Adara Oaks Living

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



Resident 1 moved into the facility in 05/2025 with diagnoses including unspecified mood disorder and chronic pain.



The resident’s Oregon Resident Evaluation was reviewed, and the following required elements were not addressed:

* Vital signs if indicated by diagnosis, health problems, or medications;

* Cognition including memory and orientation;

* Personality including how the person copes with change or challenging situations;

* Laundry;

* Transportation;

* Indicators of nursing needs including potential for delegated nursing tasks;

* Recent losses;

* Gender; and

* Pronouns.



The need to address all required elements on the resident’s move-in evaluation was discussed with Staff 2 (Administrator Designee – Compliance Specialist) and Staff 3 (Director of Nursing) on 06/18/25 at 12:55 pm. They 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 reflective of residents' needs and provided clear direction to staff regarding care and services for 2 of 4 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:



1. Resident 2 moved into the residential care community with diagnoses including congestive heart failure.



Observations of the resident, interviews with staff, and review of the service plan, dated 06/06/25, and subsequent interim service plans (ISPs) identified the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

*Use of a urinal and staff instructions;

*Use of a pressure mattress and staff instructions;

*Risks and precautions related to the use of bilateral quarter-length siderails; and

*Recent falls and fall interventions.



The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Administrator Designee – Compliance Specialist) and Staff 3 (Director of Nursing) on 06/18/25 at 1:20 pm. They acknowledged the findings.



2. Resident 3 moved into the facility in 01/2025 with diagnoses including catatonia, schizophrenia and dementia.

Observations of the resident and interviews with staff were conducted. The resident’s current service plan, dated 04/23/25 and interim service plans, dated 04/07/25 to 06/10/25 were reviewed during the survey and showed Resident 3's service plan was not reflective of his/her status and did not provide clear direction regarding the delivery of services in the following:



*Bathing status, including clarification of whether services were provided by hospice or facility staff;

*Dressing status, including clarification of whether the resident was independent or required extensive assistance;

*Grooming status;

*Toileting status including use of a urinal or toilet and whether the resident was independent or dependent; and

*The protein health shake including instructions on when to offer it and how often it should be provided.





The need to ensure service plans were reflective of resident care needs and provided clear instructions for staff was reviewed with Staff 3 (Director of Nursing) on 06/18/25. He 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 ensure physician orders were carried out as prescribed for 1 of 4 sampled residents (# 3) whose orders were reviewed. Findings include, but are not limited to:



Resident 3 moved into the facility in 01/2025 with diagnoses including schizophrenia, dementia and chronic obstructive pulmonary disease.



The resident’s 05/01/25 – 06/16/25 MARs and physician’s orders were reviewed. Staff interviews were conducted and showed the following:



a. A 05/14/25 physician order indicated to administer fluticasone/samlet 250/50 mcg one puff inhale twice a day (nasal spray used for allergies).



The MAR showed the medication was not transcribed onto the 06/2025 MAR. The 05/2025 MAR showed the medication was discontinued on 05/20/25. Staff 3 (Director of Nursing) reported the medication was accidentally discontinued by the pharmacy. However, when a medication was discontinued a signed physician’s order should have been faxed to the facility. This process was not followed, and the facility was unable to identify the error.



b. A 05/14/25 physician order indicated to administer n-acetyl cysteine 600 mg 2 capsules twice daily for supplement. The MAR showed the medication was not administered to the resident on 10 occasions, with staff documenting “med [medication] not available.”



The need to ensure physician orders were carried out as prescribed was reviewed with Staff 3 (Director of Nursing) on 06/18/25. He 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 have an accurate number of care minutes included on the acuity-based staffing tool (ABST) for each of the 22 care areas, for 3 of 4 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

Review of Residents 1, 2, and 3’s ABST records revealed the allotted care minutes were not reflective of current needs in one or more of the 22 care areas of ABST.


On 06/18/25, the need to ensure the ABST accurately captured the care minutes for all residents in each of the 22 ADL areas was discussed with Staff 2 (Administrator Designee – Compliance Specialist) and Staff 3 (Director of Nursing). They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time

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

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure they were staffing to meet the requirements under the Specific Needs Contract. Findings include, but are not limited to:

The Acuity-Based Staffing Tool (ABST) data, Specific Needs Contract, staffing plan, staff time reports, and the staff schedule was reviewed from 06/08/25 through 06/18/25. The following was identified:

a. The Specific Needs Contract stated “Contractor shall provide a minimum ratio of 1 direct care staff for every 6 Individuals during day and swing shifts. Contractor shall provide a minimum ratio of 1 direct care staff for every 7 Individuals during night shift. Contractor shall increase staffing when it is warranted by Individual acuity… In addition to the above direct care staffing, regardless of census, Contractor shall ensure each shift includes one (1) designated Medication Aide per shift when Individual census is 26 or less and two (2) per shift for an Individual census of 27 or higher…”



Upon entrance of the facility on 06/16/25 at 9:00 am, the resident census was 42. According to the Specific Needs Contract, the facility was required to have seven direct care staff and two MTs.



The posted staffing plan in the facility lobby indicated the following information:
* Day shift (6:00 am – 6:00 pm): seven CGs and two MTs; and
* NOC shift (6:00 pm – 6:00 am): six CGs and two MTs.



Observations and interviews with direct care staff on 06/16/25 between 10:00 am and 4:00 pm revealed the facility had four direct care staff (CGs), three less than required by the Special Needs Contract and staffing plan posted by the facility.



b. Facility Staff Time reports, the schedule and facility census, reviewed from 06/08/25 to 06/15/25, revealed six of 17 shifts, or 35%, that the facility did not have the required number of direct care staff (CGs) per the census and Special Needs Contract.

During interviews with Staff 7 (Business Office Manager) on 06/18/25 at 11:25 am, she acknowledged the facility did not consistently staff the required number of direct care staff (CGs) per the Special Needs Contract.

The need to ensure the facility was staffing to meet the requirements under the Specific Needs contract was discussed with Staff 2 (Administrator Designee – Compliance Specialist) and Staff 3 (Director of Nursing) on 06/18/25. The findings were acknowledged.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:

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



The outdoor areas were toured on 06/16/25. The following issues were identified:



* The concrete sidewalk in the front, side and back of the building had several areas where the top layer of concrete was missing and exposed an uneven walking surface. Seams in the sidewalk had degraded in several areas, causing splits up to four inches wide in several areas. The uneven surface created a tripping hazard for residents.



The sidewalk was observed with Staff 2 (Administrator Designee – Compliance Specialist) on 06/17/25 at 9:20 am. She acknowledged it was a tripping hazard and needed to be repaired.

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 kept clean and in good repair. Findings include, but are not limited to:



Observations of the facility on 06/16/25 revealed the following:



First Floor

* Numerous resident and common use area doors/jambs had scrapes and/or gouges;

* Shower room: Dirt and debris between tiles, discoloration around the toilet base, discolored matter around the sink and faucet, and peeling paint on the wall leading to the shower area;

* Laundry/bathroom: An accumulation of dirt and debris between floor tiles and around the perimeter, a chair seat cushion had a tear, and discoloration around the toilet base;

* Chairs in sitting area had small tears and worn areas on arms and seats; and

* Dining room: Doors and jambs were scraped, multiple chairs had dried food matter and spills on the seats; table bases had an accumulation of dirt and food matter, dirt and cobwebs were visible between the soda and snack machines, and food splatters were visible on the wall behind the ice machine.



Second Floor

* Numerous resident and common use area doors/jambs had scrapes and/or gouges;

* The sitting area had chairs with tears and worn areas on the arms and/or seats, and an accumulation of dirt and debris on the floor;

* Shower rooms had dirt and debris between the floor tiles and perimeter of the floors, discolored grout between floor and wall tiles in the shower areas, discoloration around the toilet bases, or broken tile cove base;

* Laundry room had an accumulation of dirt and debris littering the floor and washer/dryer drain pans, discolored and cracked caulking behind the sink; and

* Room 219 had a broken window blind.



Third Floor

* Shower/bathroom room (located on the right side of the hallway) had dirt and debris between the floor tiles and perimeter of the floor, discolored grout between floor and wall tiles in the shower area, discoloration around toilet base, scraped wall corners leading into shower area, and a hole in the laminate counter backsplash;

* Shower/bathroom room (located on left side of the hallway) had dirt and debris between the floor tiles and perimeter of the floor, discolored grout between floor and wall tiles in the shower area, and discoloration around the toilet base;

* Laundry room had an accumulation of dirt and debris littering the floor and washer/dryer drain pans, discolored and cracked caulking around the sink basin and behind the sink, brown matter in the sink basin, and gouges in the wall under the window;

* Numerous resident and common use area doors/jambs had scrapes and/or gouges; and

* The sitting area had chairs with tears and worn areas on the arms and seats, and an accumulation of dirt and debris on the floor.



The surveyor toured the environment with Staff 8 (Maintenance Director) on 06/16/25 at 1:30 pm, and Staff 2 (Administrator Designee – Compliance Specialist) on 06/17/25 at 9:20 am. They acknowledged the above areas needed to be cleaned and repaired.

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

Refer to: C252.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN.

(c) Each resident record must, before move-in and when updated, include the following information:

(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity.

(5) The resident evaluation must address the following elements:

(a) For service planning purposes, if indicated by the resident,

(A) Name

(B) Pronouns.

(C) Gender identity.

This Rule is not met as evidenced by:

Based on interview and record review, conducted during a site visit on 12/09/24, the facility's failure to fully implement and update an Acuity Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:A review of the Facility ABST and the facility census indicated the facility census was 39.A review of the facility's ABST Answer Export dated 12/09/24 indicated there were nine residents that had not been updated in the last quarter.In an interview on 12/09/24, Staff 1(Administrator) stated s/he updated the ABST when a resident had a change of condition and when the service plan was updated.The facility was consistently staffed according to the posted staffing plan and no missed needs were observed.The facility failed to fully implement and update an Acuity Based Staffing Tool.The findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Director of Ancillary Services) via email on 12/11/24.

The findings of the kitchen inspection, conducted 08/31/23, 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 08/31/23, conducted 11/17/23, 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 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 08/31/23 at 11:05 am the following were observed: * The ceiling, light and wall vent above the beverage area had a significant build up of dust; * The thermostat on the wall in beverage area had significant build up of dust; * The shelves below the prep counters had food debris/crumbs; and* Dry storage shelving was uncleanable - stains on shelves could not be cleaned or removed. The findings were observed by Staff 1 (Director of Food Services) and discussed with Staff 1 and Staff 2 (Administrator) on 08/31/23. The findings were acknowledged.

Based on interview and observation, it was confirmed the facility failed to maintain required postings, which include manager on duty. Findings include: During NOC site visit on 05/28/2021, Compliance Specialist (CS) observed the manager on duty posting list a name of a staff member who was not onsite. The above findings were discussed with Staff #1 who was in agreement.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Failure to follow infection control guidelines to prevent the spread of COVID-19 put residents at serious risk. Findings include, but are not limited to:During the onsite NOC visit, conducted on 05/28/2021, multiple Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. Deficiencies that were identified included, but were not limited to:Review of facility staff screening logs indicated that 9 out of 11 staff members onsite (Staff #1-#9) did not screen in before their shift today. The Compliance Specialists (CS) were not screened in at any time while being onsite. Multiple staff members were observed with their mask under their noses and/or adjusting their mask without using hand sanitizer (Staff#1-5). Staff#2 was the only staff member wearing eye protection. CS also observed and spoke to all staff on duty (Staff #1-11) and there were no concerns with staff ability to communicate their job duties or resident needs. Staff appeared coherent and there were no obvious signs of drug use or intoxication. The above findings were discussed with Staff #1, who was in agreement.

The findings of the re-licensure survey, conducted 3/15/21 through 3/16/21, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the re-visit to the re-licensure survey of 3/16/21, conducted 5/24/21, 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.

Based on interview and record review, it was determined the facility failed to ensure adequate professional oversight for a safe medication system for 1 of 4 sampled residents (#3). Findings include, but are not limited to:Resident 3 was admitted to the facility in 2020 with diagnoses including irritable bowel syndrome.Resident 3 had physician orders, dated 1/15/21, to administer Docusate/Senna 50/8.6 mg daily and Polyethylene two times daily for bowel management. Staff documented Docusate/Senna 50/8.6 mg was administered to the resident daily and Polyethylene was administered at least one time daily from 3/1/21 through 3/15/21. The Polyethylene was held on 3/9/21 and 3/10/21 due to loose stool.Resident 3's clinical records indicated s/he experienced diarrhea or loose stool from 3/4/21 through 3/13/21, and staff documented the resident complained of pain and discomfort on the bottom area. On 3/9/21, the facility obtained a physician order to treat the bottom area.Resident 3's 3/1/21 through 3/15/21 MAR was reviewed during the survey and revealed staff administered as needed anti-diarrhea medication from 3/3/21 through 3/11/21 to the resident due to episodes of diarrhea or loose stool. Staff documented they administered two contradicting medications on the same day without evaluating or reviewing the resident's medical condition.On 3/16/21, the findings were reviewed with Staff 3 (RN). Staff 3 stated she put the Polyethylene medication on hold due to diarrhea for 3 days, but not the Docusate/Senna daily medication. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. Findings include, but are not limited to:On 03/16/21, fire drill records from August 2020 to February 2021 were reviewed with Staff 7 (Maintenance). The records indicated and Staff 7 confirmed the facility was not relocating residents during fire drills. Therefore, there was no documentation of the escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, the evacuation time period needed, and number of occupants evacuated.On 3/16/21, the need to ensure the facility conducted fire drills according to the Oregon Fire Code was reviewed with Staff 1 (Executive Director) and Staff 7 (Maintenance). The surveyor provided a copy of the CBC Fire and Life Safety regulation. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safety area in the event of an actual fire. Findings include but are not limited to:On 03/16/21, fire drills and life safety records from August 2020 to February 2021 were reviewed and lacked the following components:* Alternating evacuation routes during the fire drills.On 3/16/21, Staff 7 (Maintenance) was asked the process for instruction in general safety procedures and fire and life safety procedure for the residents. He acknowledged the facility did not have a process for the residents in generally safety procedures. The need to develop a process for providing the residents information on fire drill and other safety procedures, which would include documentation of each resident's ability to understand the information and evacuation methods, was reviewed. On 3/16/21, the need to ensure the facility conducted fire drills according to the Oregon Fire Code was reviewed with Staff 1 (Executive Director) and Staff 7 (Maintenance). They acknowledged the findings.