Heritage House of Woodburn

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ current status and care needs and provided clear direction to staff regarding the delivery of services for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the MCC in 10/2024 with diagnoses including Alzheimer’s disease and anxiety disorder.

The resident’s current service plan was reviewed, staff were interviewed, and observations of the resident were made. The service plan was not reflective of the resident’s current status and care needs and/or did not provide clear direction to staff regarding the delivery of services in the following areas:

* When protein shakes should be offered;
* PRN psychotropic medications and non-pharmacological interventions;
* Use of fall mat;
* Sleeping patterns;
* Use of tab alarm in bed, wheelchair, and recliner; and
* Tilt wheelchair.

The need to ensure service plans were reflective of the resident’s current status and care needs and provided clear direction to staff was discussed with Staff 1 (ED) on 07/17/25 at 1:05 pm. She acknowledged the findings.

2. Resident 1 moved into the MCC in 04/2025 with diagnoses including type 2 diabetes mellitus and unspecified dementia.
The resident’s record, including progress notes dated 04/22/25 through 07/14/25, were reviewed. Observations of the resident were made, and staff were interviewed. The following was identified:

A review of Resident 1’s service plan dated 05/22/25 was completed. The service plan was not reflective of the resident’s needs, did not provide clear direction to staff, and/or was not being implemented as instructed in the following areas:

* Non-pharmaceutical interventions for pain;
* Use of a gait belt during transfers; and
* When protein shakes should be offered.

The need to ensure service plans were reflective of the residents’ current status and care needs, provided clear direction to staff, and were being implemented as instructed was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Vice President of Operations) on 07/17/25 at 10:00 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 an RN assessment was completed in a timely manner for a significant change of condition for 1 of 1 sampled resident (#2) reviewed with weight loss. Resident 2 continued to lose weight. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 10/2024 with diagnoses including Alzheimer’s disease.

During the acuity interview on 07/14/25, staff indicated Resident 2 was on hospice and had experienced significant weight loss within the last 90 days,

The resident’s progress notes and temporary service plans (TSPs), dated 04/15/25 through 07/09/25, were reviewed, as well as weight loss records from 01/03/25 through 07/04/25. Observations were made of the resident, and staff were interviewed.

The resident’s weight records indicated the following:

* 01/03/25 – the resident weighed 141.5 pounds;
* 06/03/25 – the resident weighed 114.5 pounds; and
* 07/04/25 – the resident weighed 110.4 pounds.

Between 01/03/25 and 06/03/25, the resident lost 27 pounds, or 19.08% of his/her total body weight, in five months. This constituted a severe weight loss and a significant change of condition.

There was no documented evidence a significant change of condition assessment was completed by the RN. The resident continued to lose weight.

A temporary service plan (TSP) dated 06/04/25 instructed staff to “encourage and assist with meals as needed or tolerated. Staff are to encourage a protein shake with all meals.” There was no documented evidence staff were providing protein shakes to the resident with meals.

Between 06/03/25 and 07/04/25, the resident lost another 4.1 pounds. This was a total loss of 31.1 pounds between 01/03/25 and 07/04/25, or 21.97% of his/her total body weight. This constituted a severe weight loss.

In an interview on 07/15/25 at 7:50 am, Staff 1 (ED) reported the RN had “overlooked” the need for a significant change of condition assessment after being notified when the resident’s weight loss was first identified on 06/04/25.

Further weight loss was identified on 07/04/25, the RN was notified, and a significant change of condition assessment was completed and signed on 07/10/25. In that assessment, the RN incorrectly documented the resident had gained 4.1 pounds in one month.

Survey requested the resident be weighed on 07/15/25. At 8:10 am, the resident’s weight was documented as 114.1 pounds, a gain of 3.7 pounds since 07/04/25.

During the survey the resident was observed to begin eating lunch independently on 07/14/25. The resident was able to take a few bites but then appeared to be unable to cut up the food, at which time Staff 5 (MT/CG) began to assist the resident with eating. Resident 2 ate 100% of his/her lunch with staff assistance.

In interviews on 07/14/25 and 07/15/25, Staff 4 (MT) and Staff 9 (MT/CG) indicated they had noticed Resident 2 losing weight in the last few months based on how his/her clothing fit.

On 07/15/25 at 1:25 pm, Staff 4 (MT) reported Resident 2 ate 100% of his/her breakfast and approximately 75% of his/her lunch. When asked if the resident was provided with a protein shake after lunch, Staff 4 stated she was unsure if there were protein shakes for the resident. She indicated protein shakes were not on the resident’s MAR.

The resident experienced severe and ongoing weight loss, with no documented evidence staff were assisting the resident with meals or providing protein shakes as noted in the 06/04/25 TSP. The RN significant change of condition assessment was completed and signed six days after the second identified severe weight loss.

The need for all significant changes of condition to be assessed by an RN in a timely manner was discussed with Staff 1 (ED) on 07/16/25 at 1:05 pm and with Staff 1 and Staff 3 (VP of Operations) on 07/17/25 at 8:32 am. Staff 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 observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 2 of 2 sampled residents and multiple unsampled residents related to dining services and 1 of 2 sampled residents (# 2) who were dependent on staff for ADL care. Findings include, but are not limited to:

1. Lunch service was observed on 07/14/25 at 12:11 pm.

a. Staff were observed serving meals and beverages, touching residents and various surfaces in the dining room and kitchen, and assisting residents with feeding without changing their gloves or performing hand hygiene.

b. Direct care staff were observed serving food to residents without donning a protective barrier over potentially contaminated clothing.

On 07/17/25 at 10:00 am, the need to maintain infection prevention and control protocols was reviewed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Vice President of Operations). They acknowledged the findings.

2. Resident 1 moved into the MCC in 04/2025 with diagnoses including type 2 diabetes mellitus and unspecified dementia.

On 07/15/25 at 12:06 pm Staff 6 (MT/CG) was observed providing feeding assistance for Resident 1. Staff 6 was not observed wearing hand or clothing protection while feeding Resident 1. During the meal, Staff 6 paused assisting the resident, walked to the kitchen, and retrieved food for another resident. Staff 6 resumed assisting Resident 1 without performing hand hygiene. When Staff 6 finished feeding the resident, she began gathering soiled dishes and was observed with the right thumb of her right hand on the plate surface of a soiled plate. Staff 6 brought the plate to the kitchen and poured a glass of juice and handed it to a an unsampled resident without performing hand hygiene.

The need to maintain infection prevention and control protocols was discussed with Staff 1 (ED) on 07/16/25 at 2:15 pm. She acknowledged the findings.

3. Resident 2 was admitted to the MCC in 10/2024 with diagnoses including Alzheimer’s disease and anxiety disorder. S/he was identified in the acuity interview as dependent on staff for all ADL care.

Incontinence care for Resident 2 was observed on 07/14/25 at 12:06 pm. Staff were observed to wear the same gloves throughout incontinence care, not changing them between clean and dirty tasks. Staff removed their gloves when the incontinence care was completed, but they did not perform hand hygiene after removing the gloves.

The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (ED) on 07/16/25 at 1:05 pm. She acknowledged the findings.

4. On 07/14/25 at 12:30 pm, a staff member was observed to enter the kitchen area, run her hands under water, turn the water off, shake their hands once, remove a fork from a drawer, and leave the kitchen to provide meal assistance to a resident in the dining room.

The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (ED) on 07/16/25 at 1:05 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 interview and record review, it was determined the facility failed to ensure there were written, resident-specific parameters for PRN psychotropic medication and failed to document non-pharmacological interventions as ineffective prior to administering a PRN psychotropic for 1 of 1 sampled resident (#2) who was prescribed PRN psychotropics. Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 10/2024 with diagnoses including Alzheimer’s disease and anxiety disorder.

The resident’s 07/01/25 through 07/14/25 MAR and physician orders were reviewed, and staff were interviewed.

The resident had two PRN psychotropic medication prescriptions:

* Haloperidol lactate 2 mg/ml solution, 2.5 ml every two hours as needed for anxiety, agitation, and restlessness; and
* Lorazepam 1 mg tablet, one tablet every two hours as needed for agitation, anxiety, and restlessness not relieved by haloperidol.

There were no resident-specific parameters related to how the resident exhibited anxiety, agitation, and restlessness, nor were there non-pharmacological interventions listed on the resident’s MAR. There was no documented evidence staff had attempted non-pharmacological interventions and documented them as being ineffective prior to administering the PRN psychotropic medications.

In an interview on 07/15/25 at 8:15 am, Staff 1 (ED) verified there were no resident-specific parameters or non-pharmacological interventions for the two PRN psychotropic medications on the MAR. Staff 1 stated the non-pharmacological interventions had been on the MAR in the past, but had not been re-entered when a new prescription was entered on the MAR by the RN.

The need to ensure all PRN psychotropics on the resident’s MAR included resident-specific parameters and non-pharmacological interventions to attempt prior to administering the PRN psychotropic was discussed with Staff 1 (ED) on 07/16/25 at 1:05 pm. She acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure an RN, PT, or OT had conducted a thorough assessment of all supportive devices with restraining qualities for 1 of 1 sampled resident (#2) who had a supportive device. Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 10/2024 with diagnoses including Alzheimer’s disease and anxiety disorder.

The resident’s clinical record was reviewed, observations of the resident were made, and staff were interviewed. The following was identified:

* The resident’s current service plan, most recently updated on 07/10/25, indicated the resident used a tilt back wheelchair;
* The resident was observed to be escorted to and from meals in the tilt back wheelchair.

There was no documented evidence a thorough assessment of the tilt back wheelchair had been conducted by an RN, PT, or OT. In an interview on 07/16/25 at 9:05 am, Staff 1 (ED) reported the tilt back wheelchair was no longer being tilted back when the resident was using it and verified there was no assessment of the tilt back wheelchair completed by an RN, PT, or OT.

The need for an RN, PT, or OT to thoroughly assess all supportive devices with restraining qualities was discussed with Staff 1 on 07/16/25 at 1:05 pm. She acknowledged the findings. Staff 1 provided an assessment of the tilt back wheelchair completed by the RN on 07/16/25, and stated she had ordered a new, non-tilt back wheelchair for the resident which was to be delivered later that day.

OAR 411-054-0060 Restraints and Supportive Devices

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident during the overnight shifts, based on resident acuity. Findings include, but are not limited to:

During the acuity interview at 9:45 am on 07/14/25 and other staff interviews throughout the survey, the following was noted:

* The facility was a licensed MCC with a current census of 15 residents;
* Two residents required a two-person assist to transfer;
* Observations of the community, conducted from 07/14/25 to 07/17/25, revealed multiple sampled and unsampled residents used wheelchairs for mobility; and
* Seven residents required two-person assist for behavioral symptoms.

Review of staffing schedules from 07/07/25 through 07/13/25 revealed the facility staffed two Universal Workers on the overnight shifts from 07/07/25 through 07/13/25.

The overnight shift staffing from 07/07/25 through 07/13/25 was insufficient to meet the unscheduled needs for multiple sampled and unsampled residents based on their acuity.

The need to have a sufficient number of direct care staff to meet the scheduled and unscheduled needs of the residents was discussed with Staff 1 (ED) on 07/17/25 at 10:15 am. She acknowledged the findings.

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

Facility fire and life safety records were reviewed on 07/14/25. The facility lacked documented evidence residents were instructed in general safety procedures, evacuation methods, and responsibilities at least annually.

The need to ensure residents were instructed in fire and life safety procedures at least annually, was discussed with Staff 1 (ED) on 07/16/25 at 2:15 pm. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure all individuals had the right to freedom from restraints. Findings include, but are not limited to the following:

Refer to C340.

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom

(1) Residential and non-residential HCB settings must have all of the following qualities:
(d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS
443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting.

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 C295, C360, and C422.

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 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 C260, C280, C330, and C340.

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 interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individualized activity plan based on their activity evaluation, for 1 of 2 sampled residents (# 2) whose records were reviewed. Findings include, but are not limited to:

Resident 2’s activity evaluation and service plan were reviewed. Though the activity evaluation offered some information about the residents’ past and current interests and included activities that could be used as behavioral interventions, the facility had not evaluated the resident’s:

* Current abilities and skills;
* Emotional and social needs and patterns;
* Physical abilities and limitations; and
* Adaptations necessary for participation.

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

The need to complete an activity evaluation which addressed all required elements and for an individualized activity plan to be developed from the evaluation for each resident was discussed with Staff 1 (ED) on 07/17/25 at 1:05 pm. She 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 on-site investigation, conducted on 10/24/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Based on interview and record review, during a site visit conducted on 10/24/23, it was confirmed the facility failed to ensure the staff person who administed the medication visually observed the resident take the medication for 1 of 1 sampled resident (#1). Findings include, but not limited to: A review of the facility self-report, dated 08/30/23, confirmed staff had not observed Resident 1 take his/her Quietiapine, and they had provided the resident with an extra dose of the medication.During an interview on 10/24/23, Staff 1 (ED) confirmed that on 08/30/23 staff had not observed Resident 1 take their medication and had provided the resident with an extra dose of Quietiapine. It was confirmed the facility failed to ensure that the staff person who administered the medication visually observed the resident take the medication.On 10/24/23, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: Staff 1 did verbally coach the med tech to remind him/her to visibly observe resident take medication and went over medication errors. The community self-reported medication error to APS, completed an Incident Report, ISP's, placed resident on Alert Charting.

Based on interview and record review, during a site visit conducted on 10/24/23, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but not limited to:A review of the facility self-report dated 08/30/23, confirmed Resident 1 had been given two doses of the PRN medication Quietiapine. A review of the physician order dated 08/16/23 indicated Resident 1 was to receive one tablet of Quietiapine by mouth daily at breakfast, lunch, and dinner. During an interview on 10/24/23, Staff 1 (ED) confirmed Resident 1 had been given a double dose of his/her medication. It was confirmed the facility failed to carry out medication orders as prescribed.On 10/24/23, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: Staff 1 did verbally coach the med tech to remind him/her to visibly observe resident take medication and went over medication errors. The community self-reported medication error to APS, completed an Incident Report, ISP's, placed resident on Alert Charting.

Based on interview and record review, conducted during a site visit on 10/24/23, it was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to:A review of the resident roster indicated the facility was home to 14 residents. A review of the facility's ABST indicated 12 residents were entered into the tool. Eight of those residents had not been updated quarterly or upon move-in. In an interview on 10/24/23, Staff 1 (ED) stated, "There are two new residents who had not been added into the ABST tool. One resident moved in on 09/22/23 and the second resident moved in on 10/03/23."It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility.On 10/24/23, the findings were reviewed with and acknowledged by Staff 1.

Based on interview and record review it was confirmed the facility failed to provide records to the Department upon request. Findings include:Compliance Specialist (CS) requested documentation on 01/18/24 from the facility for an investigation conducted on 10/24/23 and did not receive them. Reviewed email request dated 01/18/24 following up on the request for documentation still needed to Staff #1 (S1). The facility did not provide the documentation requested. On 01/25/24 CS informed S1 about documentation not being provided upon request. Plan Of Correction: Not provided.

The findings of the Change of Ownership survey, conducted 07/18/22 through 07/20/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first revisit to the Change of Ownership survey of 07/20/22, conducted 10/19/22 through 10/20/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the second re-visit to the change of ownership survey of 07/20/22, conducted 02/10/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to:Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control.1. On 07/18/22 at 11:20 am, the surveyor obtained permission and observed a CG provide incontinent care to Resident 3. During the observation, the CG removed the wet brief and placed it on the bathroom floor. Additionally, the CG failed to change gloves after removing the soiled incontinent product and wiping urine from Resident 3's perineum. The CG touched the resident's hands, clothing and clean incontinent brief while wearing the same soiled gloves. After care was completed, the CG removed the gloves.The above observation was discussed with Staff 1 (ED) and Staff 3 (Assistant ED) on 07/19/22 at 3:15 pm. They acknowledged appropriate infection control practices were not implemented.
2. During the survey, observations of staff and residents were made to determine compliance of proper infection control. On 07/19/22 at 10:23 am, a CG was observed wearing single-use gloves to adjust multiple unsampled residents' clothing, to move adaptive equipment, to transfer another unsampled resident to his/her room and then to deliver the morning snack to the residents. The CG did not change gloves or perform hand hygiene between providing personal care tasks or before delivering the morning snack.This surveyor requested that the CG remove the soiled gloves and perform hygiene prior to passing food.The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety or welfare of residents was discussed with Staff 1 (ED) and Staff 3 (Assistant ED) on 07/20/22 at 9:17 am. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observation of the kitchen on 07/18/22 at 10:41 am revealed an accumulation of food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:* Interior shelving of standing refrigerator/freezer units;* Exterior sides of standing refrigerators;* Walls and outlets behind countertops;* Blender; * Coffee maker;* Kettle;* Baking pans;* Countertops between standing refrigerators;* Cabinet doors and shelving throughout the kitchen;* Drawers throughout the kitchen;* Floors under counters and near appliances;* Lighting fixtures;* Exterior edges of dishwashers;* Stove vent;* Control panel of stove; and* Warming drawer of stove.Cupboard shelves throughout the kitchen had exposed bare wood edges, and drywall under the microwave was gouged rendering the surfaces uncleanable. The areas that required cleaning and repair were observed and discussed with Staff 3 (Assistant ED) on 07/19/22 at 1:19 pm. She acknowledged the areas that needed to be cleaned and repaired.

Based on observation, interview and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and create opportunities for active participation in the community at large. Findings include, but are not limited to:During the survey, the MCC was home to 13 residents. Random resident observations made on 07/18/22 and 07/19/22, review of the activity calendar, and interviews with staff revealed the following: a. The July 2022 Memory Care Activity Program calendar provided during the entrance conference indicated the following activities would occur on 07/18/22:* "Coffee & News;* Daily Chronicle;* Bake muffins;* Puzzles; and * Jeopardy on TV."On 07/18/22, the only activity observed occurred at 10:00 am with one resident coloring at the dining table. Although music and television played sporadically, no other activities were observed between 9:30 am and 3:30 pm. Residents sat for long periods of time during waking hours in the common areas, outside or in their rooms with no activity. b. On 07/19/22, the activity calendar noted the following activities would occur:* "AM Exercise;* Finish the line;* Bingo;* Gardening; and * Write Cards." The only activities observed between 8:30 am - 3:30 pm were "AM Exercise" and "Finish the line" between 10:20 am and 11:00 am. Music and television played, but no other activities were observed. In an interview with a family member on 07/19/22, he stated he received a flyer in the mail for scheduled activities in May and believed he would get a flyer monthly. He had not received any additional activity flyers. He stated he visited often and had not seen any activities except for on 07/19/22.Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and create opportunities for active participation in the community at large was discussed with Staff 1 (ED) and Staff 3 (Assistant ED) on 07/19/22 at 3:15 pm. Staff 1 stated the facility scheduled a caregiver to conduct activities from 1:00 pm to 5:00 pm daily. However, if the facility had a "call out", then that person was pulled from activities to provide care. She added "it's a work in progress." Both acknowledged the lack of activities in the MCC.

3. Resident 3 was admitted to the MCC in 07/2019 with diagnoses which included dementia. Interviews with care staff and observations of Resident 3 during the survey revealed s/he was incontinent, dependent on staff for ADL care, did not use a call light to summon assistance, had ½ bilateral side rails, was on a pureed diet and needed meal assistance. Resident 3's service plan, dated 04/23/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:* Ability to communicate;* Phone use;* Independent ambulation;* Television use;* Use of fall mat;* Meal assistance;* Side rail use;* Dining chair with arms;* Bowel and bladder incontinence;* Use of barrier creams;* Use of grab bars in bathroom;* Bed placement; and* Crushed medications.The need to ensure the service plan was reflective of Resident 3's current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (Assistant ED) on 07/19/22 at 2:10 pm. They acknowledged the findings. No further information was provided.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear direction to staff regarding the delivery of service and followed for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia. Resident 2 was observed in bed most of the time and relied on staff for all ADL care. Observations of the resident, interviews with staff, review of the current service plan and clinical records during the survey, from 04/30/22 through 07/13/22, revealed Resident 2's service plan was not reflective of his/her status, did not provide specific directions to staff, and staff did not follow the plan in the following areas:* Use of a cushion;* Use of catheter;* Diet status;* Vision status;* Outside provider status; and* Wound status on coccyx area.On 07/20/22, the service plan was discussed with Staff 1 (ED) and Staff 3 (Assistant ED). They acknowledged the service plan was not reflective of the resident's status, did not provide clear direction and staff did not follow the plan.
2. Resident 1 was admitted to the facility in 03/2020 with diagnoses including Alzheimer's dementia.Review of the most current service plan dated 06/10/22 and observations and interviews conducted between 07/18/22 and 07/20/22, revealed Resident 1's service plan was not reflective, did not provide clear instruction to staff and/or was not followed in the following areas: * Sleeping routine;* Bathing;* Toileting;* Dressing;* Grooming/Hygiene;* Food preferences;* Communication;* Communication assistive devices;* Medications;* Fall History; and* Evacuation status.The need to ensure service plans were reflective of the identified needs and preferences of the resident, provided clear direction to staff and were followed by staff was discussed with Staff 3 (Assistant ED) on 07/19/22 at 1:49 pm. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to:Resident 1 and 2's clinical records and service plans were reviewed during the survey. There was no documented evidence the service plans were developed by a Service Planning Team.During an interview with a member of Resident 1's family, conducted on 07/19/22 at 2:04 pm, it was reported that s/he had not been involved in a service plan review meeting and did not receive a copy of the service plan. On 07/19/22 and 07/20/22, the facility's system for ensuring resident service plans were developed by a service planning team was discussed with Staff 1 (ED) and Staff 3 (Assistant ED). They acknowledged the findings.

2. Resident 3 was admitted to the MCC in 07/2019, was on hospice services, and had a history of falls.Resident 3's clinical record and progress notes, reviewed from 04/06/22 through 07/18/22, revealed the following:a. Resident 3 started a new medication on 04/21/22. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition.b. The resident fell on 04/08/22, 04/20/22, 05/16/22 and 05/29/22. Review of the record revealed no documented evidence the facility monitored and documented on the progress of the resident's condition at least weekly until resolved. Additionally, the facility failed to consistently evaluate if service-planned interventions were implemented, were effective, or if new interventions were needed. c. Resident 3 sustained minor injuries when s/he fell on 05/16/22 and 05/29/22. There was no documented monitoring of the injuries until resolution. Additional information was requested on 07/19/22.On 07/19/22 at 3:15 pm, Staff 1 (ED) and Staff 3 (Assistant ED) reported they reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved, and the facility failed to consistently evaluate if service-planned interventions for falls were implemented, were effective, or if new interventions were needed. No further information was provided.
Based on interview and record review, it was determined the facility failed to monitor and evaluate for falls and document weekly progress until the condition resolved for 2 of 2 sampled residents (#s 2 and 3) reviewed for change of conditions. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia.Resident 2's clinical records were reviewed during the survey and revealed the following:* 05/06/22 - New dose of Trazodone (medication to treat depression);* 06/03/22 - Received a COVID booster injection; and* 06/07/22 - New dose of Trazodone.There was no documented evidence the resident's changes of condition were monitored, at least weekly, through resolution.On 07/19/22 and 07/20/22, the above information was shared with Staff 1 (ED) and Staff 3 (Assistant ED). They acknowledged the findings.

3. Resident 3 was admitted in 07/2019 with diagnoses which included dementia and received a pureed diet during the survey.In an interview with Staff 6 (Med Aide) on 07/19/22 at 1:30 pm, she stated staff crushed Resident 3's medications prior to administering them to him/her.Review of the clinical record revealed no physician order authorizing staff to crush the medications.In an interview on 07/19/22 at 3:10 pm, Staff 1 (ED) and Staff 3 (Assistant ED) confirmed the facility had no order to crush Resident 3's medications. Staff 1 stated they would contact the physician to obtain an order.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia.a. Resident 2 had a physician's order, dated 06/03/22, to administer Milk of Magnesia 30 ml orally if there was no bowel movement in three days.Resident 2's 07/01/22 through 07/18/22 bowel record was reviewed and revealed the resident had no bowel movement from 07/04/22 to 07/09/22 (six days).Resident 2's 07/01/22 through 07/18/22 MAR revealed the medication was not administered on those days as ordered. b. Resident 2's 06/03/22 physician orders and 07/01/22 through 07/18/22 MAR were reviewed during the survey. The following prescribed medications were not administered as prescribed on 07/13/22:* Ativan 0.25 mg daily to treat anxiety.On 07/19/22 and 07/20/22, the above findings were shared with Staff 1 (ED) and Staff 3 (Assistant ED). They acknowledged the findings.
2. Resident 1 was admitted to the facility in 03/2020 with diagnoses including Alzheimer's dementia.Resident 1's MARs dated 07/01/22 through 07/18/22 and current physician's orders were reviewed and revealed the following:a. Resident 1 had a physician's order for lorazepam (for anxiety) 1 mg tablet by mouth every eight hours as needed for severe agitation. b. Lorazepam was administered three times between 07/01/22 and 07/18/22 in the following doses: * 07/05/22 - .25 mg for shower; * 07/09/22 - .50 mg for shower; and * 07/12/22 - .25 mg for shower.The need to ensure that medication orders were carried out as prescribed was discussed with Staff 3 (Assistant ED) on 07/19/22 at 1:49 pm. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia.Resident 2's record indicated s/he had an order for Ativan for "agitation and anxiety" as needed.Resident 2's 07/01/22 through 07/18/22 MAR was reviewed during the survey and revealed the following:* The as needed Ativan was administered on one occasion, 07/07/22; and* No documented evidence non-drug interventions had been attempted with ineffective results prior to administering the medication.On 07/19/22 and 07/20/22 Resident 2's record was reviewed with Staff 1 (ED) and Staff 3 (Assistant ED) who acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had resident specific parameters and staff documented that non-pharmacological interventions had been tried with ineffective results prior to administering the medications for 2 of 2 sampled residents (#s 1 and 2) who were prescribed PRN psychotropic medications. Findings include, but are not limited to:1. Resident 1 moved into the facility in 03/2020 with diagnoses including Alzheimer's dementia. Review of the resident's service plan, physician's orders and 07/01/22 through 07/18/22 MARs revealed the following: Resident 1 was prescribed lorazepam 1 mg (for anxiety) one tablet every eight hours PRN for severe agitation. The facility failed to ensure the resident's MARs and clinical record included the following required information:* Resident specific parameters regarding use of lorazepam for showers; and * Staff administered the PRN lorazepam on three occasions for showers without documentation that non-pharmacological interventions were attempted prior to administration of the medication. The need to ensure the required information for PRN psychotropic medications was documented in the MARs or clinical record was discussed with Staff 3 (Assistant ED) on 07/19/22 at 1:49 pm. She acknowledged the findings. No further documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided and documented every other month. Findings include, but are not limited to:Fire drills and fire and life safety training records for the previous six months were requested during the survey.Review of the documentation provided identified the following:* There was no documented evidence fire and life safety instruction to staff was provided every other month.On 07/19/22 and 07/20/22, the requirement regarding fire and life safety instruction for staff was reviewed with Staff 1 (ED) and Staff 3 (Assistant ED). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their Change of Ownership survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C513.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean, in good repair and free from odors. Findings include, but are not limited to:Observations of the facility on 07/18/22 and 07/19/22 revealed the following:* The common bathroom (near Room 6) had a broken towel rod, and the edge of the door had scraped areas;* Room 6 had a scraped door;* The television room carpet had several large red stains. A white loveseat had stains, food matter and urine odors on the cushions;* Cushions of a green loveseat in the piano room had a urine odor; * The outdoor patio furniture had several tears in multiple cushions;* Carpet in Room 11 had multiple stains throughout; and * Room 2 had a urine odor and a broken toilet paper holder with no toilet paper available. The surveyor toured the environment with Staff 3 (Assistant ED) on 07/19/22 at 12:25 pm. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the environment was maintained in clean and good repair. This is a repeat citation. Findings include, but are not limited to:Observations of the facility on 10/19/22 and 10/20/22 revealed the following:The carpet in the living room, hallways and resident rooms 8 and 9 had multiple areas of dark and light discoloration and stains.The surveyor discussed the carpet with Staff 1 (Administrator) and Staff 2 (Assistant ED) on 10/19/22 and 10/20/22. They acknowledged the findings and stated the carpet was scheduled to be replaced.

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 160, C 240, C 242, C 420 and C 513.

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 C513.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 260, C 262, C 270, C 303 and C 330.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design and maintained to prevent resident injury or aid in elopement. Findings include, but are not limited to:On 10/19/22 and 10/20/22, observations of the facility's outdoor area revealed the following: Furniture in the outdoor recreation area was not of sufficient weight. Several patio chairs had been modified with 10 pound dumbbell/hand weights, attached underneath the seat and on the back of the chairs. The weights were attached to the chairs with utility tape and metal brackets (underneath the utility tape) which had sharp metal edges and exposed screws and hardware. The need to ensure furniture in the outdoor recreation area was of sufficient weight and design and maintained to prevent resident injury was discussed with Staff 1 (Administrator) and Staff 2 (ED in training) on 10/20/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to:The MCC was toured on 07/18/22 and 07/19/22. Resident rooms 6, 9 and 10 lacked any means of identifying the rooms for the residents. All of these residents had resided in the facility for more than four weeks.The need to ensure each resident room was identified to assist the resident was reviewed with Staff 3 (Assistant ED) on 07/19/22. She acknowledged the findings.