Rivera Mansions RCF

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

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and failed to address sufficient information to develop the initial service plan to meet the resident's needs for 1 of 1 sampled resident (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 03/2026 with diagnoses including multiple sclerosis, paraplegia, and anxiety. The move-in evaluation, which included documentation from the resident's prior facility, was reviewed. The following required elements were not addressed: * Spiritual, cultural preferences and traditions; * Fluid preferences; * Complex medication regimen; * Recent losses; * Preferred pronouns; and * Gender identity. There was documented evidence the facility had information relating to the following elements, however the information had not been utilized to develop Resident 1's initial service plan to meet his/her needs: * Mental health issues including the presence of depression, thought disorders or behavioral or mood problems, the history of treatment, and effective non-drug interventions; * Personality including how the person copes with change or challenging situations; * Ability to be understood; * Dental status; and * Nutrition habits. During an interview on 03/30/26 at 1:33 pm, Staff 14 (CG) confirmed the resident exhibited behaviors pertaining to his/her care and meals. She stated Resident 1 spoke in a quiet tone which made it difficult to understand what the resident needed. Staff 14 reported that when care staff did not understand what Resident 1 needed, it was also a behavioral trigger for the resident. On 04/01/26 at 11:01 am, Staff 1 (Administrator) and Staff 2 (Director of Nursing) explained that they used multiple documents from the previous facility for their initial evaluation. There was no documented evidence the additional documentation provided was used to develop Resident 1's initial service plan. The need to ensure move-in evaluations addressed all required elements and was used to develop an initial service plan to meet the resident's needs was discussed with Staff 1, Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. No additional information was received.

1. Immediate correction: Resident #1’s move-in evaluation was fully updated to include all required elements including spiritual/cultural preferences, fluid preferences, complex medication regimen, recent losses, preferred pronouns, and gender identity. All previously available information (mental health, coping, communication, dental, nutrition) was incorporated into the service plan and reviewed and co-signed by the RN. 2. A comprehensive move-in evaluation checklist has been developed that mirrors all required elements under OAR 411-054-0034, including: spiritual/cultural preferences; fluid preferences; complex medication regimen; recent losses; preferred pronouns; gender identity; mental health history; personality/coping; communication abilities; dental status; and nutrition habits. This checklist will incorporated onto the facility's electronic health record (EHR) system as a required prompt that must be completed prior to finalizing any move-in evaluation. A corresponding paper sign-off form has also been implemented, confirming all elements have been addressed and that all available information has been incorporated into the resident's initial service plan. Staff have been educated on the updated process and the requirement that all elements must be documented — and if information is unavailable, a specific notation of "unable to obtain at this time" must be entered with a plan for follow-up within the initial 30-day period. 3. The RCC will audit all new move-in evaluations within 24 hours of completion to verify all required elements are present. The Facility Nurse will conduct a monthly review of any move-in evaluations completed during that month to ensure ongoing compliance. Additionally, all move-in evaluations will be reviewed at the quarterly service plan update to confirm required elements remain current and that any changes in condition have been incorporated. Any significant change of condition will trigger an immediate evaluation review. 4. The Resident Care Coordinator (RCC) is the primary person responsible for completing and auditing move-in evaluations at the time of admission. The Facility Nurse is responsible for reviewing and co-signing all completed move-in evaluations to verify compliance with all required elements. The Administrator is responsible for overseeing the overall process and will review audit results monthly.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 12/2025 with diagnoses including vascular dementia and functional quadriplegia. A review of the 03/08/26 service plan and progress notes, dated 03/03/26 through 03/30/26, identified the service plan was not reflective of the resident's current care needs and did not provide clear direction regarding the delivery of services in the following areas: * Continence of bladder; * Assistance required with toileting, activities, bathing, and use of glasses; * Behaviors exhibited and monitoring; * Number of staff required to assist during evacuation, with wheelchair mobility, and dressing; * Individual who was assisting with financial management; * Risks and precautions related to the use of bilateral side rails; * Ability to use call system and type of device used; * Direction regarding Foley catheter care, including emptying/cleaning catheter bag; and * Use of alternating pressure mattress, right wrist splint, and roll placed in left hand. Observations on 03/30/26 through 04/01/26 revealed the resident had bilateral half-length side rails placed in a raised position, an alternating pressure mattress, a touch pad call switch, a right wrist splint, and a roll placed for positioning in the left hand while awake. During an interview on 03/30/26 at 10:30 am, Resident 3 stated s/he did not use the side rails for mobility because his/her hands could not grab onto them. However, s/he confirmed the use of the right wrist splint and the roll placed in the left hand while awake. During an interview on 03/31/26 at 10:42 am, Staff 4 (RCC) acknowledged much of the conflicting information was that the resident had previously lived at the facility and was much more independent at that time. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4, and Staff 5 (RCC in training) on 04/01/26 at 10:55 am. They acknowledged the findings. 2. Resident 2 moved into the facility in 03/2023 with diagnoses including heart failure and diabetes. A review of the 03/08/26 service plan and progress notes, dated 01/01/26 through 03/30/26, identified the service plan was not reflective of the resident’s needs and did not provide clear direction regarding the delivery of services in the following area: * Risks and precautions related to the use of bilateral half-length side rails. During an observation and interview with Resident 2 on 03/31/26 at 10:30 am, bilateral half-length side rails were observed on the resident’s bed in the raised position. The need to ensure residents’ service plans were reflective of residents’ needs and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1(Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 12:05 pm. They acknowledged the findings. 3. Resident 1 moved into the facility in 03/2026 with diagnoses including multiple sclerosis, paraplegia, and anxiety. A review of the 03/03/26 service plan and progress notes, dated 03/03/26 through 03/30/26, identified the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Risks and precautions related to the use of bilateral siderails; * Behaviors including triggers and interventions; * Amount of assistance the resident required with snacks; * Personal seasoning assistance on meals; and * Detailed directions on transfers and positioning. During an interview on 03/30/26 at 1:33 pm, Staff 14 (CG) confirmed the resident exhibited behaviors, could independently eat “chips” if she opened the bag, had personal seasoning for CGs to add to the resident’s food, and wanted “things specific” relating to transfers and repositioning. During an observation and interview with Resident 1 on 03/30/26 at 1:47 pm, bilateral half-length siderails were observed on the resident’s bed, in the raised position. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. They acknowledged the findings.

1.Immediate action for cited residents: The Resident Care Coordinator (RCC) reviewed and updated the service plans for Residents 1, 2, and 3 to reflect all current care needs identified during the survey. Updates in progress include: bilateral side rail risks and precautions for all three residents; Foley catheter care instructions including emptying and cleaning the catheter bag; documentation of assistive devices in use including the alternating pressure mattress, right wrist splint, touch pad call switch, and hand roll (Resident 3); behavior triggers, interventions, and monitoring protocols; number of staff required to assist with evacuation, wheelchair mobility, and dressing; required assistance levels for toileting, bathing, activities, and use of glasses; snack assistance and personal seasoning instructions (Resident 1); and detailed transfer and repositioning directions (Resident 1). Each corrected service plan is reviewed and co-signed by the Facility RN to confirm accuracy and completeness before implementation. All updates are dated and initialed per OAR requirements. 2. A service plan review checklist has been developed and integrated into the pre-admission, move-in, 30-day review, and quarterly review processes to ensure all care elements are captured and clearly communicated to direct care staff. The checklist requires explicit documentation of: all assistive devices in use and associated care instructions; required number of staff for all assisted activities; risk and precaution statements for any restrictive devices including side rails; behavioral triggers, interventions, and monitoring frequency; and individualized directions for transfers, repositioning, and ADL assistance. The facility's ABST care elements are updated concurrently with each service plan revision. Service plans are reviewed in PointClickCare and verified to align with observed care practices prior to finalization. 3. Service plans will be reviewed and updated pre-admission, upon move-in, at the 30-day review, quarterly in conjunction with the resident evaluation and ABST update, and immediately upon any significant change of condition. The RCC reviews and updates service plans at each required interval. The Facility RN co-signs each completed service plan update to verify clinical accuracy. The Administrator conducts a spot-check audit of service plans monthly to ensure ongoing compliance and that care directions are current and clearly written for direct care staff. 4. The Resident Care Coordinator (RCC) is the primary person responsible for completing and updating service plans at all required intervals. The Facility RN is responsible for reviewing and co-signing each service plan update. The Administrator is responsible for monthly spot-check audits and overall accountability for service plan compliance across the facility.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3) who were administered medications and treatments. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 03/2023 with diagnoses including heart failure and diabetes. The resident’s practitioner orders, dated 03/04/26, and MAR, dated 03/01/26 to 03/30/26, were reviewed, and the following was identified: The resident had orders for insulin degludec pen, 64 units once a day between 4:00 pm and bedtime. The MAR was blank on 03/13/26 and 03/24/26. In an interview on 03/31/26 at 11:40 am, Staff 2 (Director of Nursing) could not verify the insulin had been administered as ordered on 03/13/26 or 03/24/26. The need to ensure the facility carried out medication orders as prescribed was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 12:05 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 12/2025 with diagnoses including vascular dementia and functional quadriplegia. The resident’s practitioner orders, signed 03/18/26, and MAR, dated 03/01/26 to 03/30/26, were reviewed, and the following was identified: a. The resident had a 01/07/26 order for barrier cream to buttocks twice daily and as needed, following cleaning skin after brief changes. The MAR was blank on three occasions. b. The resident had a 01/07/26 order for positioning for pressure injury prevention. The MAR was blank on one occasion. The order was discontinued on 03/17/26. Additionally, the resident had a 03/17/26 order for positioning every two hours, use of disposable pads, and barrier cream application each brief change. The MAR was blank on two occasions. c. The resident had a 02/26/26 order for positioning every three hours, use of disposable pads, and barrier cream application after each brief change. The MAR was blank on seven occasions, and the order was discontinued on 03/17/26. In an interview on 03/31/26 at 10:45 am, Staff 2 (Director of Nursing) stated that the treatment documentation was “a work in progress” and acknowledged the inability to determine if the barrier cream administration, brief change, and positioning had occurred when the MAR was blank. The need to ensure the facility carried out medication orders as prescribed was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 10:55 am. They acknowledged the findings.

1. Immediate action for cited residents: A root cause review was conducted for all cited MAR blanks. It was determined that the omissions were documentation errors — care and treatments were provided by staff but were not signed off at the time of administration. The Facility RN reviewed and addressed the documentation gap for both Resident 2 and Resident 3, with progress notes written to account for the omissions and the identified root cause. Staff responsible for the unsigned entries were individually counseled regarding the requirement to sign the MAR at the time of administration or prior to the next resident-specific medication or treatment, per OAR 411-054-0055(2)(a). All current MAR entries for Residents 2 and 3 have been reviewed and verified to be complete and accurate. 2. The RCCs conduct MAR audits every Monday and Thursday to identify any unsigned, blank, or incomplete entries. Upon identifying an omission, the RCC immediately addresses the responsible MT/CG to determine whether care was provided and to document accordingly. The Facility RN conducts a quarterly 90 day med list review of all active practitioner orders to verify that orders are current, clearly written, and being carried out as prescribed. Staff have been re-educated on the requirement to sign the MAR at the time medications or treatments are administered and that blank entries are not acceptable regardless of whether care was provided and thus reviewed by MTs before shift end. Any MAR blank identified during an audit that cannot be explained is escalated to the Facility RN for clinical review and documentation within the same business day. 3. MAR audits are conducted by the RCC a minimum of twice weekly with additional random audits performed by the RCC and Administrator as needed. The Facility RN reviews all practitioner orders at a minimum quarterly and for any significant changes. Any identified omission or documentation concern is addressed immediately. Monthly, the Administrator reviews audit findings as part of the facility's quality improvement process. 4. The Resident Care Coordinators (RCCs) are responsible for twice-weekly MAR audits and immediate follow-up on any identified omissions. The Facility RN is responsible for quarterly order reviews and clinical escalation of any unresolved MAR concerns. The Administrator is responsible for monthly review of audit outcomes and overall accountability for medication and treatment documentation compliance.

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

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications administered by the facility, and MARs included resident-specific parameters and instructions for PRN medications for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 03/2023 with diagnoses including heart failure and diabetes. The resident’s MAR, dated 03/01/26 to 03/30/26, and corresponding prescriber orders were reviewed, and the following was identified: a. The resident had orders for insulin degludec pen, 64 units once a day between 4:00 pm and bedtime. The MAR was blank on 03/19/26. In an interview on 03/31/26 at 10:45 am, Staff 2 (Director of Nursing) confirmed the MT had not documented the resident’s refusal of the medication on 03/19/26, and it had not been administered. b. The following PRN bowel medications lacked the sequential order for administration: * MiraLax oral packet 17 GM; and * Senna 8.6 mg tablet. The need to ensure the resident’s MAR was accurate and included resident-specific parameters for PRN medications used for the same diagnosis was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 12:05 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 12/2025 with diagnoses including vascular dementia and functional quadriplegia. The resident’s MAR, dated 03/01/26 to 03/30/26, and corresponding prescriber orders were reviewed, and the following was identified: The following PRN bowel medications lacked sequential order for administration: * Polyethylene glycol 3350, 17 grams; and * Senexon-S 50-8.6 mg tablet. During an interview on 03/31/26 at 10:40 am, Staff 4 (RCC) confirmed the lack of resident-specific parameters. The need to ensure the MAR was accurate and included resident-specific parameters for PRN medications used for the same diagnosis was discussed with Staff 1(Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4, and Staff 5 (RCC in training) on 04/01/26 at 10:55 am. They acknowledged the findings. 3. Resident 1 moved into the facility in 03/2026 with diagnoses including multiple sclerosis, paraplegia, and anxiety. The resident’s MAR, dated 03/01/26 to 03/30/26, and corresponding prescriber orders were reviewed. The following was identified: a. Resident 1 had orders for a PRN bisacodyl suppository (for constipation) that had not been transcribed onto the MAR. b. The following PRN bowel medications lacked the sequential order for administration: * Enema; * Milk of Magnesia; * Polyethylene glycol powder; and * Senna. On 03/30/26 at 12:45 pm, Staff 11 (MT/CG) was able to review the electronic MAR and verified the parameters were not listed in the system. The need to ensure the resident’s MAR was accurate and included resident-specific parameters for PRN medications used for the same diagnosis was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. They acknowledged the findings.

1. Immediate actions taken: All medication orders for all residents were reviewed by the Facility RN and RCCs to ensure each order contains complete and accurate information including medication name, route, dosage, date, time, and diagnosis or indication. For any order missing a diagnosis or indication, the prescribing practitioner was contacted and the order was updated per their instructions. Resident allergies and sensitivities have been reviewed and updated in each resident's medication profile. Parameters for holding blood pressure medications and insulin have been reviewed and clarified in the MAR. For all PRN bowel medications across all residents, the sequential order of administration has been written into the MAR designating which medication is the first intervention and the order in which subsequent medications are to be used for constipation management. Resident 1's PRN bisacodyl suppository has d/c by provider. Resident 2's medication refusal documentation process has been reviewed with the responsible MT, and the requirement to document refusals in real time has been reinforced. 2. A MAR accuracy checklist has been implemented for use during the RCC's twice-weekly audits. The checklist verifies: all PRN medications have resident-specific parameters and sequential instructions when multiple PRN medications exist for the same diagnosis; all new orders are transcribed completely and accurately onto the MAR within 24 hours of receipt; medication refusals are documented on the MAR at the time of occurrence; and all required MAR fields (medication, route, dosage, date, time, indication, allergies) are present and accurate. The Facility RN reviews all new orders to verify completeness. Staff have been re-educated that documentation of a refusal is required in real time and that omitting this documentation is a MAR accuracy violation. 3. MAR accuracy is evaluated by the RCC a minimum of twice weekly (Monday and Thursday audits), with random additional audits performed by the RCC, Facility RN and Administrator. The Facility RN conducts weekly audits and quarterly comprehensive order and MAR review and review of new orders. Quarterly, the Administrator reviews cumulative audit findings as part of quality improvement oversight. 4. The Resident Care Coordinators (RCCs) are primarily responsible for twice-weekly MAR audits and immediate correction of any identified inaccuracies. The Facility RN is responsible for weekly audits and quarterly comprehensive reviews and clinical oversight of MAR accuracy. The Administrator is responsible for quarterly quality improvement review and overall accountability for MAR compliance across all residents.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure ability to safely self-administer medications for 1 of 1 sampled resident (# 4) who was reviewed for self-administration of medications. Findings include, but are not limited to: Resident 4 moved into the facility in 10/2024 with diagnoses including type 2 diabetes and asthma. The resident’s clinical record, including “Medication Self-Administration Evaluations,” were reviewed. The following was identified: Resident 4’s 03/01/26 through 03/30/26 MAR reflected an insulin glargine order with the directions to inject 10 units every morning for type 2 diabetes. The additional directions instructed staff that the resident “can self-administer this medication.” A PRN albuterol inhaler (for asthma) was also listed on the MAR. Resident 4’s 03/01/26 through 03/30/26 TAR reflected the resident self-administered Nystatin powder (for rash), four times a day. The treatment was started on 11/24/25. The most recent “Medication Self-Administration Evaluation” was dated 11/06/25. The evaluation was for the insulin and the Albuterol. There was no documented evidence of an evaluation completed for the self-administration of the Nystatin powder. On 03/30/26 at 2:07 pm, Staff 11 (MT/CG) confirmed Resident 4 injected his/her own insulin and stated that the resident “may have an inhaler and some Nystatin in [his/her] room.” Staff 11 confirmed that she did not administer the Nystatin powder. On 04/01/26 at 11:01 am, Staff 2 (Director of Nursing) confirmed the “Medication Self-Administration Evaluation” had not been completed at least quarterly and there was no evaluation completed for the Nystatin powder. The need to ensure residents who chose to self-administer their medications were evaluated at least quarterly, to assure ability to safely self-administer medications, was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. They acknowledged the findings.

1. Immediate actions taken: A self-administration evaluation for Resident 4 has been completed by the Facility RN to address all medications the resident currently self-administers, including insulin glargine, albuterol inhaler, and Nystatin powder. A practitioner order has been obtained authorizing self-administration for each applicable medication per OAR 411-054-0055(5)(b). A facility-wide audit of all residents who self-administer any prescription or treatment medication has been initiated. There are more than five residents who self-administer medications. For each identified resident, the Facility RN is completing an initial or updated self-administration evaluation to ensure all self-administered medications are covered and that evaluations are current. Any resident whose evaluation is overdue or missing is being prioritized for immediate completion. 2. Going forward, the self-administration evaluation process has been restructured as follows: The Facility RN completes all new and initial self-administration evaluations at the time a resident begins self-administering any medication, including any new medication added to an existing self-administration regimen. The RCC completes the quarterly re-evaluation for each self-administering resident, tied directly to that resident's quarterly service plan review date, so that no evaluation is separated from the broader care review cycle. Each evaluation is reviewed and co-signed by the Facility RN. A tracking log of all self-administering residents and their evaluation due dates is maintained by the RCC and reviewed at each quarterly service plan meeting. Any new admission who self-administers medications triggers an immediate self-administration evaluation prior to or at move-in. 3. Self-administration evaluations are completed quarterly, tied to each resident's quarterly service plan review date. The RCC reviews the tracking log at each quarterly service plan meeting to confirm evaluations are current for all self-administering residents. The Facility RN reviews and co-signs all evaluations. The Administrator reviews the tracking log monthly as part of overall medication management oversight. Any new self-administered medication added between quarterly reviews triggers an immediate evaluation by the Facility RN. 4. The Facility RN is responsible for completing all new and initial self-administration evaluations. The Resident Care Coordinator (RCC) is responsible for completing quarterly re-evaluations, maintaining the self-administration tracking log, and ensuring evaluations are completed on schedule in conjunction with the quarterly service plan review. The Administrator is responsible for monthly oversight of the tracking log and overall accountability for self-administration evaluation compliance.

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

Based on interview and record review, it was determined the facility failed to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: On 03/30/26 the acuity interview identified the following: * The facility was home to 27 residents; * Twenty-one residents were served by a specific needs contract (SNC); * Six residents were not served by the SNC; and * The facility had three separate buildings - A, B, and C. On 03/30/26 the “ABST [acuity-based staffing tool] Facility Entrance Questionnaire” was provided to the facility and was returned on 03/31/26. The following was noted: * The facility had three shifts – day shift was from 7:00 am to 3:00 pm, evening shift was from 3:00 pm to 11:00 pm, and night shift was from 11:00 pm to 7:00 am; and * Day shift had eight direct care staff on duty, evening shift had eight direct care staff on duty, and night shift had six direct care staff on duty. On 03/30/26 at 10:50 am, the “Facility Section Details” were reviewed on the ABST. The following was noted: * “Specific Needs Beds” required up to 29.58 hours of care during the night shift; and * “Regular Beds” required up to 1.5 hours of care during the night shift. The SNC contract was reviewed and specified, “There shall always be no less than [two] direct care staff in each building” for the 21 residents covered under the contract. Per the facility’s staffing plan, there were only two direct care staff members working in each building during the night shift, which did not account for the time needed relating to the six residents whom the facility referred to as “Regular Beds.” The need to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. They acknowledged the findings.

1.Immediate action: The facility has reviewed the night shift staffing plan for all three buildings (A, B, and C) and adjusted direct care staffing during the night shift to account for the care time required for all 27 residents to ensure the scheduled and unscheduled needs of all residents — both Specific Needs Contract (SNC) and Regular Bed — can be met without compromising care. The facility reviewed and clarified SNC staffing requirements with SNC Policy Administrator and facility has passed 90-day compliance review. The ABST continues to be updated to reflect the current acuity and care time requirements of all residents across all three buildings, and the posted staffing plan has been revised accordingly. 2. The facility's staffing planning process ensures all residents included in staffing calculations. Two separate ABST reports are maintained: one for residents served under the SNC and one for residents classified as Regular Beds. The posted staffing plan for each shift reflects the combined staffing requirements from both ABST reports, inclusive of unscheduled care time needs. Resident Care Coordinator (RCC) manages daily schedule and reviews staffing every shift to ensure adequate staffing in accordance with staffing plan and communicates any staffing issues with Administrator as needed. Staff have been educated on staffing plan. 3. The Administrator and RCC (Scheduler) will conduct a bi-weekly review of the posted staffing plan and actual staffing levels against ABST-calculated requirements for all shifts. The ABST will be reviewed and updated no less than quarterly in conjunction with each resident's quarterly service plan update. The ABST will also be reviewed and updated following any significant change of condition and at the time of each new admission to ensure staffing levels remain sufficient for the changing acuity of the resident population. 4. The RCC is responsible for staff schedules and ongoing monitoring of staffing levels and ensuring the posted staffing plan is current and accurately reflects ABST requirements. The Director of Nursing is responsible for communicating significant changes of condition and new admissions that may require ABST updates. The Administrator holds final accountability for ensuring the facility is staffed in compliance with OAR 411-054-0070(1) at all times.

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) was updated no less than quarterly at the same time the resident’s service plan for 2 of 3 sampled residents (#s 2 and 3) whose ABST evaluations were reviewed. Findings include, but are not limited to: Review of clinical records, including service plans for Residents 2 and 3, revealed the facility's ABST was not updated quarterly at the same time as the resident’s service plan in order to ensure the ABST accurately determined the needed staffing level. On 04/01/26 at 11:01 am, the need to ensure the ABST was updated at least quarterly was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training). They acknowledged the findings.

1. Immediate action for cited residents: The RCCs are actively reviewing and updating the ABST evaluations for Residents 2 and 3 concurrently with the service plan corrections currently in progress. Updates to the ABST are being made to reflect each resident's current acuity, care needs, and level of assistance required, ensuring the ABST accurately determines the staffing level needed for each resident. ABST updates for all remaining residents are being reviewed to identify and correct any that are not current. 2. A process document has been updated to require that the ABST is completed or updated at the same time as each resident's service plan at every required interval. The ABST update is now a required step within the service plan review workflow - the RCC cannot finalize a service plan without concurrently updating the ABST in the facility's system. For facilities with both SNC and non-SNC residents, two separate ABST reports are maintained as required: one for residents served under the Specific Needs Contract and one for residents not served by the Contract. The posted staffing plan is reviewed and updated following each ABST update to ensure staffing levels reflect the combined acuity requirements of all residents. Per OAR 411-054-0037(6)(b), if ABST analysis indicates staffing numbers higher than the Contract minimum, the facility staffs to the numbers indicated by the ABST. 3. The ABST is updated no less than quarterly concurrent with each resident's service plan review, upon any significant change of condition, before a new resident's move-in, and whenever the resident population changes in a way that affects overall acuity. The RCC reviews all ABSTs at each quarterly service plan cycle. The Administrator reviews the posted staffing plan monthly to verify it aligns with current ABST outputs and that actual staffing meets or exceeds the plan. 4. The Resident Care Coordinators (RCCs) are responsible for updating the ABST concurrently with each service plan review and ensuring ABST updates are completed at all required intervals. The Administrator is responsible for monthly review of the posted staffing plan against ABST outputs, and for overall accountability for ABST accuracy and compliance. The Facility Nurse is responsible for communicating significant changes of condition that require an out-of-cycle ABST update.

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 7, 12, and 15) had documented evidence of training in the use of abdominal thrust and first aid within 30 days of hire. Findings include, but are not limited to: On 03/31/26, staff training records were reviewed with Staff 4 (RCC) and Staff 5 (RCC in training) and revealed Staff 12 (MT/CG) and Staff 15 (CG), each hired on 02/17/26, lacked documented evidence they had completed first aid certification and abdominal thrust training within 30 days of hire. Staff 7 (MT/CG), hired 11/28/25, had documentation of completion of first aid certification and abdominal thrust on 02/21/26, more than 30 days after hire. The need for staff to complete all required training in the specified time frames was discussed on 04/01/26 at 10:55 am with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 and Staff 5. The findings were acknowledged.

1. Immediate actions for cited staff: Staff 7, 12, and 15 are in the process of completing first aid and abdominal thrust training. Documentation of completed training will be placed in each staff member's personnel file upon completion. In addition to addressing the cited training gap, the facility has initiated a comprehensive retraining program for all current direct care staff that includes, but is not limited to: abdominal thrust and first aid; caregiving skills and ADL assistance; medication administration; and all required online training modules. Retraining documentation is being collected and filed for each staff member. 2. A 30-day new hire training checklist has been implemented that lists all required competencies under OAR 411-054-0070(5), including abdominal thrust and first aid, caregiving, ADL assistance, changes associated with aging, condition recognition and reporting, general food safety, and medication and treatment administration competency demonstration where applicable. The RCC assigns the checklist to each new hire on their first day and is responsible for tracking completion. A master staff training calendar has been created that lists each employee, their hire date, required training items, due dates, and completion dates. This calendar is reviewed monthly by the RCC and quarterly by the Administrator to ensure no training deadlines are missed. A new hire cannot be scheduled to work independently with residents until all required 30-day training items are documented as complete and signed off by the appropriate supervisor. 3. The 30-day new hire training checklist is reviewed by the RCC at the time of hire and monitored throughout the 30-day window, with a check-in at day 14 to identify any incomplete items. The master training calendar is reviewed monthly by the RCC and quarterly by the Administrator. Ongoing training requirements for all current staff are tracked on the same calendar and reviewed at each monthly and quarterly cycle to ensure no deadlines are missed. 4. The Resident Care Coordinator (RCC) is the primary person responsible for assigning the 30-day training checklist to new hires, monitoring training completion throughout the 30-day window, maintaining the master training calendar, and conducting monthly reviews of training records. The Administrator is responsible for quarterly audits of training records and overall accountability for ensuring all direct care staff meet training requirements per OAR 411-054-0070. The Facility RN is responsible for documenting observed and evaluated competency demonstrations for medication and treatment administration per OAR 411-054-0070(5)(b)(G).

OAR 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request.

Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year in accordance with the Oregon Fire Code (OFC) and other applicable state and local codes as required. Findings include, but are not limited to: The facility was a licensed RCF with residents housed in three two-story buildings. During the acuity interview on 03/30/26, twelve residents were identified as requiring the assistance of two direct care staff to transfer. Fire and life safety records were reviewed with Staff 1 (Administrator) on 03/31/26 at 1:25 pm. During the interview, Staff 1 reported the facility had not conducted any drills of the emergency preparedness plan, encompassing all three buildings, in the last 12 months. The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required was discussed with Staff 1, Staff 2 (Director of Nursing), Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 12:05 pm. They acknowledged the findings.

1. The facility has scheduled a full emergency preparedness evacuation drill encompassing all three buildings (A, B, and C) to be completed within 60 days, no later than May 31, 2026. The drill will include scenarios reflective of the resident population's acuity, including the evacuation of residents who require the assistance of two direct care staff for transfers. In addition, a structured disaster preparedness education session will be conducted for all staff, covering scenarios such as prolonged power outages, addressing how residents' care needs — including medical equipment dependencies — will be managed during an emergency. 2. The facility has established a written emergency preparedness drill schedule that meets at least twice-yearly requirement under the Oregon Fire Code (OFC). The annual drill schedule will include: (1) one full evacuation drill across all three buildings, and (2) one additional drill or tabletop/discussion exercise, which may address a specific disaster scenario such as power failure, water loss, or pandemic response. The emergency preparedness plan has been reviewed and updated to ensure it reflects current resident acuity, including the number of residents requiring two-staff assists for evacuation. Drill completion and outcomes, including any identified gaps, will be documented and retained on-site. Staff and Residents will receive education following each drill to reinforce emergency response procedures. 3. Emergency preparedness drills will be conducted no less than twice per calendar year, in compliance with OAR 411-054-0093 and the Oregon Fire Code. Following each drill or tabletop exercise, the RCC will document the outcome, note any deficiencies identified, and develop a corrective action plan as needed. The emergency preparedness plan itself will be reviewed and updated annually, or sooner if resident acuity, building configuration, or staffing changes warrant a revision. 4. The RCC is responsible for scheduling, coordinating, and documenting all emergency preparedness drills and education sessions. The Administrator is responsible for ensuring drills are conducted within required timeframes, reviewing drill outcomes, and ensuring the emergency preparedness plan remains current. The Facility Nurse will assist in assessing resident-specific evacuation needs and ensuring those needs are reflected in the drill design and emergency plan.

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

Based on observation and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to: During an observation and interview with Resident 1 on 03/30/26 at 1:47 pm, the resident reported having a key to his/her apartment that had not worked since s/he moved in. This surveyor attempted to use Resident 1’s key to unlock the door. The key did not fit the lock. Resident 1 stated that s/he had reported it to the facility and was told the lock “needed to be changed out.” The resident could not recall when s/he reported the issue or to whom the issue was reported to. On 04/01/26 at 11:01 am, Staff 2 (Director of Nursing) confirmed the locking mechanism needed to be changed on Resident 1’s apartment door. On 03/31/26 at 11:30 am, an unsampled resident reported that his/her key did not work in his/her apartment door. The unsampled resident took the surveyor to his/her apartment to demonstrate what the issue was, but the key was not where s/he had thought it would be. The resident stated, “I have no idea where it is.” On 04/01/26 at 11:01 am, Staff 1 (Administrator) confirmed she took the key the previous week as it needed to be replaced but forgot to follow up on the issue. The need to ensure all residents were provided keys to their units was discussed with Staff 1, Staff 2, Staff 3 (Facility RN), Staff 4 (RCC), and Staff 5 (RCC in training) on 04/01/26 at 11:01 am. They acknowledged the findings.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity.

Based on interview and record review, the facility failed to ensure move-in evaluations addressed all required elements, including preferred pronouns and gender identity, for 1 of 1 sampled resident (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 01/06/26 showed the following areas needed cleaning or repair: Main Kitchen a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, white billowy matter, and/or black matter was visible on or underneath the following: * Hood vents above range; * Interior of oven; * Floor drain under prep table; * Stainless steel shelf holding spice containers; * Bottom of standing reach-in freezer; * Stainless steel shelf where cutting boards are stored; * Floor behind oven; and * White coated racks in standing reach-in cooler. b. Items in need of maintenance or repair: * Cutting board observed with scoring and or burned/melted areas; * Mechanical ware washing machine not working; * Rust observed on white coated racks in stand-up reach-in cooler; and * Red multi section scoop plates with scoring and or dull finish/lack of glossy coating. c. Multiple open food containers found without open date. d. Non pasteurized eggs in shell being used for preparing egg dishes that are not fully cooked to 145 degrees Fahrenheit. e. Bagged potatoes in dry storage stored in a wire crate that allows for the direct contact of the food product with the floor. f. Spring scale observed stored directly on the floor of the dry storage area. g. Staff 2 (Cook) was unable to adequately describe the two-stage cooling method for hot foods. h. Staff 2 was not able to state desired sanitizer solution concentration range (200 parts per million to 400 ppm) for effective surface sanitation. i. Probe thermometer observed to be used without first sanitizing. Staff 2 indicated probe thermometer is sanitized after use using sanitizer solution and washed with soap and water at the end of the service day; sanitizer solution is not rinsed off before using again resulting in potential chemical contamination. No alcohol wipes in kitchen. j. Multiple dented/damaged food products were observed in the dry storage area, stored with ready-to-use products. Surveyor was told damaged food containers stay on the shelf with usable product. No clear system to prevent use of damaged, potentially hazardous food product. k. Non enclosed wood and spring style “snap trap” for rodents observed on floor behind standing reach in freezer. l. All care staff were observed to handle/deliver food to residents without wearing aprons/protective barriers over their clothing to minimize the potential for cross contamination. m. Hazardous chemicals observed to be stored directly above the designated area for holding clean dishes creating the potential for chemical contamination of the dishes. n. Food observed being prepared without a surface sanitation solution bucket set up and available for use. 2. Building C Kitchenette a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, white billowy matter, and/or black matter was visible on or underneath the following: * Interior of oven; * Range top of oven; and * Bottom of freezer storage area. b. Items in need of maintenance or repair: * Stained, cracked plastic cup with dulled finish. c. Multiple food items on counter without open date. d. Multiple items in refrigerator without open date. 3. Building A Kitchenette a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, white billowy matter, and/or black matter was visible on or underneath the following: *Microwave interior; *Toaster, interior/exterior; *Bottom of the cabinet under the sink; and *Catch tray/ “drain” of ice/water dispenser on front of refrigerator. b. Items in need of maintenance or repair: *Interior of microwave has a non cleanable surface; *Open food items on counter without open date; and *Multiple items in refrigerator without open date. At approximately 1:18 pm, the surveyor reviewed the deficiencies and repair/replacement areas with Staff 1 (Executive Director), Staff 2 and Staff 3 (Nutritionist). They acknowledged the findings

ID Prefix Tag C0240 OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule Main Kitchen: A. Accumulation of food spills, splatters, etc. 1. On 1/6/2026 hood vent was cleaned by maintenance staff. On and between 1/6/2026 and 1/11/2026, interior of oven, floor drain, stainless steel spice rack, bottom of standing reach in freezer, stainless steel shelf that holds cutting boards, floor behind oven, and white coated racks in reach in cooler were assigned to be thoroughly wiped clean, scrubbed, and sanitized by cooks. Cooks completed all assignments within this timeframe. 2. In between professional hood cleanings, maintenance team will address dusty hood vents by wiping clean 1x/ week. Two times per week, every week there will be a deep clean in which the interior of the oven, floor drain, spice rack, bottom of standing reach in freezer, stainless steel shelf that holds cutting boards, floor behind oven, and white coated racks in standing reach-in cooler will be cleaned and sanitized by cook. Nutritionist will be responsible for ensuring this gets done thoroughly by checking and signing off on the duty the morning after. Nutritionist and Resident Care Coordinator (RCC) will also do random audits at least once a week. 3. Main kitchen deep cleans to be completed by cooks 2x/ week. Nutritionist and RCC to ensure task has been completed the following morning and report to Administrator monthly and as needed. 4. Nutritionist, RCC, Administrator B. Items in need of repair 1. On and between 1/6/2026 and 1/11/2026, items in need of repair, including but not limited to plastic cutting boards and red sectioned plates were disposed of and replaced with new items. Mechanical ware washing machine scheduled to be fixed 2/21/2026. White coated racks in standing reach in cooler ordered 1/13/2026 and were delivered and installed 1/15/2026. 2. All cooking and serving supplies, tools and equipment will be audited monthly to ensure heavily scored or worn items are being disposed of and replaced. Mechanical ware washing machine in use daily, if it goes down again cook is plan is to have cook immediately report this to Administrator. In addition, routine checks in kitchen will also be conducted on machinery in kitchen as well as metal racks in fridge and freezer to ensure these items work properly and are without rust and sanitized. They will be fixed/ replaced as necessary. Cooks will be given education on proper care of equipment and when to report. 3. Audits and routine checks to be conducted 1x/ month by Nutritionist and Resident Care Coordinator (RCC) who will report to Administrator monthly and as needed. 4. Nutritionist, RCC, Administrator. C. Open food containers 1. Food in containers without open date were disposed of on 1/6/2026. Labels/pens provided where it's easily accessible. 2. Education and handouts will be provided to cooks and direct care staff that includes food sanitation and the importance of dating and labeling all open food containers upon opening. Auditing fridge and dry storage to make sure everything opened has an open date will be added to nightly closing list so that every night everything has been dated. Random audits of coolers will take place by Nutritionist and Resident Care Coordinator (RCC) to confirm cooks are meeting these expectations. 3. Nutritionist and RCC to check that all food items are being dated 2x/ week and report to Administrator monthly and as needed. 4. Nutritionist, RCC, Administrator D. Non-pasteurized eggs 1. Pasteurized eggs ordered from Sysco 1/13/2026. Cooks educated on use of pasteurized eggs and limitations of non-pasteurized eggs. 2. From 1/13/2026 on, only pasteurized eggs will be ordered. Sysco rep contacted and asked to never substitute non-pasteurized eggs. Cook who accepts inventory should verify only pasteurized eggs are received and notify Nutritionist if any issues. 3. Pasteurized eggs to be ordered weekly. 4. Nutritionist E. Bagged potatoes floor contact 1. On 1/10/2026, cook rearranged kitchen so that there are no items on the bottom of wire racks. All food stored on shelves at least 6 inches off the floor. Education about keeping food items at least 6 inches off the ground provided. 2. Education provided to cooks about keeping food and food items off of the floor, and at least 6 inches above the floor. Nutritionist will verify this rule is being followed weekly when doing inventory and report to Administrator monthly and as needed. 3. Weekly walkthroughs 4. Nutritionist, Administrator F. Spring scale on floor 1. On 1/6/2026, the scale spring was taken off the floor and returned to its place on the wire rack in dry storage. Furthermore, on 1/10/2026 the cook rearranged the dry storage to give the spring scale a more convenient home. 2. Education will be provided to cooks about cross contamination and cleanliness to assure that items that have the potential to be placed on surfaces that food is placed on never comes into contact with the floor. Upon doing inventory, nutritionist will verify all kitchen utensils are not in contact with the floor. 3. Nutritionist will conduct walkthroughs once per week and report to Administrator monthly and as needed. 4. Nutritionist, Administrator G. Two stage cooling method 1. On 1/6/2026 surveyor provided facility with handouts that described the two stage cooling method. Cooks will be assigned further education about the two-stage cooling method by 2/21/2026. 2. Educational handouts will be kept available and posted in the kitchen. Cooks will be randomly quizzed every 3-4 months and observed about safely cooling foods by Nutritionist and/or Resident Care Coordinator (RCC) and report to Administrator every 3 months. 3. Cooks will be quizzed every 3-4 months to brush up on kitchen knowledge. 4. Nutritionist, RCC, Administrator H. Sanitizer solution 1. Nutritionist will walk both cooks through the importance of filling the sanitizer bucket each morning, changing the solution every 3 hours, and testing the solution with strips. 2. Cooks will be responsible for checking sanitizer solution during the day. Nutritionist and RCC will do regular walkthroughs to audit proper sanitizer solution set up and report to Administrator monthly and as needed. 3. Nutritionist and RCC walkthroughs at least 2x/week. Cooks will be quizzed every 3-4 months to brush up on kitchen knowledge. 4. Nutritionist, RCC, Administrator I. Probe thermometer 1. Nutritionist will discuss with both cooks sanitzing the probe thermometer before and after use, and rinsing thoroughly after sanitation to prevent chemical contamination. Alcohol wipes are made available in the kitchen near thermometer probes. 2. Nutritionist and RCC will regularly observe Cooks use of probe thermometers to ensure proper sanitation and rinsing. Questions about sanitizing probe thermometers will be added to kitchen quizzes. 3. Nutritionist & RCC observations at least 2x/week and report to Administrator monthly and as needed. Cooks will be quizzed every 3-4 months to brush up on kitchen knowledge. 4. Nutritionist, RCC, Administrator J. Dented/ damaged food products 1. Dented and damaged products were disposed off on 1/10/2026. Milk crate placed in dry storage by 2/21/2026 with label for “dented/ damaged food products-Do not use" will be used as temporary storage for these items. Education will be provided to cooks and staff about this process by 2/21/2026. 2. Discuss with staff and cooks upon hire about our process for dealing with dented and damaged food products. Nutritionist and RCC will check inventory for dents/damages and discard or return weekly. 3. Nutritionist and RCC will inventory cans weekly when completing inventory. Report to Administrator monthly and as needed. 4. Nutritionist, RCC, Administrator K. Non-Enclosed Snap Trap 1. Non-closed snap trap removed from kitchen 1/10/2026. 2. Verbal education during all staff meeting will be provided to cooks and staff about what snap traps are allowed to be installed in this environment and which snap traps are not. During kitchen walk through, nutritionist and RCCwill check for traps and other potential hazards. 3. Kitchen education for staff 2x/ year. Nutritionist and RCC will do kitchen walk throughs weekly and report to Administrator monthly. 4. Nutritionist, RCC, Administrator L. Aprons 1. Aprons purchased 1/12/2026. Staff instructed to wear via staff messaging portal, to be discussed at next all staff meeting. Aprons will be kept with serving carts. 2. Staff will be reprimanded if seen serving food without apron. RCC will be responsible for guaranteeing staff is wearing aprons when serving meals, and for ordering aprons. 3. Evaluated daily by RCC and cooks. Report to Nutritionist and Administrator monthly and as needed. 4. Cooks, Nutritionist, RCC, Administrator M. Hazardous Chemicals 1. Hazardous chemicals moved into janitorial closet 1/10/2026. Signs to be placed above kitchen sink listing items that are not to be placed in this area. 2. Nutritionist will inventory weekly when doing inventory and during kitchen audits monthly and will report to Administrator monthly. 3. Audited weekly with inventory, monthly during kitchen audit. 4. Nutritionist, Administrator N. Surface Sanitation Bucket 1. Sanitation bucket immediately set up on day of audit when noticed it was not set up. Both cooks have been educated about the importance of setting up a sanitation bucket. 2. Setting up sanitation bucket added to list of opening duties, which needs to be crossed off and initialed daily. RCC to look for sanitation bucket whenever in the kitchen. 3. Daily, setting up sanitation bucket will need to be crossed off list and initialed, RCC will need to check this is done daily. Report to Administrator monthly and as needed 4. RCC, nutritionist, Administrator 2. Building C Kitchenette A. Accumulation of Food Spills 1. Interior of oven and range stovetop cleaned 1/10/2026 by direct care staff. Bottom of freezer storage cleaned 1/6/2026. 2. Cleaning oven that is not in use and stovetop range added to list of cleaning duties for direct care staff. Clean fridge and freezer also added to duties. 3. Weekly cleaning to take place. Monitored weekly by RCC and report to Administrator monthly and as needed 4. RCC, Administrator B. Items in Need of Maintenance Repair 1. Plastic cups inventoried 1/17/2026 and damaged cups disposed of. 2. Nutritionist to also conduct kitchenette audits 1x/ month with help of RCC. Any damaged/ scratched items will be disposed of during audits. Nutritionist and RCC will report to administrator monthly. 3. Audits 1x/ month. 4. Nutritionist, RCC, Administrator C. Multiple Food Items on Counter w/o Open Date 1. Staff alerted that everything needs an open date on 1/6/2026 via staff messaging portal. Staff also asked to toss anything that has been opened and does not have an open date. Further education to take place during all staff meeting. 2. Kitchenette’s food items in kitchenettes checked 2x/ week by nutritionist and RCC to look for opened and undated foods in fridge and on counters. Staff will be asked to initial when dating food items. Nutritionist and RCC will report to Administrator monthly. 3. Audits 2x/ week. 4. Nutritionist, RCC, Administrator D. Multiple Items in Refrigerator without Open Date 1. Staff alerted that everything needs an open date 1/6/2026 via staff messaging portal. Staff also asked to toss anything that has been opened and does not have an open date. Further education to take place during all staff meeting. 2. Kitchenette’s audited 2x/ week by nutritionist and RCC to look for opened and undated foods in fridge and on counters. Staff will be asked to initial when dating food items. Nutritionist and RCC will report to Administrator monthly. 3. Audits 2x/ week. 4. Nutritionist, RCC, Administrator 3. Building A Kitchenette A. Accumulation of Food Splatters... 1. Microwave interior cleaned 1/06/2026. Toaster cleaned 1/16/2026. Bottom of the cabinet cleaned under the sink 1/06/2026. Catch tray/ “drain” of ice water/ dispenser on front of refrigerator cleaned 1/06/2026. 2. Staff notified to clean and sanitize microwave interior out daily; toaster, catch tray/drain weekly. Added to list of duties for direct care staff. Toaster cleaning added to list of duties for caregivers, to be done weekly. 3. Nutritionist and RCC responsible for random audits at least 2x/week and weekly walk-throughs. report to Administrator monthy 4. Nutritionist, RCC, Administrator B. Items in Need of Maintenance or Repair 1. Microwave replaced 1/18/2026. Staff alerted that everything needs an open date on 1/6/2026 via staff messaging portal. Staff also asked to toss anything that has been opened and does not have an open date. Further education to take place during all staff meeting about microwave safety and the prevention of burns. 2. This will be added to audit by Nutritionist and RCC completes for kitchenette’s weekly to look for damaged items. Report to Administrator monthly and as needed 3. Audits 1x/ week. 4. Nutritionist, RCC, Administrator

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental and psychosocial needs for the residents and created opportunities for active participation in the community at large. Findings include, but are not limited to: Observations during the re-licensure survey, dated 02/27/23 through 03/02/23, and a review of the 02/2023 and 03/2023 activity calendars revealed a lack of scheduled and unscheduled activities provided for the residents. On 02/28/23 at 10:00 am, a group interview was conducted with four unsampled residents in attendance. The attendees reported a lack of activities within the community with only Bingo and holiday or birthday parties offered. One resident reported activities were often canceled when the activity director was called to be a caregiver due to staffing needs. Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (Administrator) on 02/28/23 at 11:18 am. She acknowledged the findings.

1.a. The facility will 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. 1.b. The facility will provide equipment, supplies and space to meet individual and group activity needs. 2.a.  The Activities Coordinator will plan a monthly calendar of social and recreational activities.  More offerings and greater variety will be added to meet individual and group interests on a daily basis.  A printed calendar will be distributed to all residents monthly.  If there is a change to calendar or scheduled activities the Activities Coordinator will notify residents as soon as possible and give a back-up activity plan.  A back-up activity plan will be available and accessible to residents and direct care staff. 2.b.  The Activities Coordinator will interview and survey the residents and community to: - identify residents' individual and group activity preferences - gather feedback on current and on going activity offering and gather resident suggestions and wishes - explore options for residents to participate in activities in and around the community at large - create and update individual resident activity profiles 2.c.  Direct Care Staff and Activities Coordinator will document and track resident participation in daily social and recreational activities. 2.d.  The Activities Coordinator will document a summary of each resident activity preference and participation quarterly and as needed. 2.e.  All Staff will be trained and re-trained in their role on Resident Services including daily program of social and recreational activities. 3.a.   Activities Coordinator will evaluate this plan of correction at least monthly. 4.a.  The Life Enrichment director and Activities coordinator are responsible for ensuring these corrections are compeleted/monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services and were followed for 1 of 3 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/2019 with diagnoses including diabetes, dysphagia and neuromuscular dysfunction of bladder. The resident's current service plan dated 01/10/23 was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 02/27/23 and 03/02/23. Resident 1's service plan was not reflective, did not provide clear instruction to staff and/or was not followed in the following areas: * Use of the catheter leg bag versus the larger urine collection bag; * Catheter bag cleaning; * Location of incontinent care; * Diagnosis and monitoring of depression; * History of dehydration and the need to encourage fluids; * Diagnosis and monitoring of diabetes; * Plugging in the electric wheelchair nightly; * Home exercise program; * Monitoring skin related to the use of a foot strap; * Providing visual supervision with meals; and * Assistance with dressing. The need to ensure service plans were reflective of the identified needs of the resident, provided clear direction to staff, and were followed by staff was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 03/02/23 at 1:00 pm. They acknowledged the findings.

1. a. Facility updated Resident #1 service plan to reflect resident's current identified needs and provide clear direction to staff. 1.b. Staff education, coaching and monitoring provided to ensure service plan is followed. 2. a. Facility will incorporate all elements that are identified in the person-centered service into the residents service plan. We will ensure that the service plan reflects the resident's needs and preferences as identified during evaluation. 2. b. Service plans will be made readily available to staff and provide clear direction of services including a description of who will provide services and what, when, how and how often the services shall be provided. 2. c. Services will be provided by staff according to the current service plan.  Ongoing monitoring will be implemented to ensure delivery of these services. 2. d. Daily team huddle will be implemented to communicate to staff any updates or changes and get feedback on service plans. 2. e. Service Plan team meeting will be conducted before move-in and quarterly. 2. f. Electronic Health Record system will be changed to a better system that integrates all aspects of resident services. Facility is moving from an old sytem QuickMar to PointClickCare. 3. a. All Service plans will be reviewed and updated if needed during this period in the next 60 days. 3. b. Moving forward, service plans will be completed prior to move-in date with updates and changes as appropirate within 30 days of move-in; during quarterly evaluations; and when a resident has a significant change in condition. 4. a. Facility Administrator, Facility RN & RCC are responsible for ensuring these corrections are compeleted/monitored.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were monitored through resolution for 1 of 3 sampled residents (#1) with a short-term change of condition. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/2019 with diagnoses including hypertension and cerebrovascular disease. Resident 1's clinical record and charting notes, reviewed from 11/29/22 through 02/27/23, revealed the following: * Resident 1 had an order for carvedilol 6.25 mg by mouth twice daily for hypertension; and * The medication was not administered due to lack of availability between 01/29/23 through 01/31/23. There was no documented evidence the facility monitored the resident's condition for potential complications due to not receiving his/her routine dose of antihypertensive medication. This was confirmed during an interview with Staff 1 (Administrator) and Staff 2 (RN) on 03/01/23 at 1:52 pm. The need to ensure the facility monitors short-term changes of condition through resolution was discussed with Staff 1, Staff 2 and Staff 4 (RCC) on 03/02/23. They acknowledged the findings.

1. a. Facility RN re-assessed Resident #1 and completed documentation of resolution of short-term change in condition related to missed Carvedilol 6.25mg. 2. a. Facility staff will identify and monitor residents for any short-term changes in condition and determine and document what actions or interventions are needed. 2. b. Any short-term changes in condition will be communicated to staff on each shift.  Staff instructions and interventions will be resident specific.  Monitoring will be documented by progress notes at least weekly until condition resolves. 2. c. Utilization of Temporary Service Plan or Alert Flowsheet to allow staff to: - have a guide in identifying and recognizing short-term changes in condition - determine what actions and interventions are needed - what and when to monitor, document and report - who and when to notify Administrator, RN or Healthcare provider 2. d. Utilization of 24-hour report log for short-term changes in condition to be used as: - communication tool for all staff on all shifts - tracking tool to ensure timely monitoring and documentation until resolution 2. e. Daily team huddle to be led by Officer-in-charge to go over any new/resolving changes in condition including short-term changes. 2. f. Daily review by Officer-in-charge of health record system reports or dashboards for any missed or refused medications and treatments. 2. g. Electronic Health Record system will be changed to a better system that integrates all aspects of resident care and allow for a more streamlined and timely documentation of monitoring and intervention for short-term changes of condition. Facility is moving from an old sytem QuickMar to PointClickCare. 2. h.  All Staff will be trained or re-trained on identifying changes in residents' condition and corresponding policies and procedures on staff responsibilities, reporting, monitoring, documentation until resolution. 3. a. Officer in charge/RCC will review at least daily. 3. b. RN/Administrator will evaluate at least weekly.   4. a. Facility Administrator, Facility RN & RCC are responsible for ensuring these corrections are compeleted/monitored.

Based on observation and interview, the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include, but are not limited to: Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room. Upon entering the facility for the survey on 02/27/23 at 9:00 am, some administrative staff and direct care staff were observed not wearing face masks. During the remainder of the survey, 02/27/23 through 03/02/23, multiple kitchen and direct care staff were observed on several occasions having their masks pulled down so as not to cover their nose and, in some cases, not covering their mouth or nose. These staff were in the kitchen, medication rooms or common areas with the doors open, and residents were observed to be able to enter freely into the rooms. The need to ensure staff consistently complied with masking requirements was discussed with Staff 1 (Administrator) during the exit meeting on 03/02/23.

1.a. Strictly implement proper use of mask and PPE according to current Federal, State and County guidelines. 2.a. Frequent rounding, reminder and correction by Officer in Charge and Infectious disease specialist for proper mask and PPE use. 2.b. Staff and resident training and re-training on proper mask and PPE use to include current rules, how, where and when to use. 3.a. At least daily rounding by officer in charge 3.b. Evaluated at least weekly by Infectious disease specialist. 4.a. Infectious disease specialist will be responsible to see that corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to: During the relicensure survey, conducted 02/27/23 through 03/02/23, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on the following: a. The medication room door near the front entrance reception area was unlocked and the door was open when survey entered the building on 02/27/23. Multiple bubble packed medications were accessible on the counter. b. Administrative oversight was found to be ineffective based on the deficiencies in the following areas: C 303: Systems: Medication and Treatment Orders; C 305: Systems: Resident Right to Refuse; C 310: Systems: Medication Administration; C 325: Systems: Self-Administration of Medication; and C 330: Systems: Psychotropic Medications. The need to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 03/02/23. Staff 1 (Administrator) acknowledged the findings.

1.a. Strictly implement for all medications administered by the facility will be stored in locked containers in a secured environment such as a medcart or medication room.   Only authorized facility staff (Medtech/RCC/Officer-in-charge/dietitian/RN/Administrator) will have access to these storage units and must be kept secure and locked when not in direct sight by authorized facility staff. 2.a. Frequent rounding, reminder and correction by Officer in Charge, RCC and RN to ensure medication storage units are secure. 2.b. Staff training and re-training on medication storage and security. 3.a. At least daily rounding by Officer-in-charge/RCC. 3.b. Evaluated at least weekly by RN/Administrator. 4.a. The Facility Administrator/Facility RN & RCC will be responsible to see that corrections and completed and monitored.

2. Resident 1 was admitted to the facility in 10/2019 with diagnoses including hemiplegia and hemiparesis. Resident 1's MAR/TAR, dated 02/01/23 through 02/27/23 and corresponding progress notes and prescriber orders were reviewed and revealed the following: * The resident had an order for oxycodone 5 mg as needed for pain with no more than one tab administered per day. The resident received two doses on 02/01/23; and * The resident had an order for nystatin to be applied topically once a day for rashes. The TAR was blank on 02/04/23 and 02/07/23. On 02/28/23 at 1:12 pm, the surveyor and Staff 14 (Agency LPN/MT) observed and checked the MAR/TAR and medication supply. Staff 14 was unable to verify if the above orders had been followed. The need to ensure medications were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 03/02/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a physician or other legally recognized practitioner were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 2) whose records were reviewed.  Findings include, but are not limited to: 1. Review of Resident 2's 02/01/23 through 02/26/23 MAR/TAR's and current signed physician orders, identified the following orders were not carried out as prescribed: * Carvedilol 12.5 mg tablet (for hypertension), order noted to notify PCP [primary care provider], if systolic blood pressure (top number) was greater than 160; and * Lidocaine-Prilocaine 2.5% cream (for pain), as needed every four hours. The 02/2023 MAR indicated on 23 occasions, Resident 2's systolic blood pressure was over 160. During an interview with Staff 1 (Administrator) and Staff 2 (RN) on 02/28/23, it was reported there was no documentation the physician was notified of the elevated systolic blood pressure. During an interview on 03/01/23 at 10:30 am, Resident 2, reported s/he had Lidocaine cream for pain in his/her feet, however, s/he was always told the medication was not available. The resident stated s/he would like the treatment, if they had it. During an observation and interview on 03/01/23 at 10:45 am, Staff 13 (Agency LPN/MT), stated the Lidocaine was not located in the resident's room or in the medication cart and she was not able to administer it. The need to ensure all orders for medications from a physician or legally recognized practitioner were carried out as prescribed was discussed with Staff 1 and Staff 2 on 03/01/23. They acknowledged the findings.

1. a. Facility corrected medication and treatment orders for Resident #2 by: - Notifying PCP according to order parameters of blood pressure medication - Requested PCP for clarification of frequency of notification for any out of range vital signs - Making sure supply of as needed cream available and accessible to medtech 1. b. Facility corrected medication and treatment orders for Resident #1 by: - Medtech staff education, coaching and monitoring of medtech staff on dosing frequency parameters for prn Oxycodone and timely and accurate documentation of Nystatin and other treatments. - Adding additional eMAR controls to space prn Oxycodone doses according to order. 2. a. Medication and treatment orders by a legally recognized practitioner will be carried out as prescribed.  All medications and treatments facility administers will be documented in the resident's record.   2. b. Medication and treatment orders including associated parameters for administering and reporting, ie. Blood pressure parameters, will be followed and documented accordingly. 2. c. Medication and treatment orders will be reviewed for completeness and clarity.  Any unclear parameters will be clarified with ordering practitioner. ie. Oxycodone 1 tablet PO daily PRN need clarified if daily means 24hours apart in dosing or day-by-day allowance to take prn with parameter on how many hours in between daily dose. 2. d. Medication and treatment supplies will be available and on hand at all times in order to be carried out and administered as prescribed.   Medications and treatments will be ordered and re-ordered timely to ensure adequate supply and stored in a location accessible to authorized staff. Medtech should take steps in locating, re-ordering and reporting any missing medications and treatments. 2. e. All facility administered medications and treatments will be documented timely in resident's record by responsible medtech. 2. f.  Facility will conduct an audit of all medications and treatment orders for all residents to address the following: -  Ensure there are corresponding signed orders from each resident's legally recognized practitioner and that these orders are correctly written on residents facility record.   -  Orders will be reviewed for completeness and clarity and facility will make every effort to request for clarification from ordering practitioner. -  Ensure all medications and treatments administered by facility are available and on hand. 2. g.  All new medication and treatment orders will be reviewed via triple-check process per facility policy. 2. h.  Daily review by Officer-in-charge/RCC of health record system reports or dashboards for any missed entries, missed administration or refused medications and treatments. 2. i. Electronic Health Record system will be changed to a better system that integrates all aspects of resident care including Medication and Treatment management and documentation. Facility is moving from an old sytem QuickMar to PointClickCare with scheduled GoLive date in mid-April 2023.  New system will allow for tracking dashboards, setting and flagging parameters on medications, re-ordering medications and documentation. 2. j.  All Medtechs will be trained or re-trained on Medication and Treatment Administration and Policies and Procedures. 3. a. Officer in charge/RCC will review at least daily. 3. b. RN/Administrator will evaluate this plan of correction at least weekly until substantial complaince met. 3. c.  All medications and treatments will be audited and updated if needed during this period of correction, in the next 60 days.  Moving forward, Medications and treatments will be reviewed prior to and at resident move-in day, as needed and quarterly thereafter.   4. a. Facility Administrator, Facility Nurse & RCC are responsible for ensuring these corrections are compeleted/monitored.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to an order, for 1 of 1 sampled resident (#2) with multiple medication refusals. Findings include, but are not limited to: Resident 2 was admitted to the facility in 05/2022 with diagnoses including chronic obstructive pulmonary disease (COPD) and constipation. Resident 2's MAR from 02/01/23 through 02/27/23 was reviewed and identified the following medication refusals: * Chlorhexidine rinse (for gums and tongue) was refused on 14 occasions; * Combivent Respimat inhaler (for COPD) was refused on 19 occasions; * Fluticasone nasal spray (for congestion) was refused on 22 occasions; * Lactulose solution (for constipation) was refused on 11 occasions; and * Wixela inhaler (for Asthma) was refused on 18 occasions. There was no documented evidence the facility notified the physician of the resident's refusals. The need to ensure the facility notified the physician when Resident 2 refused prescribed medication or treatment orders was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 02/28/23. Staff 1 acknowledged the physician had not been informed of the refusals.

1. a. Facility made correction to rule on Resident Right to Refuse for Resident #2 by: - Notified PCP of medication and treatment refusals - Requested PCP clarification of frequency of notification for any medication or treatment refusal 2. a. Facility will notify physician or prescriber of any refusals of medication or treatment order. Subsequent refusals will be reported as requested by physician or prescriber. 2. b. Medtechs will report and document each refusal per physician or prescriber order. 2. c. Officer in charge/RCC will review any refusals and ensure Medtechs have reported and documented per physician orders.  Review will be done at least daily during rounding and electronic health record dashboard review. 2. d. For subsequent or frequent refusals and if no parameters are set Officer in-charge/RCC will request review and parameters from physician or prescriber on frequency of notification for frequently refused medications and facility records to be update as necessary. 2. e.  All Medtechs will be trained or re-trained on Resident Right to Refuse in relation to medications and treatments and related Policies and Procedures. 3. a. Officer in charge/RCC will review at least daily. 3. b. RN/Administrator will evaluate this plan of correction at least weekly until substantial complaince met. 3. c.  All resident refusal parameters will be audited and updated if needed during this period of correction, in the next 60 days.  Moving forward, edications and treatments refusals will be audited every quarter and as needed. 4. a. Facility Administrator, Facility Nurse & RCC are responsible for ensuring these corrections are compeleted/monitored.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, had resident-specific parameters for PRN medications and clear instructions to staff for 3 of 3 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 05/2022 with diagnoses including osteoporosis and a history of fractures. Resident 3's 02/01/23 through 02/27/23 MAR and physician orders were reviewed and identified the following PRN medications lacked resident specific parameters:   * PRN Tylenol (for pain) and PRN Oxycodone (for pain); * PRN Naproxen (for headache) and PRN Rizatriptan (for migraines); and * PRN Miralax (for constipation) and PRN bisacodyl suppository (for constipation).   The need to ensure the MAR had clear parameters and instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1 (Administrator) on 03/01/23. She acknowledged the findings. 2. Resident 1 was admitted to the facility in 10/2019 with diagnoses including hemiplegia, hemiparesis and cerebrovascular disease. Resident 1's MAR/TAR dated 02/01/23 through 02/27/23 and corresponding progress notes and prescriber orders were reviewed and revealed the following: a. Resident 1 had the following two PRN medications prescribed for pain: * Acetaminophen 500 mg - give one tablet every eight hours as needed for pain. Administer first, and if not effective after one hour administer oxycodone; and * Oxycodone 5 mg - one tablet by mouth once a day as needed for pain. Oxycodone was administered outside of the resident specific parameters established by the RN on eleven occasions in 02/2023. b. The resident had an order for Senexon-S 50-8.6 mg - give two tablets by mouth once a day, as needed for constipation. Staff 2 (RN) included parameters to administer after two days of no bowel movement. The bowel medication was not administered per the RN parameters on 02/07/23 and 02/15/23. c. The following PRN medication lacked resident specific parameters to ensure unlicensed caregivers used no discretion in administering the medication: * Meclizine 25 mg tablet, take 1 tablet three to four times a day as needed for dizziness. The need to ensure resident specific parameters were included on the MAR for PRN medications and were followed was discussed with Staff 1 (Administrator), Staff 2 and Staff 4 (RCC) on 03/02/23. They acknowledged the findings. 3. Resident 2 admitted to the facility in 05/2022 with diagnoses including functional paraplegia and constipation. Resident 2's MAR/TAR from 02/01/23 through 02/27/23 and current signed physician orders were reviewed and identified the following inaccuracies on the MAR/TAR: * Bowel monitoring instructions included to give PRN Lactulose if no bowel movement in three days. There was no documented evidence Resident 2 was prescribed PRN Lactulose. The need to ensure MAR/TAR's were accurate and included clear instructions for unlicensed staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 02/28/23. They acknowledged the findings.

1. a. Facility corrected Resident #3 medication orders adding clear parameters and instructions that reflect resident's preference and ability to self-direct use of one or more PRN medication for the same condition. 1. b. Facility corrected Resident #1 medication by: - adding clear parameters and instructions that reflect resident's preference and ability to self-direct use of more than 1 PRN medication for pain and bowel medications. - education, coaching and monitoring of staff on bowel monitoring and following prn bowel medications per order - requested PCP clarification of prn Meclizine order to eliminate ranges if possible. RN reviewed order and set clear parameters for staff to follow. 1. c. Facility corrected Resident #2 bowel monitoring and prn Lactulose for instructions to match according to current order. 2. a. Facility will keep an accurate Medication Administration Record (MAR) as ordered by a legally recognized prescriber.  All medications and treatments facility administers will be documented in the resident's record.   2. b. Medication and treatment orders including associated parameters for administering and reporting will be followed and documented accordingly. 2. c. Medication and treatment orders will be reviewed for accuracy, completeness and clarity to ensure unlicensed caregivers are able to understand and follow without use of their own discretion in administering these orders.  Resident specific parameters and clear instructions for prn medications will be established and reviewed by or in collaboration with community RN, community pharmacist or legal recognized prescriber. 2. d. Medication and treatment monitoring parameters will likewise be reviewed, documented and followed accordingly. ie. bowel monitoring reviewed to use prn Lactulose 2. e.  Facility will conduct an audit of all medications and treatment orders for all residents to address the following: -  Ensure there are corresponding signed orders from each resident's legally recognized practitioner and that these orders are correctly written on residents facility record.   -  Orders will be reviewed for completeness and clarity and facility will make every effort to request for clarification from ordering practitioner or consult/collaborate with community RN/community pharmacy partner for any additional resident and order specific parameters 2. f.  All new medication and treatment orders will be reviewed via triple-check process per facility policy. 2. g.  Daily review by Officer-in-charge/RCC of health record system reports or dashboards for any PRN medications used 2. h. Electronic Health Record system will be changed to a better system that integrates all aspects of resident care including Medication and Treatment management and documentation. Facility is moving from an old sytem QuickMar to PointClickCare with scheduled GoLive date in mid-April 2023.  New system will allow for tracking dashboards, setting and flagging parameters on medications, re-ordering medications and documentation. 2. i.  All Medtechs will be trained or re-trained on Medication and Treatment Administration and Policies and Procedures. 3. a. Officer in charge/RCC will review at least daily. 3. b. RN/Administrator will evaluate this plan of correction at least weekly until substantial complaince met. 3. c.  All medications and treatments will be audited and updated if needed during this period of correction, in the next 60 days.  Moving forward, Medications and treatments will be audited and reviewed prior to and at resident move-in day, as needed and quarterly thereafter. 4. a. Facility Administrator, Facility Nurse & RCC are responsible for ensuring these corrections are compeleted/monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated for safety and ensure physician's orders were in place for the self-administration of prescription medications for 1 of 1 sampled resident (#1) who self-administrated prescription medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/2019 with diagnoses including cognitive dysfunction and dysphagia. Review of Resident 1's quarterly evaluation, dated 01/10/23, revealed staff were to administer and watch the resident take all his/her medications. During an interview with Resident 1 on 02/28/23, s/he showed this surveyor a medication cup filled with Enulose (for bowel regulation) and stated MT's left liquid medications at his/her bedside frequently. A current quarterly evaluation of the resident's ability to self-administer prescription medications and a prescriber's order was requested on 03/01/23. The facility was unable to provide the requested self-medication evaluation or prescriber's order. The need to ensure residents who chose to self-administer medications were evaluated for safety and had a physician's written order of approval for the self-administration of prescription medications was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 03/02/23. They acknowledged the findings.

1. Facility re-evaluated Resident #1 for preference and ability to self-administer medications and requested his primary care physician for a written order approval.  In the meantime, staff have been educated, coached and monitored to follow proper medication administration policies and procedures. 2. a. Facility will evaluate Residents who choose to self-administer their own medications upon move in, quarterly and as needed or when a resident prefers to start self-administering their medications. 2. b. Trained staff will evaluate resident for safety in self-administration of medication and will document this evaluation.  This evaluation will conclude with a physician's written order of approval for the self-administration of prescribed medications. If approved for self-administration, this will be noted in the MAR for medtech/staff to follow. Residents will likewise be notified and education provided on self-administration of medications when applicable. 2. c. All Medtechs will be trained or re-trained on Self-Administration of Medications and corresponding Policies and Procedures. 3. a. Frequent rounding, reminder and correction by Officer in charge/RCC at least daily to ensure policy on self-administration is followed. 3. b. RN/Administrator will evaluate this plan of correction at least weekly until substantial complaince met. 3. c.  All resident medications and treatments will be audited and updated if needed during this period of correction, in the next 60 days.  Moving forward, self-medication will be audited and reviewed prior to and at resident move-in day, as needed and quarterly thereafter. 4. a. Facility Administrator, Facility Nurse & RCC are responsible for ensuring these corrections are compeleted/monitored.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#2) who was prescribed a PRN medication to treat the resident's anxiety. Findings include, but are not limited to: Resident 2 was prescribed PRN hydroxyzine to treat symptoms of anxiety. The 02/01/23 through 02/27/23 MAR indicated the resident was administered the medications on 15 occasions. The facility failed to document non-pharmacological interventions were attempted and ineffective prior to administering the psychotropic medication on 15 occasions. The need to ensure staff attempted and documented non-pharmacological interventions were ineffective prior to administering PRN psychotropic medications to treat a resident's behavior was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 02/28/23. They acknowledged the findings.

1. a. Facility corrected Resident #2 use of psychotropic medications by: - added clear instructions, parameters and documentation of non-pharmacologic interventions for behaviors prior to administration of psychotropic medications - updated prescriber of frequency of behaviors that lead to use of psychotropic medications and requested update on recommendations to manage behaviors 2. a. Facility will use psychotropic medications only according to a prescription from a legal authorized prescriber that specifies the circumstances, dosages and duration of use.  These medications can only be used when required to treat a resident's medical symptoms or to maximize a resident's functioning and must have resident-specific paramters. 2. b.  Staff will attempt and document all non-pharmacologic interventions tried prior to administration of prn psychotropic medications. 2. c. Officer in charge/RCC will review any psychotropic medication administration and corresponding non-pharmacological behavior interventions tried. Review will be done at least daily during rounding and electronic health record dashboard review. 2. d.  All Direct Care Staff will be trained or re-trained on non-pharmacologic behavior interventions and related Policies and Procedures.  Additionally, all Medtechs will be trained or re-trained on use of psychotropic medications when non-pharmacologic interventions are ineffective and related documentation and policies and procedures. 3. a. Officer in charge/RCC will review at least daily. 3. b. RN/Administrator will evaluate this plan of correction at least weekly until substantial complaince met. 3. c.  All resident Psychotropic medication orders and non-pharmacologic behavioral intervention will be audited and updated if needed during this period of correction, in the next 60 days.  Moving forward, these will be reviewed and audited before and at move-in, every quarter and as needed. 4. a. Facility Administrator, Facility Nurse & RCC are responsible for ensuring these corrections are compeleted/monitored.

Based on observation and interview, it was determined the facility failed to ensure pathway edges did not have drop-offs and the facility grounds were kept orderly and free from refuse. Findings include, but are not limited to: 1. Observations of the exterior of the facility 02/27/23 through 02/28/23 showed drop-offs along pathway edges of 3 inches or greater in multiple areas. 2. An exterior corridor between buildings A and B had items including discarded and broken pottery, a grill, gate frames and garbage. The need to ensure pathways did not have drop-offs and the exterior of the facility was kept free of refuse was discussed with Staff 1 (Administrator) on 03/01/23 at 10:15 am. She acknowledged the findings.

1a. We will direct our landscape maintenance subcontractor fill in the pathway drop-offs with grave, soil, and/or bark dust to ensure that the drop-offs on each side of the exterior pathway do not exceed an 1 inch drop-off. On a bi-annual basis, we will have our maintenance crew, including our lanscape maintenance contractor inspect and make sure these drop offs on each side of the exterior pathways do not exceed more than an inch. 1b. The items along the exterior corridor were already cleaned and removed. On a bi-weekly basis, we will have our housekeeping and maintenance crew inspect the exterior of the facility and ensure that it is kept orderly and free of litter and refuse. 2. See comments under 1a and 1b above.We will also re-train and re-orient all maintenance and housekeeping staff regarding this deficiency, and corrective actions and processes that are (or will be) setup to address this issue. 3. Please see 1a and 1b above. 4. The Business Support/Accounting Specialist will be the responsible person to inspect the exterior walkways and drop offs/edges are kept to an inch or less. The Resident Care Coordinator will be responsible to oversee the Housekeeping staff and ensure that the exterior grounds are kept orderly and free of litter/refuse on a bi-weekly basis, as part of their cleaning plan.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to: Observations of the facility on 02/27/23 through 02/28/23 revealed the following areas were in need of cleaning and/or repair: Building A * Multiple resident apartment doors throughout building A had scrapes, missing paint and/or gouges (large gouge across from room 5); * The walls throughout building A were gouged exposing the sheet rock below and/or had drip marks, splatters and scuff marks; * The handrails and baseboards throughout building A had scrapes, scuffs and gouges; * The ceiling fans and vents were covered with dust and cobwebs; * Exit doors were dirty with scuffs and the front door had exposed wood; and * There were bugs in the light fixture by the elevator. Building B * Multiple resident apartment doors throughout building B had scrapes, missing paint and/or gouges (large gouge outside room 1); * Outlet cover by room 1 was broken; * Wall in dinning room by water bottle storage had splatters and drips; * There were stains in the carpet by the fireplace; * The fireplace screen was dirty and had a rip in it; * The walls throughout building B were gouged exposing the sheet rock below and/or had drip marks, splatters and scuff marks; * The handrails and baseboards throughout building B had scrapes, scuffs and gouges; * The vents were covered with dust; and * Exit doors were dirty with scuffs and the front door had exposed wood. Building C * Multiple resident apartment doors throughout building C had scrapes, missing paint and/or gouges (large gouge outside room 5); * Exit doors were dirty with scuffs and paint scraped off; * The walls throughout building C were gouged exposing the sheet rock below and/or had drip marks, splatters and scuff marks; * The baseboards throughout building C had scrapes, scuffs and gouges; * There were cobwebs on the ceiling above room 1; * Elevator wall was gouged; * Wall outside kitchenette had splatters and drips; * The wall below the upstairs TV had a brown substance smeared on it; * Ceiling vents covered with dust and dirt; and * Second floor stairway door covered with splatter. The environment was toured and the need to maintain interior surfaces clean and in good repair was discussed with Staff 1 (Administrator) on 03/01/23. She acknowledged the findings.

1a. We will engage a third party subcontractor to repair and repaint the resident doors, hallways, including handrails and baseboard materials for all buildings. 1b.  Please note that the old (existing) wing of Building A will be under renovation as part of the ongoing 8 bedroom construction/addition, which is expected to be complete by by end of June 2023. All of the observed wall scrapes, missing paint, and / or gouges throughout Building A be replaced and/or repaired and re-painted. 1c. We will re-orient and re-train all housekeeping staff to follow the daily cleaning routine tasks that is designed to maintain the cleanliness and orderliness, of all the interior surfaces of the three buildings, which includes the floors, walls, ceiling, doors, windows, furniture, light fixtures, and all equipment. 1d. We will create a repairs and maintenance checklist including routine inspections that will list and identify preventive measures to ensure that all equipment furniture and fixtures are operating effectively and efficinetly. We will also re-orient and re-train all interior maintenance staff to ensure that they understand the process and procedures regarding maintenance so appropriate actions are taken to repair and maintain all facility equipment, furniture and fixtures. 2. Please see 1a - 1d above. In additon, we will conduct spot audits by the Administrator/Resident Care Coordinator staff and monthly inspections to ensure that the housekeeping and maintenance activities are carried out timely and properly. 3. Please see item 2 above. 4. Please see item 2 above. In addition, the Administrator will coordinate all of the repairs and renovation of Buildings B and C with the Building Owners.

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used when washing soiled linens and soiled clothing. Findings include, but are not limited to:   All facility laundry was washed in the laundry room in Building C. A tour of the laundry room in Building C on 03/01/23 at 10:15 am revealed the following: * There was no way to verify the washing machines reached at least 140 degrees F. during the rinse cycle; and * The facility was using a detergent that did not indicate it had disinfecting properties. The need to ensure laundry detergents included a disinfectant when rinse temperatures were less than 140 degrees F. was discussed with Staff 1 (Administrator) on 03/01/23. She acknowledged the findings.

1. We implemented use of detergents with disinfectant properties when washing soiled linens and soiled clothing.   2. Laundry policy and procedures has been updated to include disinfecting detergent use for soiled linen.  A laundry in-service training will be conducted with all direct care staff emphasizing the importance of proper laundry care, including adding detergents with disinfecting properties when washing soiled linen and soiled clothing.  Written, clear laundry instructions will be made available for staff. 3.  Initial evaluation will be done within 60 days of this correction period.  Policies and procedures will be monitored monthly until substantial compliance reached then quarterly and as needed thereafter. 4. The Administrator, and the Resident Care Coordinator will be the accountable persons in ensuring that all direct care staff are trained on this process.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to: On 02/28/23, gas fireplaces were observed in common living rooms of Buildings A, B and C. The fireplaces were located where residents could come into incidental contact with them. The fireplace in building A was not turned on. The fireplaces in Buildings B and C were on and hot to the touch. The temperatures were taken with the surveyor's thermometer. The fireplace in Building B was observed to have a surface temperature of 142.9 degrees F. The fireplace in Building C was observed to be 155.1 degrees F. Staff 1 (Administrator) was notified 02/28/23. Staff 1 acknowledged the surface temperatures were too hot and immediately alerted staff to turn off the fireplaces. Staff 1 explained she would have the temperatures adjusted or install screens on all the fireplaces.

1. We will replace all gas fireplaces in all building with electric fireplace(s) to avoid the risks associated with this deficiency. For Building A, the fireplace replacement was included in the scope of the renovation that is expected to be completed by end of June 2023. For Buildings B and C, we will include the replacement of the gas fireplace with electric fireplaces in the scope of the painting and minor renovation. In the interim, we will disable the use of the gas fireplaces. 2. Please see item 1 above. 3. Once the gas fireplaces are replaced, this deficiency will be eliminated and resolved permanently. 4. The Administrator will work with the Building Owners to make sure that this task is completed.

The findings of the re-licensure survey, conducted 02/27/23 through 03/02/23, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 03/02/23, conducted 07/19/23 through 07/20/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.