Hearthstone at Murrayhill

Based on observation and interview, it was determined the facility failed to ensure a homelike environment for multiple sampled and unsampled residents who received beverages in disposable cups during meal service. Findings include, but are not limited to:

Meal observations were made between 01/06/25 and 01/08/25 in the Lily, Iris and Rose houses of the MCC and revealed beverages were delivered to residents in disposable cups.

During an interview on 01/07/25 at 11:46 am, Staff 10 (MCC CG) was asked why the facility was using disposable cups, she stated, “the [reusable] plastic cups are so small we use disposable.” She also reported, “the larger cups are sparse…” Staff 10 then counted the plastic cups within the Rose kitchenette and said, “but it looks like we have enough for everyone right now.”

On 01/08/25 at 9:25 am, Staff 4 (Food Services Director) reported the MCC had “red” reusable cups that kitchen staff delivered to the MCC three times a day, and the facility expected caregivers to serve drinks in the reusable cups. Additionally, Staff 4 stated he had been “harping” on facility staff to use the reusable cups “for months.”

At 9:35 am on 01/08/24, observations were made of the red reusable cups in the three kitchenettes in the MCC. The Lily house had 12 red reusable cups available, the Iris house had over 21 reusable cups, and the Rose house had 12 reusable cups. The MCC’s census at survey entrance was 29; therefore, there were enough cups for all residents to receive a reusable cup.

The need to ensure a homelike environment during meal service was discussed with Staff 2 (MC Administrator) on 01/08/25 at 1:23 pm. She acknowledged the findings.

OAR 411-054-0027 (1) Resident Rights and Protection - General

(1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right:
(a) To be treated with dignity and respect.
(b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences.
(c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided.
(d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made.
(e) To receive information about the method for evaluating their service needs and assessing costs for the services provided.
(f) To exercise individual rights that do not infringe upon the rights or safety of others.
(g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse.
(h) To receive services in a manner that protects privacy and dignity.
(i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays).
(j) To have medical and other records kept confidential except as otherwise provided by law.
(k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone.
(l) To be free from physical restraints and inappropriate use of psychoactive medications.
(m) To manage personal financial affairs unless legally restricted.
(n) To have access to, and participate in, social activities.
(o) To be encouraged and assisted to exercise rights as a citizen.
(p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence.
(q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation.
(r) To be free of retaliation after they have exercised their rights provided by law or rule.
(s) To have a safe and homelike environment.
(t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion.
(u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse for 3 of 4 sampled residents (#s 6, 8, and 9) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 9 moved into the facility in 04/2024 with diagnoses including dementia.

The resident's progress notes, dated 10/12/24 through 12/30/24, and a facility investigation, dated 12/12/24, were reviewed and revealed the following:

On 12/13/24, staff documented, “Resident being monitored for a skin issue starting 12/12/24. Resident has bruising to the left side of their [chest]. Please monitor if bruise gets bigger, swelling, changes in pain or discomfort. Please notify [RN]/MT if there are any changes.”

Per the facility investigation, “Resident is unable to state what happened or how [s/he] got the bruise.” On 12/13/24, staff documented, “While ruling out abuse and neglect it appears to be a new blister on [Resident 9’s] left rib cage. While interviewing caregivers” “none of the caregivers recall seeing the area that appears to be a blister on [his/her] rib cage.”

The investigation dated 12/12/24 had no documented evidence the injury of unknown cause was not the result of abuse. Staff 5 (RCC) verified on 01/07/25 at approximately 4:00 pm the incident had not been reported to the local SPD office.

Survey requested the facility report the incident and received verification of the report on 01/08/25 at 11:45 am.

The need to ensure all injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse was discussed with Staff 1 (ED), Staff 2 (MC Administrator), and Staff 5 on 01/08/25 at 10:22 am. They acknowledged the findings.

2. Resident 8 moved into the facility in 06/2022 with diagnoses including dementia.

The resident’s progress notes, dated 10/08/24 through 01/06/25, and facility investigations, dated 10/07/24 through 01/05/25, and interviews with staff revealed the following:

On 11/23/24, staff documented, “Bruise on right forearm is about 9 cm long and 5 cm wide. Dark purple/red in color.”

According to the facility’s investigation, the resident was unable to explain how the s/he acquired the bruise on their arm. The facility was unsure of the origin of the bruise. Additionally, it was stated the incident was reported to the local SPD office, however, there was no confirmation that the incident had been reported. During the survey, facility staff contacted local SPD office to obtain the case number of the incident, but SPD staff reported that they had not received the report. The facility subsequently reported the incident to the local SPD office on 01/09/25 and confirmation of the report was provided before the survey exited.

On 01/09/25 at 9:50 am, the finding was shared with Staff 2 (MC Administrator). Staff acknowledged the findings.

3. Resident 6 moved into the facility in 01/2021 with diagnoses including Alzheimer’s disease.

The resident’s progress notes, dated 10/08/24 through 01/06/25, and a “Skin Incident” investigation, dated 10/09/24, were reviewed. Interviews with staff were completed and the following was revealed:

On 10/09/24, staff documented in the progress notes that Resident 6 had a, “dark purple/blue bruise with no drainage, bleeding or pain.”

According to the facility’s “Skin Incident” investigation dated 10/09/24, the resident was unable to explain how s/he acquired the bruise on his/her arm, and the facility was “unsure how the bruise appeared.” The incident report documented the bruise was reported to the local SPD (Seniors and People with Disabilities) office; however, the facility did not have confirmation the injury of unknown cause had been reported. During the survey, facility staff contacted the local SPD office to obtain the case number of the incident, but Staff 2 (MC Administrator) confirmed on 01/08/25 at approximately 12:55 pm that the SPD office did not have documentation the incident was reported. The facility subsequently reported the bruise on 01/08/25, and confirmation of the reporting was provided to the survey team prior to exit.

The need to ensure all injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the injury was not the result of abuse was discussed with Staff 2 on 01/08/25 at 1:23 pm. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse for 1 of 2 sampled residents (# 10) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to:


Resident 10 moved into the facility in 04/2025 with diagnoses including dementia.

The resident's progress notes, dated 04/29/25 through 05/20/25, were reviewed and revealed the following:

On 05/02/25, staff documented, “[At 4:00 am] caregiver noted light [reddish] like [smear] of blood on [his/her brief] unable to find where [it] was coming from”.

There was no documented evidence the facility reported the incident to the local SPD office or that the facility conducted an immediate investigation to rule out abuse.


Survey requested the facility report the incident and received verification of the report on 05/22/25 at 2:13 pm.

The need to ensure all injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse was discussed with Staff 2 (MC Administrator) and Staff 3 (Health Services Director) on 05/22/25. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 5) whose move-in evaluations was reviewed. Findings include, but are not limited to:

Resident 5 moved into the facility in 10/2024.

The new move-in evaluation failed to address the following elements:
* Pronouns;
* Gender identity;
* Spiritual and cultural preferences and traditions;
* Physical health status including visits to health practitioner(s) ER, in the past year, Vital signs if indicated by diagnoses, health problems, or medications;
* Mental health issues including Presence of depression, thought disorders, or behavioral or mood problems, history of treatment and Effective non-drug interventions;
* Personality, including how the person copes with change or challenging situations;
* Pain including pharmaceutical and non-pharmaceutical interventions and how a person expresses pain or discomfort;
* List of treatments type, frequency, and level of assistance needed;
* Indicators of nursing needs, including potential for delegated nursing tasks;
* Complex medication regimen;
* History of dehydration or unexplained weight loss or gain;
* Elopement risk or history;
* Smoking, including the resident's ability to smoke without causing burns or injury to themselves or others or damage to property;
* Alcohol and drug use including the resident's use of alcohol or the use of drugs not prescribed by a physician; and
* Environmental factors that impact the resident's behavior including, noise, lighting, and room temperature.

The need to ensure the move-in evaluation included all required elements was discussed with Staff 3 (Health Services Director) and Staff 2 (MC Administrator) on 01/08/25 and 01/09/25. Staff acknowledged the findings.

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed following quarterly evaluations, reflective of residents' needs, provided clear direction to staff regarding the delivery of service or implemented the service plan for 4 of 7 sampled residents (#s 3, 4, 5 and 8) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 10/2024 with diagnoses including Alzheimer’s disease.

Observations of the resident, interviews with staff and current service plan reviewed during the survey, from 01/06/25 thru 01/09/25, revealed Resident 5's service plan was not reflective of the resident's needs and did not provide clear instructions in the following areas:

* Outside provider service including identifying when and whom to contact;
* The use of a pad/cushion while in a wheelchair;
* Spiritual and cultural preferences and traditions;
* Mental health issues including presence of depression, thought disorders, or behavioral or mood problems, history of treatment and effective non-drug interventions;
* Personality, including how the person copes with change or challenging situations;
* Pain, pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;
* Elopement risk or history;
* Smoking including the resident's ability to smoke without causing burns or injury to themselves or others or damage to property;
* Alcohol and drug use including the resident's use of alcohol or the use of drugs not prescribed by a physician; and
* Environmental factors that impact the resident's behavior including, noise, lighting, and room temperature.

On 01/08/25 and 01/09/25, the service plan was discussed with Staff 2 (MC Administrator) and Staff 3 (Health Services Director). They acknowledged the service plans were not reflective of the resident's status and lacked clear instructions.

2. Resident 8 was admitted to the facility in 06/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff and current service plan reviewed during the survey, from 01/06/25 thru 01/09/25, revealed Resident 8's service plan was not reflective of the resident's needs and did not provide clear instruction the following areas:

* The use of a pad or cushion in the wheelchair; and
* Presence of three signs on the wall to prevent falls.

On 01/08/25 and 01/09/25, the service plan was discussed with Staff 2 (MC Administrator) and Staff 3 (Health Services Director). They acknowledged the service plans were not reflective of the resident's status and lacked clear instructions.

3. Resident 3 moved into the facility in 09/2024 with diagnoses including unspecified dementia.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/06/25 thru 01/09/25, and revealed Resident 3's service plan was not reflective of the resident's needs and did not provide clear instruction the following areas:

* Frequency of visits by spouse and the routine s/he provided for Resident 3;
* Direction to staff if spouse does not visit to keep the resident's routine consistent;
* Preferred pronouns;
* Full assistance with dressing;
* Staff to hand the resident his/her grooming items (e.g. comb, toothbrush with toothpaste already on it, etc.) for Resident 3 to be able to finish the task;
* Refusals of assistance in the restroom;
* Toileting behavior interventions;
* Staff interventions for when the resident requests toilet paper;
* Response time and interventions needed to try to negate self harm;
* How the resident communicates pain; and
* Person centered interventions to try to negate resident to resident altercations.

The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (MC Administrator) and Staff 5 (RCC) on 01/08/25 at 10:22 am. They acknowledged the findings.

4. Resident 4 moved into the facility in 11/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/06/25 thru 01/09/25, and revealed Resident 4's service plan was not reflective of the resident's needs, did not provide clear instruction, and/or was not implemented in the following areas:

* Specific beverage preferences;
* No concentrated sweets;
* Preferred pronouns;
* Incontinent of bowels;
* Frequency of visits from spouse;
* Ability to communicate pain;
* Ability to communicate when s/he is cold; and
* Assistance needed with laundering sheets and towels weekly.

In addition, the service plan that was available to staff was dated 05/28/24.

The need to ensure service plans were completed following quarterly evaluations, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED), Staff 2 (MC Administrator) and Staff 5 (RCC) on 01/08/25 at 10:22 am. They acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were completed at least quarterly, and were reflective of residents' current care needs, provided clear direction to staff regarding the delivery of services, and were implemented for 3 of 3 sampled residents (#s 11, 12, and 13) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 13 moved into the facility in 09/2024 with diagnosis including severe protein-calorie malnutrition and hypertension.

The current service plan with hand-written updates, dated 03/28/25, was reviewed and interviews with Resident 13 and facility staff were conducted. The following was identified:

Resident 13's service plan was not implemented in the following areas:

* Encourage resident to join activities that promote additional food intake;
* Encourage resident to order room service; and
* Weekly weights.

On 05/22/25 at 1:55 pm, Resident 13 confirmed the above had not been implemented and/or had not occurred in “about a month.”

The need to ensure the service plan was implemented, was reviewed with Staff 2 (MCC Administrator) and Staff 3 (Health Services Director) on 05/22/25 at 3:18 pm. They acknowledged the findings.

2. Resident 12 moved into the facility in 12/2020 with diagnoses including dementia, mood disturbance, and anxiety.


Observations were made of the resident's care from 05/21/25 through 05/22/25. Interviews with the facility staff were conducted. The current service plan dated 04/20/25 was reviewed.

Resident 12's service plan was not reflective of the resident's current needs and was not implemented in the following areas:

* Wipe or wash hands prior meals;
* Provide cueing and encouragement during meals;
* Provide physical assistance with meal intake as needed if unable to direct their own intake; and
* Pain status including the use of a lidocaine patch.

The need to ensure the service plan reflected residents' current needs and was implemented was reviewed with Staff 2 (MCC Administrator) and Staff 3 (Health Services Director) on 05/22/25. They acknowledged the findings.

3. Resident 11 moved into the facility in 01/2025 with diagnoses including dementia and edema.

The resident's service plan, dated 02/05/25, and temporary service plans were reviewed. Staff were interviewed. The following was not reflective of the resident's current needs and/or did not provide clear caregiving instruction:

* Oriented to person, place, time, and situation;
* Where s/he prefers to watch television;
* Preference of eating in his/her room on days that the resident is experiencing increased confusion;
* Organizing drawers and magazines to self soothe;
* The need for two staff members to transfer when Resident 11 verbalizes not feeling very strong;
* Staff assistance needed for oral hygiene;
* The ability to let staff know when s/he needs assistance to the restroom;
* The use of a gait belt;
* Direction to staff on what to monitor the siderails for and who to report to if they are in disrepair; and
* Painful bilateral shins.

Additionally, the resident’s service plan had not been updated quarterly.

The need to ensure service plans were reflective of the resident’s current needs, provided clear caregiving instruction, and were updated quarterly was reviewed with Staff 2 (MCC Administrator) and Staff 3 (Health Services Director) on 05/22/25. They acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to monitor the change of condition, at least weekly, until resolved for 4 of 8 sampled residents (#s 3, 5, 6, and 8) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 5 moved into the facility in 10/2024 with diagnoses including Alzheimer’s disease.

Review of the resident's clinical record including progress notes from 10/24/24 through 01/04/25, service plan updated on 10/28/24 and Temporary Service Plans were completed during the survey.

The facility failed to monitor the change of condition, at least weekly, until resolved for the following changes of condition:

* 10/24/24: New move-in/ New environment;
* 11/06/24: Bruise to right anterior leg;
* 11/13/24: Removed cast from the right leg;
* 11/26/24: Receiving injection in the right eye;
* 11/28/24: Bruise on left shin area;
* 12/05/24: A new medication, anti-fungal medication; and
* 12/17/24: Antibiotic treatment for urinary tract infection.

The need to ensure the facility monitored the change of condition, at least weekly, until resolved was discussed with Staff 2 (MC Administrator) and Staff 3 (Health Services Director) on 01/08/25 and 01/09/25. Staff acknowledged the findings.

2. Resident 8 moved into the facility in 06/2022 with diagnoses including dementia.

Review of the resident's clinical record including progress notes from 10/08/24 through 01/06/25, service plan updated on 11/13/24 and Temporary Service Plans were completed during the survey.

The facility failed to monitor the change of condition, at least weekly, until resolved for the following changes of condition:

* 10/09/24: Bruises on both hands;
* 11/03/24: Fall;
* 11/11/24: Bruise on the right hip area; and
* 12/07/24: Fall

The need to ensure the facility monitored the change of condition, at least weekly, until resolved was discussed with Staff 2 (MC Administrator) and Staff 3 (Health Services Director) on 01/08/25 and 01/09/25. Staff acknowledged the findings.

3. Resident 3 moved into the facility in 09/2024 with diagnoses including unspecified dementia.

The resident's clinical record, including progress notes dated 10/31/24 through 01/06/25, Temporary Service Plans, and an After Visit Summary, dated 11/23/24 were reviewed. The following was identified:

On 11/23/24, Resident 3 had a fall and sustained a laceration to the back of his/her head. Although there was documentation of some monitoring, there was no documented evidence the resident’s laceration was monitored through resolution.

On 01/07/25 at 3:36 pm, Staff 3 (Health Services Director) confirmed Resident 3’s skin laceration was not monitored through resolution.

The need to ensure residents were monitored with weekly progress noted until resolution was discussed with Staff 1 (ED), Staff 2 (MC Administrator) and Staff 5 (RCC) on 01/08/25 at 10:22 am. They acknowledged the findings.

4. Resident 6 moved into to the MCC in 01/2021 with diagnoses including Alzheimer’s disease.

The current service plan, dated 10/08/24, Temporary Service Plans, dated 10/08/24 through 01/06/25, and progress notes, dated 10/08/24 through 01/06/25, were reviewed. Interviews with staff were completed between 01/06/25 and 01/08/25.

The facility failed to determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:

* 10/08/24 – Eating napkins;
* 10/09/24 – Bruise to left upper arm;
* 10/20/24 – Non-injury fall;
* 10/21/24 – Non-injury fall;
* 11/06/24 – Elbow bruise;
* 12/10/24 – Non-injury fall;
* 12/10/24 – “Old bruises found on arms and legs”;
* 12/11/24 – Fall with abrasion;
* 12/12/24 – Assisted fall;
* 12/12/24 – Missing fingernail; and
* 12/17/24 – New medication for nail fungus.

The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, communicated the actions or interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 2 (MC Administrator) on 01/08/25 at 1:23 pm. She acknowledged the findings, and no additional information was provided.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined, the facility failed to document actions or interventions related to short term changes of condition, communicated the actions or interventions to staff on each shift, and monitor the changes in condition through resolution for 3 of 3 sampled residents (#s 10,11 and 12) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

1.Resident 12 moved into the facility in 12/2020 with diagnoses including dementia, mood disturbance, and anxiety.

Clinical records, including the current service plan, dated 04/20/25, and progress notes, dated 03/17/25 through 05/16/25 were reviewed. Interviews with facility staff were conducted. The following changes of condition were identified:

* 03/26/25: Staff documented the resident experienced fever and was congested;
* 03/27/25: The resident was admitted to hospice service and started supplemental oxygen; and
* 03/28/25: Multiple medications were discontinued.

There was no documented evidence that the resident's short-term changes of condition were consistently monitored weekly to resolution.

The need to monitor the resident’s condition through resolution was discussed with Staff 2 (MCC Administrator) and Staff 3 (Health Services Director) on 05/22/25. They acknowledged the findings.

2. Resident 10 moved into the facility in 04/2025 with diagnoses including dementia.

Clinical records, including progress notes, dated 04/29/25 through 05/20/25, were reviewed, and interviews with facility staff were conducted. The following changes of condition were identified:

* 05/02/25: Staff documented a "[reddish] like [smear] of blood" in the resident's brief; and
* 05/09/25: Increase of quetiapine (for depression).

There was no documented evidence the facility determined actions or interventions, communicated the actions or interventions to staff on each shift, and/or monitored the changes through resolution.

The need to ensure short term changes of condition had documentation of actions or interventions determined, those actions or interventions were communicated to staff on each shift, and were monitored through resolution was discussed with Staff 2 (MCC Administrator) and Staff 3 (Health Services Director) on 05/22/25. They acknowledged the findings.

3. Resident 11 moved into the facility in 01/2025 with diagnoses including dementia, nutritional anemia, and edema.

Clinical records, including progress notes, dated 03/10/25 through 05/21/25, weight records, and temporary service plans were reviewed. Interviews with facility staff were conducted. The following changes of condition were identified:

* 03/10/25: Return from the hospital; and
* Continued weight gain.

There was no documented evidence the facility determined actions or interventions, communicated the actions or interventions to staff on each shift, and/or monitored the above changes through resolution.

The need to ensure short term changes of condition had documentation of actions or interventions determined, those actions or interventions be communicated to staff on each shift, and were monitored through resolution was discussed with Staff 2 (MCC Administrator) and Staff 3 (Health Services Director) on 05/22/25. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment for 2 of 4 sampled residents (#s 1 and 6) who experienced significant changes of condition. Findings include, but are not limited to:



1. Resident 1 moved into the facility in 06/2022 with diagnoses including end stage renal disease, polyneuropathy, and a history of falls.

The resident's clinical record was reviewed and revealed Resident 1 was hospitalized and admitted to a rehabilitation center from 09/17/24 through 10/24/24 due to a fall and increased confusion.

The hospitalization and rehabilitation stay constituted a significant change of condition for which an RN assessment was required.

There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. During an 01/07/25 interview, Staff 3 (Health Services Director) acknowledged an RN assessment had not been completed for Resident 1's hospitalization and rehabilitation stay. No further documentation was provided.


The need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (ED), Staff 2 (MC Administrator), and Staff 3 on 01/08/25. They acknowledged the findings.



2. Resident 6 moved into to the facility in 01/2021 with diagnoses including Alzheimer’s disease.

Resident 6's weight records were reviewed and revealed the following:

* 08/23/24: 151.4 pounds;
* 11/08/24: 146.2 pounds;
* 11/23/24: 139.8 pounds;
* 12/06/24: 132.8 pounds; and
* 01/07/25: 140.3 pounds (requested during survey).

From 08/23/24 to 11/23/24, Resident 6 had a weight loss of 11.6 pounds or 7.66% of his/her body weight in three months. Additionally, from 11/08/24 to 12/06/24 the resident had a weight loss of 13.4 pounds or 9.17% of his/her body weight in one month. Both weight fluctuations indicated a significant change of condition and required an RN assessment.

RN assessments for both significant changes of condition were requested. On 01/07/25 at approximately 3:30 pm, Staff 3 (Health Services Director) confirmed no RN assessments were completed for either change of condition at that time the weight changes were triggered. Staff 3 reported the weight loss was identified on 12/30/24, and an assessment was initiated; however, the RN assessment was signed on 01/07/25 which was during the re-licensure survey.

There was no documented evidence the facility RN completed a timely assessment of Resident 6's significant weight losses.

The need to ensure all significant changes of condition were assessed by an RN and were completed in a timely manner was discussed with Staff 2 (MC Administrator) on 01/08/25 at 1:23 pm. She acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 2 of 5 sampled residents (#s 3 and 8) who received outside health services. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 09/2024 with diagnoses including unspecified dementia.

The resident's clinical record, including progress notes dated 10/31/24 through 01/06/25, Temporary Service Plans, and an After Visit Summary, dated 11/23/24 were reviewed. The following was identified:

On 11/23/24, Resident 3 had a fall and sustained a laceration to the back of his/her head. The resident's spouse took him/her to the emergency department and Resident 3 returned to the facility with two staples. The After Visit Summary recommended the following interventions:

* “Keep cut dry for the first 24 to 48 hours”;
* “Don't soak the cut, such as in a bathtub”;
* “After the first 24 to 48 hours, wash around the cut with clean water twice a day”;
* “The cut may be covered with a thin layer of petroleum jelly and a nonstick bandage, re-apply as needed”;
* “Avoid any activity that could cause your cut to reopen”;
* “Don't remove the staples on your own”, go to “Nurse Treatment Rooms, urgent care, or emergency department” to have them removed;
* “Take pain medications as directed”; and
* “Call your doctor if there is new pain or the pain gets worse, the skin near the cut is cold or pale or changes color, you have tingling or numbness near the cut, if blood soaks through the bandage, symptoms of infection, or if the wound is not healing as expected.”

Although the wound was healed at the time of survey, there was no documented evidence the facility had a system in place to ensure recommendations from outside providers were communicated to staff.

The need to ensure staff were informed of new interventions obtained by an outside medical provider and included in the resident's record was discussed with Staff 1 (ED), Staff 2 (MC Administrator) and Staff 5 (RCC) on 01/08/25 at 10:22 am. They acknowledged the findings.

2. Resident 8 moved into the facility in 06/2022 with diagnoses including dementia.

A review of the resident and their clinical records, including OT visit notes, dated from 08/08/24 through 12/12/24, were completed and showed the following recommendations:

10/22/24: Staff to encourage the resident to actively participate in brushing their teeth and handwashing activities include setting up the activity, handing the resident a toothbrush with toothpaste applied on it;

10/30/24: Fold a wheelchair cushion to raise the height, ensuring the hips were positioned above the knees, to facilitate easier transition to a standing position; and

11/11/24: Please use the simplified version of ‘Call for help’ sign on yellow paper to post in the resident’s room.

There was no documented evidence that these recommendations were communicated with staff to follow as coordination of care related to outside Healthcare Service.

On 01/08/25 and 01/09/25, the need to ensure on-going coordination of care was discussed with Staff 2 (MC Administrator) and Staff 3 (Health Services Director). Staff acknowledged the findings. No additional information was provided.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc

(2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 1 of 1 sampled resident (# 6) who received ADL assistance and multiple unsampled residents during dining services. Findings include, but are not limited to:

1. Resident 6 moved into the MCC in 01/2021 with diagnoses including Alzheimer's disease.

Observations of Resident 6 during the survey revealed s/he was dependent on two staff members for transfers using a mechanical lift and for toileting assistance.

On 01/07/25 at 10:44 am, the surveyor obtained permission and observed two caregivers provide ADL assistance for Resident 6. Both caregivers entered the resident’s room wearing single-use gloves and failed to don new gloves or to perform hand hygiene prior to initiating cares. The staff members assisted the resident to the toilet via a mechanical lift, obtained a clean incontinence brief and perineal wipes, completed perineal care, managed a soiled brief, assisted the resident with donning a clean incontinence brief and with his/her pant management, and transferred Resident 6 back into his/her wheelchair. The caregivers did not change gloves between dirty and clean tasks and did not complete hand hygiene.

The need to establish and maintain effective infection prevention and control protocols during ADL care was discussed with Staff 2 (MC Administrator) on 01/08/25 at 1:23 pm. She acknowledged the findings.

2. Observations of meal service were completed in the Iris, Lily and Rose houses of the MCC between 01/06/25 and 01/08/25.

Multiple care staff were observed serving meals and beverages to residents, touching ready to eat products, placing clothing protectors on residents, retrieving items from drawers, cupboards or refrigerators in the kitchenettes, leaving the dining area and then returning, entering resident rooms, assisting with feeding, touching residents, touching furniture, coughing, touching their own faces or glasses, and touching phones without changing soiled gloves and/or performing hand hygiene between dirty and clean tasks.

The need to ensure the facility maintained effective infection prevention and control protocols during meal service was discussed with Staff 2 (MC Administrator) on 01/08/25 at 1:23 pm. She acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 1 sampled resident (# 8) who received nutritional supplements. Findings include, but are not limited to:

Resident 8 moved into the facility in 06/2022 with diagnoses including dementia and gastrointestinal stromal tumor.

Review of the resident's current orders, signed on 07/15/24, showed Resident 8 was prescribed a liquid nutritional supplement twice a day, scheduled for administration at 10:00 am and 6:00 pm.

Observation of the resident on 01/07/25 and 01/08/25, from approximately 9:00 am to 11:00 am, revealed the resident was having breakfast independently in the dining room, eating at a slow pace. The resident was served a cup of coffee and a cup of water with their meal, with no other beverages or supplements provided.

On 01/08/25 at approximately 10:10 am, Staff 9 (MCC CG) reported she worked the evening shift and offered the nutritional supplement as needed when the resident was not eating much. Staff 17 (MCC CG) reported she worked in the morning and was unaware of the nutritional supplement but did encourage the resident to eat more food.

On 01/09/25 at 10:02 am, Staff 21 (MCC MA) reported she reminded the care staff to give the nutritional supplement to the resident, as it was kept in the refrigerator in the kitchenette.

The need to ensure physician orders were followed as prescribed was discussed with Staff 2 (MC Administrator) and Staff 3 (Health Services Director) on 01/08/25 and 01/09/25. Staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC) and provide fire and life safety instruction to staff on alternating months. Findings include, but are not limited to:

On 01/07/25 at 11:50 am, fire and life safety records, dated 07/2024 through 12/2024, were reviewed with Staff 27 (Director of Maintenance). The following was identified:

a. The facility lacked documented evidence fire drills were conducted according to OFC.

b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternating months from fire drills.

On 01/07/25, Staff 27 stated fire drills were completed once every three months and was unaware fire and life safety instruction was required to be provided to staff on alternating months of drills.

The need to ensure unannounced fire drills were conducted according to the OFC and fire and life safety instruction was provided to staff on alternating months was reviewed with Staff 2 (MC Administrator) on 01/09/25 at 11:24 am. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on interview and record review it was determined the facility failed to ensure that fire drills were conducted and to document all required elements. This is a repeat citation. Findings included but are not limited to:

Fire and Life Safety documentation was requested during the entrance conference on 05/21/25.

Review of Fire ad Life Safety records, dated 03/2025 through 05/2025, revealed a lack of documented evidence fire drills were conducted every other month and at different times of the day.

On 05/21/25 at 2:35 pm, Staff 27 (Director of Maintenance) provided documentation indicating the facility completed a fire drill and fire life safety in-service training to staff on the same day. When the surveyor asked if there was any additional documentation, such as records from previous fire drills, Staff 27 reported there was no additional documentation.

There was no documented evidence that the following areas were addressed during the fire drills:

* Date and time of fire drill;
* Location ff simulated fire origin;
* Escape route used;
* Resident evacuation problems encountered;
* Evacuation time-period;
* Staff members on duty and participating;
* Number of occupants evacuated; and
* Evidence alternative routes were used.

On 05/21/25 and 05/22/25, the need to ensure the facility conducted fire drills and documented all required elements was reviewed with Staff 2 (MCC Administrator) and Staff 27. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

Refer to C231, C260, C270, C420, and C513.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

(Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure garbage was stored in a covered refuse container and the grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to:

On 01/08/25 facility grounds were toured, and the following was identified:

a. Approximately 90-feet to the right of the memory care main entrance a fenced area was identified with broken and used equipment and furniture. The fenced area was not equipped with a cover.

b. The fenced garbage area was surrounded with broken equipment and furniture, wood planks, metal bars, broken ladders, torn and broken assistive devices, garbage cans, a meat smoker, and a large unclean and broken flattop stove that was removed from the facility kitchen.

On 01/08/25 at 1:28 pm, Staff 28 (Maintenance Staff) stated the fenced area was the “junk” area where staff throw away “stuff that residents leave behind” and confirmed most of the “junk” inside and around the fenced area had been there for “quite some time” but some of it has “only been there a month or so.”

c. The memory care had a small courtyard that had an overflowing garbage can with empty boxes and bags of garbage surrounding the garbage can.

On 01/09/25 at 10:12 am, Staff 13 (MCC CG) was observed to leave a bag of soiled cleaning supplies next to the overflowing garbage can in the courtyard.

On 01/09/25 at 10:47 am, Staff 2 (MC Administrator) confirmed she was aware of the “junk” area and stated the small courtyard was being used for garbage because they did not have another place to store it.

The need to ensure garbage was stored in a covered refuse container and facility grounds were kept orderly and free of litter and refuse was reviewed with Staff 2 on 01/09/25 at 11:24 am. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

On 01/07/25 through 01/09/25, walk-throughs of the RCF and memory care were conducted. The following areas were identified in need of cleaning and/or repair:

a. RCF first floor:

* Handrails were scratched, chipped, and/or gouged;
* The fireplace located in the ALF dining room, that RCF residents accessed and used, was out of order; and
* Wooden double doors at the North side entrance were heavily scratched, chipped, and gouged.

b. RCF second floor:

* Handrails were scratched, chipped, and/or gouged;
* Side table outside of the activity room was scratched and chipped;
* The library bookshelf had cabinet doors that had worn off surface finish;
* The desk in the library outside of the Executive Director’s office had worn off surface finish;
* The library had a wooden fish tank stand that had worn off surface finish; and
* The patio attached to the activity room had multiple pieces of outdoor furniture that were not clean.

c. RCF third floor:

* Handrails were scratched, chipped, and/or gouged;
* The yellow chair outside of the fitness center had stained material;
* The floral chair outside of room 3002 had stained material;
* The carpet transition outside of room 3010 had material that appeared to be separating;
* Three chairs in the chapel had stained material and/or a chipped/scratched wooden frame;
* The large patio had multiple pieces of outdoor furniture that were not clean including a large table, multiple chairs at the large table, multiple lounge chairs, and the cushions located on the lounge chairs had dark spots/stains;
* The large patio had a pillar to the left of a large table that had pealed paint and exposed unfinished wood with two pieces of broken wood; and
* Chair outside of room 3002 had stained material.

d. Memory care – Lily House:

* Handrails were scratched, chipped, and/or gouged;
* Multiple living room chairs had stained material, scuffs, scrapes, and worn off surface finish;
* Dining room chairs had stained material, scuffs, scrapes, and worn off surface finish;
* The “Pastor Alter” in the living room had a broken leg and the broken leg was on the alter;
* The sink faucet in unit six was broken; and
* The wooden table with a star on the top had scuffs, scrapes, and worn off surface finish.

e. Memory care – Iris House:

* Handrails were scratched, chipped, and/or gouged;
* Living room chairs had stained material, scuffs, scrapes, and worn off surface finish;
* Dining room chairs had stained material, scuffs, scrapes, and worn off surface finish;
* The flooring transition between the dining room laminate and the carpet was separating;
* Corner of the wall by unit 26 had gouged and broken material that exposed drywall;
* Unit 25’s door and door frame was scratched and chipped;
* The wall and baseboards by units 23 and 24 had a dried yellow color substance and was unclean; and
* The baseboard was missing by the double door corridor leading to the Rose House, near unit 25.

f. Memory care – Rose House:

* Handrails were scratched, chipped, and/or gouged;
* Living room chairs had stained material, scuffs, scrapes, and worn off surface finish;
* Dining room chairs had stained material, scuffs, scrapes, and worn off surface finish;
* Wooden fish tank stand and top had worn off surface finish;
* Unit 13’s door frame was scratched and chipped;
* The wall to the right of unit 20 had spills and splatters; and
* The corridor that connected Rose and Lily House was used as a storage space and was found to be unclean.

g. The memory care had two locked and secure courtyards. The small courtyard with single door access was identified to have three wooden planter boxes that had unfinished and bare wood exposed.

On 01/09/25 at 10:55 am, Staff 2 (MC Administrator) stated she was aware of most of the areas identified.

The need to ensure areas in need of cleaning and repair were reviewed and discussed with Staff 2 on 01/09/25 at 11:24 am. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in good repair. This is a repeat citation. Findings include, but are not limited to:

On 05/21/25 at 10:58 am, the memory care environment was toured. The following was identified to not be in good repair:

a. Iris House –

* Corner of the wall by units 24 and 26 had broken material that exposed drywall;
* Unit 25’s door frame was scratched and chipped; and
* The baseboard was missing by the double door corridor that led to Rose House, near unit 25.

b. Rose House –

* Unit 13’s door frame was scratched and chipped.

c. The memory care had two locked and secure courtyards. The small courtyard with single door access had two wooden planter boxes that were unfinished and had bare wood exposed.

On 05/22/25 at 10:09 am, a walk-through of the above noted areas was completed with Staff 27 (Director of Maintenance).

The need to ensure the facility was maintained in good repair was reviewed with Staff 2 (MCC Administrator) on 05/22/25. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure laundry facilities had a separate area with closed containers to ensure the separate storage and handling of soiled linens and soiled clothing. Findings include, but are not limited to:

On 01/08/25 and 01/09/25, the memory care laundry area was toured, and the following was revealed:

a. The laundry room had multiple open containers that were overflowing with linen and clothing, and multiple clear garbage bags were piled on the floor with clothing and linen. Direct-care and housekeeping staff were interviewed and stated they did not handle soiled linen or clothing and did not know the facility system for soiled linen processing.

b. The laundry room was not used in a way that provided a one-way flow of soiled linen and clothing and was not arranged in a way to keep soiled linen processing separate from regular linen.

On 01/08/25, Staff 5 (Resident Care Manager), Staff 9 (MCC CG), and Staff 11 (MCC CG) stated the laundry attendant was on vacation and they did not know who was responsible for handling soiled laundry and linen. Additionally, they stated they did not know the process relating to soiled laundry.

On 01/09/25 at 10:55 am, Staff 2 (MC Administrator) confirmed the facility did not have a system for soiled linen and laundry when the laundry attendant was not on shift.

The need to ensure laundry facilities had a separate area to ensure the separate storage and handling of soiled linens and clothing that had closed containers, had space to handle soiled linen and clothing processing separate from regular linen and clothing, and was arranged in a way that provided a one-way flow of soiled linen and clothing was reviewed with Staff 2 on 01/09/25 at 11:24 am. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure laundry facilities had a separate area with closed containers to ensure the separate storage and handling of soiled linens and soiled clothing. Findings include, but are not limited to:

On 01/08/25 and 01/09/25, the memory care laundry area was toured, and the following was revealed:

a. The laundry room had multiple open containers that were overflowing with linen and clothing, and multiple clear garbage bags were piled on the floor with clothing and linen. Direct-care and housekeeping staff were interviewed and stated they did not handle soiled linen or clothing and did not know the facility system for soiled linen processing.

b. The laundry room was not used in a way that provided a one-way flow of soiled linen and clothing and was not arranged in a way to keep soiled linen processing separate from regular linen.

On 01/08/25, Staff 5 (Resident Care Manager), Staff 9 (MCC CG), and Staff 11 (MCC CG) stated the laundry attendant was on vacation and they did not know who was responsible for handling soiled laundry and linen. Additionally, they stated they did not know the process relating to soiled laundry.

On 01/09/25 at 10:55 am, Staff 2 (MC Administrator) confirmed the facility did not have a system for soiled linen and laundry when the laundry attendant was not on shift.

The need to ensure laundry facilities had a separate area to ensure the separate storage and handling of soiled linens and clothing that had closed containers, had space to handle soiled linen and clothing processing separate from regular linen and clothing, and was arranged in a way that provided a one-way flow of soiled linen and clothing was reviewed with Staff 2 on 01/09/25 at 11:24 am. She acknowledged the findings.

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry

(b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the temperature of the area surrounding fireplaces in the facility did not exceed 120 degrees Fahrenheit. Findings include, but are not limited to:

On 01/07/25 a walk-through of the RCF was completed and multiple fireplaces were identified to be in use and the areas surrounding the fireplaces were hot to touch. Temperatures of the areas surrounding the fireplaces were recorded and the following was identified:

a. Fireplaces located on the first floor:

* The main entrance living room fireplace had temperatures recorded up to 162.8 degrees Fahrenheit and continued to rise; and
* The North entrance living room fireplace had temperatures recorded up to 157.1 degrees Fahrenheit.

b. The fireplace located on the second floor in the library had temperatures recorded up to 166.4 degrees Fahrenheit.

On 01/07/25 at 1:57 pm, fireplace temperatures were reviewed with Staff 1 (ED) and Staff 2 (MC Administrator). Staff 1 stated he would have all of the fireplaces deactivated immediately until they figure something out.

The need to ensure temperatures of the area surrounding fireplaces did not exceed 120 degrees Fahrenheit was reviewed with Staff 2 on 01/09/25 at 11:24 am. She acknowledged the findings.

OAR 411-054-0200 (8) Heating and Ventilation

(8) HEATING AND VENTILATION SYSTEMS. A RCF must have heating and ventilation systems that comply with the building codes in effect at the time of facility construction.
(a) TEMPERATURE. For all areas occupied by residents, design temperature for construction must be 75 degrees Fahrenheit.
(A) A RCF must provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Required minimum temperatures are no less than 70 degrees Fahrenheit during the day and 60 degrees Fahrenheit during sleeping hours.
(B) During times of extreme summer heat, fans must be made available when air conditioning is not provided.
(b) EXHAUST SYSTEMS. All toilet and shower rooms must be equipped with a mechanical exhaust fan or central exhaust system that discharges to the outside.
(c) FIREPLACES, FURNACES, WOODSTOVES, AND BOILERS. Where used, installation must meet standards of the building codes in effect at the time of construction. The glass and area surrounding the fireplace must not exceed 120 degrees Fahrenheit.
(d) WALL HEATERS. Covers, grates, or screens of wall heaters and associated heating elements may not exceed 120 degrees Fahrenheit when they are installed in locations that are subject to incidental contact by people or with combustible material. Effective 01/15/2015, wall heaters are not acceptable in new construction or remodeling.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure hot water temperature in residents' units were maintained within a range of 110 - 120 degrees Fahrenheit. Findings include, but are not limited to:

From 01/06/25 through 01/09/25, hot water temperatures in resident units were recorded with a digital thermometer. Interviews with staff were conducted and observations were completed. The following was revealed:

During an ADL observation on 01/07/25 at 10:26 am, Staff 11 (MCC CG) assisted Resident 6 in performing hand hygiene in his/her room. Resident 6’s hands were guided under the faucet, and s/he said, “It’s very, very hot.”

From 01/07/25 through 01/08/25, the following hot water temperatures were recorded:

a. Rose House – 122.8 degrees Fahrenheit and continued to rise in temperature; and

b. Lily House – 124.2 degrees Fahrenheit and continued to rise in temperature.

On 01/08/25 at 11:29 am, Staff 11 stated while providing shower assistance that morning an unsampled resident had continuous complaints the water was too hot. Additionally, another unsampled resident had made the same complaints the day before.

On 01/08/25 at 12:27 pm, hot water temperatures were reviewed with Staff 2 (MC Administrator).

On 01/09/25 at 10:54 am, Staff 2 stated there had not been any adjustments completed to correct the hot water temperature.

The need to ensure hot water temperature in residents' units were maintained within a range of 110 - 120 degrees Fahrenheit was reviewed with Staff 2 on 01/09/25 at 11:24 am. She acknowledged the findings.

OAR 411-054-0200 (9) Plumbing Systems

(9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to provide each individual privacy in his or her own unit for multiple residents who resided in units with shared bathrooms. Findings include, but are not limited to:

From 01/07/25 through 01/09/25, while conducting walkthroughs of the memory care, multiple units were identified and observed to have a shared bathroom without the ability to lock the door to provide privacy.

On 01/08/25 at 12:10 pm, Staff 5 (Resident Care Manager) stated the memory care had multiple units with a shared bathroom that did not have the ability to lock.

On 01/09/25 at 10:54 am, Staff 2 (MC Administrator) and this surveyor toured a shared bathroom and confirmed units with shared bathrooms did not have the ability to lock in a way to ensure privacy.

The need to ensure residents who resided in a unit with a shared bathroom had privacy in his or her own unit was reviewed with Staff 2 on 01/09/25 at 11:24 am. She acknowledged the findings.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(d) Each individual has privacy in his or her own unit.

This Rule is not met as evidenced by:

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

Refer to C200, C231, C295, C510, C513, C530, C530, and C545.

OAR 411-057-0140(2) Administration Compliance

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

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

Refer to C231, C420, and C513.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 14 and 21) demonstrated satisfactory performance in any duty they were assigned within the first 30 days of hire, 2 of 2 long-term staff (#s13 and 23) completed the required annual in-service training, and 2 of 3 long-term non-care staff (#s 24 and 25) completed annual infectious disease training. Findings include, but are not limited to:

On 01/08/25, staff training records were reviewed, and the following was identified:

a. There was no documented evidence Staff 14 (MCC MT) and Staff 23 (ALF CG), hired 09/06/24 and 02/19/24, respectively, demonstrated satisfactory performance in assigned job duties within 30 days of hire in one or more of the following areas:

* Role of service plans;
* Changes associated with normal aging;
* Identifying, documentation, and reporting changes of condition;
* Conditions that require assessment, treatment, observation, and reporting;
* General food safety, serving, and sanitation; and
* Medication and treatment administration.

On 01/08/25 at 9:00 am, Staff 3 (Health Services Director) confirmed the current system did not identify each of the required components and that Staff 14 and 23 would demonstrate competency in the identified areas prior to working their next shift.

b. There was no documented evidence Staff 13 (MCC CG) and Staff 23 (ALF MT), hired 04/24/12 and 04/20/22, respectively, completed the required hours of annual in-service training.

c. There was no documented evidence Staff 24 (Housekeeper) and Staff 25 (Housekeeper), hired 04/16/21 and 11/08/22, respectively, completed the required infectious disease control training.

On 01/07/25 at 12:49 pm, Staff 26 (Human Resources) stated she “discovered an error in the staff training system” and had “started to create a system to fix the errors”.

The need to ensure staff demonstrated competency in any duty assigned within the first 30 days of hire, completed the required hours of annual in-service training, and non-care staff completed infectious disease training, was discussed with Staff 2 (MC Administrator) on 01/09/25 at 11:24 am. She acknowledged the findings.

OAR 411-057-0155(1-6) Staff Training Requirements

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

This Rule is not met as evidenced by:

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

Refer to C252, C260, C270, C280, C290 and C303.

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

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

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

Refer to C260 and C270.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation, for 4 of 5 sampled residents (#s 3, 4, 5, and 8) whose activity plans were reviewed. Findings include, but are not limited to:

Resident 3, 4, 5, and 8's records were reviewed, and observations were made during the survey. The current activity evaluations did not address one or more of the following required components:

* Current abilities and skills;
* Emotional/social needs and patterns;
* Physical abilities and limitations;
* Adaptations needed to participate; and
* Identification of activities for behavioral interventions.

The current activity plans were not individualized to each resident based on their activity evaluation and were not included on the resident's activity or service plan.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (ED), Staff 2 (MC Administrator), and Staff 5 (RCC) on 01/08/25 and 01/09/25. They acknowledged the findings.

OAR 411-057-0160(2d) Activities

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

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 07/11/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
The findings of the revisit to the kitchen inspection of 07/11/24, conducted on 03/04/25, are documented in this report. The facility was found in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:On 07/11/24 at 11:00 am, the facility kitchen flooring was observed to need cleaning and repair in the following areas: * Multiple areas were patched with areas missing flooring covering; * Significant build up of black matter in corners, on cove base, underneath and behind prep counters, dishwashing area and equipment; * Stained areas throughout the kitchen, including significant yellow stain in dishwashing area;* Hard water stains under and around ice maker; and* Significant build up of black/white matter in corner next to grease trap. The flooring concerns were observed and discussed with Staff 1 (Food Service Director) and Staff 2 (Memory Care Administrator) on 07/11/24. The findings were acknowledged.

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

The findings of the kitchen inspection, conducted 07/28/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 07/28/22, conducted on 11/02/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facilities kitchen, food storage areas, food preparation, and food service on 07/28/22 revealed:* Splatters, spills, debris, and drips noted: - Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen; - Storage shelves throughout the kitchen and walk in refrigerator; - Interiors of reach in refrigerators and freezers; - Walls throughout the kitchen; - The dishwashing area walls, floors and equipment; - Both sides and the interior of the range, grill and oven; - Behind and underneath appliances; - The surface and underneath the tray line steam table; - Interior of the microwave; - The stand mixer; - A telephone on the food preparation counter; and - Food delivery carts.* Food was stored on the floor of the refrigerator;* Scoops were left in bins of food in dry storage;* Dish racks were stored directly on the floor;* Dust and debris noted on cage of walk in refrigerator ventilation fans;* Undated food items and food items with dates older than seven days were noted in the walk in refrigerator;* No documented evidence the wiping cloth sanitizer bucket was monitored to ensure the sanitizer was dispensing at the correct parts per million;* Staff were observed to not change gloves between tasks or sanitize hands upon entering the kitchen; * Staff in the kitchen did not have hair and beards restrained; and * Caregiving staff assisting with meal service and delivery were not using aprons.A bag of frozen raw chicken was left in the sink in tepid standing water. Staff 2 (Executive Chef) was immediately notified and directed to use cold running water to thaw the raw chicken.Spills, splatters, debris, and undated and unlabeled foods were noted in the reach-in refrigerators of the Memory Care kitchenettes.The Surveyor and Staff 2 toured the kitchen. The food handling, hand hygiene process and areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings.

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

The findings of the re-licensure survey conducted 8/23/21 through 8/24/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 8/24/21, conducted on 11/23/21, 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.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second re-visit to the re-licensure survey of 08/24/22, conducted on 01/26/22, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. Findings include, but are not limited to:Resident 4 was admitted to the facility in 6/2021 with diagnoses including dementia with behavioral disturbance.The resident's move-in evaluation dated 6/7/21, lacked information regarding the following required elements: * Ability to manage medications;* Dental status;* Personality, including how the person copes with change and challenging situations; and * Environmental factors that may impact the resident's behavior.The lack of addressing all required elements in the move-in evaluation was discussed with Staff 1 (MCC Administrator) and Staff 2 (MCC RN) on 8/24/21. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 6/2021 with diagnoses including edema of lower extremity and dementia with behavioral disturbance. Review of the resident's clinical records revealed the following:a. In a 7/16/21 progress note, Resident 4 was noted to have experienced weeping of the lower left and lower right leg chronic lymphedema.b. A 7/19/21 progress note identified the resident to have superficial open wounds to both shins.There was no documented evidence the facility determined and documented what actions or intervention were needed for each of Resident 4's skin conditions, andmonitored and documented the progress of the conditions at least weekly until the conditions resolved.In an 8/24/21 interview with Staff 2 (MCC RN), she stated monitoring of Resident 4's edema had been difficult due to the resident's resistive behaviors. The need to ensure the facility determined and documented what actions or interventions were needed for Resident 4's skin conditions and documented on the progress of skin conditions at least weekly until resolution was discussed with Staff 1 (MCC Administrator) and Staff 2 on 8/24/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to monitor the resident's condition until resolution for 2 of 5 sampled residents (#s 1 and 4) who had skin conditions. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in April 2021 with diagnoses including dementia and had a history of being resistive to care. A review of the resident's service plan, temporary service plans and progress notes, 5/23/21 through 8/24/21, indicated the following change of condition related to skin:* 8/16/21: blisters observed to both lower legs and reported to staff. MD was notified and ordered oral antibiotics and a cream to be applied daily to the area.During an interview on 8/24/21, Staff 2 (MCC RN) reported a skin monitoring log had not been initiated since the areas on the legs were not open wounds. There was no additional documentation on the status of the skin condition since starting the medication and treatment.A temporary service plan was initiated on 8/16/21 instructing staff to "monitor for ...diarrhea, rash, drainage, odor, swelling, pain and warmth to the touch". Progress notes between 8/16/21 through 8/23/21 included information on the resident's refusals of medications and other behaviors but did not include information on the status of the leg blisters.The need to ensure there was a system for documenting and monitoring changes of condition was discussed with Staff 1 (MCC Administrator) and Staff 2 (MCC RN) on 8/24/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia care training had been completed prior to providing care to residents, for 3 of 3 newly-hired staff (#s 19, 20 and 21). Findings include, but are not limited to:Staff training records were reviewed on 8/24/21 and revealed the following:1. Staff 20 (CG), hired on 4/22/21, and Staff 21 (CG), hired on 5/17/21 did not have documented evidence the following training was completed prior to providing direct care to residents: * Standard precautions for infection control; and * Fire safety and emergency procedures.2. Staff 19 (CG), hired on 3/12/21, Staff 20 and Staff 21 did not have documented evidence of their completion of pre-service dementia training prior to providing direct care to residents. The need to ensure all pre-service training was completed prior to staff providing direct care to residents was discussed with Staff 3 (ALF RN) and Staff 4 (ALF LPN) on 8/24/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired memory care staff (#16) had demonstrated competency in all required areas within 30 days of hire and 3 of 3 newly-hired staff (#s 19, 20 and 21) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 8/24/21 and revealed the following:1. Staff 16 (MCC CG), hired in memory care on 6/17/21, did not have documented evidence of demonstration of competency in the following areas: * Role of service plans in providing individualized care;* Providing assistance with ADLs;* Identification, documentation and reporting of changes of condition; and* Conditions that require assessment, treatment, observation and reporting. Staff 16 lacked evidence of certification in First Aid within 30 days of hire. 2. Staff 17 (MCC CG), hired 6/24/21, lacked evidence of certification in First Aid within 30 days of hire.3. Staff 19 (CG), hired on 3/12/21, Staff 20 (CG), hired on 4/22/21 and Staff 21 (CG), hired on 5/17/21 had no documented evidence of receiving abdominal thrust and first aid training within 30 days of hire.The need to ensure all newly hired staff had documentation of demonstrated competency and completed first aid and abdominal thrust training within 30 days of hire was discussed with Staff 5 (Human Resources) on 8/24/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 long term staff (#22) completed the minimum required 12 hours of annual in-service training on topics related to the provision of care for persons in a CBC setting including 6 hours of dementia training. Findings include, but are not limited to: Staff training records were reviewed on 8/24/21 and revealed the following:Staff 22 (CG), hired in 11/2007, did not have documented evidence of completing 12 hours of annual in-service training including six hours related to dementia care topics.The need to ensure all long term staff complete 12 hours of annual in-service training was discussed with Staff 5 (Human Resources) on 8/24/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months of fire drills. Findings include, but are not limited to:Fire and life safety records were reviewed from February 2021 to August 2021 and revealed the facility lacked documented evidence it was providing fire and life safety instruction to staff on alternating months.The requirements regarding fire and life safety instruction for staff was reviewed with Staff 1 (MCC Administrator) and Staff 8 (Facility Director) on 8/24/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:Fire and life safety records from February 2021 to August 2021 revealed the facility lacked documented evidence of the following:* Fire and life safety training for residents at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and * A written record of fire safety training, including content of the training sessions and the residents attending. The need to ensure fire and life safety instruction was provided to residents at least annually was discussed during interviews on 8/24/21 with Staff 1 (MCC Administrator) and Staff 5 (Facility Director). They acknowledged the findings.

Based on interview, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to:Refer to C 555.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:The facility was toured on 8/24/21. Resident unit windows on the second and third floors opened vertically, and windowsills were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls.The lack of a mechanism to prevent accidental falls was discussed with Staff 1 (MCC Administrator) and Staff 8 (Facility Director) on 8/24/21 at 2:30 pm. They acknowledged the findings.

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 they were installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:The facility was toured on 8/24/21. Room 2011, a one-bedroom unit, had a wall heater in the bedroom located under the window where a resident could come into accidental contact with it. When the heater was turned on and the temperature of the surface of the metal grill was measured using the surveyor's digital thermometer, the temperature exceeded 150 degrees F.On 8/24/21 at 2:30 pm, the surveyor informed Staff 1 (MCC Administrator) and Staff 8 (Facility Director) of the temperature of the heater grill. Staff and the surveyor checked a two-bedroom unit, which had a similar wall heater in each bedroom. The temperature of the grills of each heater also exceeded 150 degrees F. The facility reported there were 46 one-bedroom and 23 two-bedroom units which had similar wall heaters.Staff 1 and Staff 8 acknowledged the surface of the wall heater grills exceeded the 120 degrees F specified in the rule.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents exited the RCF and MCC. Findings include, but are not limited to:The facility consisted of an three-story residential unit building, referred to by the facility as the "Independent" area of the building, and a secured memory care unit. The first floor of the independent area included the main entrance, three additional doors by which residents could exit the building into the outdoor neighborhood and four doors which exited to an enclosed courtyard. The memory care unit included several doors by which residents could exit into two separate enclosed courtyards.The facility was toured on 8/24/21. There was no system in place which alerted staff when a resident exited the RCF or MCC buildings.The need to have a system which alerted staff when residents exited the RCF and MCC buildings was discussed with Staff 1 (MCC Administrator) and Staff 8 (Facility Director) on 8/24/21. They acknowledged there were no door alarms or other system in place to alert staff when a resident exited.
The facility was granted an extension until 12/31/21 to bring exit door alarms into compliance. The exit doors were not observed during the re-visit survey.
1. All exterior doors, without notification devices, have been identified and sensors have been ordered to add to our existing iAlert system. Sensors are being programed to our system.2. This will allow exterior doors, when opened, to alert staff immediately. The notification will include which door has been opened, and staff will invistigate.3. The monitors are self-testing and will alert staff if senors cannot be detected or if battery is low.4. Facility Maintenance Director.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 370, C 372, C 374, C 420, C 422, C 515, C 540 and C 555.
Based on interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 555.
1. All exterior doors, without notification devices, have been identified and sensors have been ordered to add to our existing iAlert system. Sensors are being programed to our system.2. This will allow exterior doors, when opened, to alert staff immediately. The notification will include which door has been opened, and staff will invistigate.3. The monitors are self-testing and will alert staff if senors cannot be detected or if battery is low.4. Facility Maintenance Director.

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

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 2 sampled residents (#s 1 and 4) whose records were reviewed. Findings include, but are not limited to:Review of Resident's 1 and 4's Life Enrichment Plans found the facility had not fully evaluated the residents in the following areas: * Emotional and social needs and patterns; and * Activities that could be used as behavioral interventions, if needed. There was no specific activity plan which detailed what, when and how often staff should offer and assist the residents with individualized activities. The need to ensure each resident was evaluated and an individualized activity plan was developed from the evaluation was reviewed with Staff 1 (MCC Administrator) and Staff 25 (MCC Activities) on 8/24/21. They acknowledged the findings.