.

New hire packets will be update for compliance with required training. Universal worker checkoff sheet will be audited prior to staff working with residents. 2) Universal worker checkoff sheets completed 3) Prior to universal worker completing initial training 4) Residential Care Coordinator, ED

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 270, C 280, C 290, C 305, and C 330.

Refer to C 270, C 280, C 290, C 305, C 330

The findings of the re-licensure survey, conducted 08/08/22 through 08/10/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 revisit to the re-licensure survey of 08/10/22, conducted 12/01/22 through 12/02/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.