Senior Haven RCF

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:

During the re-licensure survey, conducted 05/06/25 through 05/08/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

OAR 411-054-0025 (1) Facility Administration: Operation

(1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to:

The Residential Care Facility (RCF) was toured on 05/05/25. The following were not posted as required:

* The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility; and

* The current facility staffing plan.

The need to ensure all required items were posted was reviewed with Staff 1 (Director of Nursing) and Staff 2 (ED) on 05/08/25 at 12:55 pm. They acknowledged the items were not posted as required.

OAR 411-054-0025 (5) Facility Administration: Required Postings

(5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following:
(a) Facility license.
(b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility.
(c) The current facility staffing plan.
(d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable.
(e) The Ombudsman Notification Poster.
(f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections.
(g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted.
(h) Other notices relevant to residents or visitors required by state or federal law.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure an unwitnessed fall was promptly investigated to rule out suspected abuse and/or neglect and was reported to the local SPD office as needed for 1 of 1 sampled resident (# 1) reviewed with incidents. Findings include, but are not limited to:

Resident 1 moved into the facility in 12/2020 with diagnoses including Alzheimer’s disease and generalized weakness.

The resident's current service plan dated 02/06/25, progress notes dated 02/06/25 through 05/06/25, and corresponding incident reports were reviewed. Observations of the resident and interviews with staff were completed between 05/06/25 and 05/08/25. The following was identified:

* 05/02/25 - Unwitnessed fall with nasal fractures and lacerations.

During an interview on 05/07/25 at 12:15 pm, Staff 7 (MT) confirmed Resident 1 was unable to state what occurred and required assistance of one staff member for all ADLs.

There was no documented evidence this incident was investigated to rule out abuse and/or neglect or was reported to the local SPD if abuse and/or neglect could not be ruled out.

The facility was asked to report the incident, and confirmation of the report was received prior to survey exit on 05/08/25 at 9:51 am.

The need to investigate all incidents promptly and to report incidents to the local SPD if abuse and/or neglect could not be ruled out was discussed with Staff 1 (Director of Nursing) and Staff 2 (ED) on 05/08/25 at 12:55 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, and provided clear directions to staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 04/2024 with diagnoses including type 2 diabetes mellitus, cellulitis of left lower limb, and paroxysmal atrial fibrillation.

Observations were made of the resident's care on 05/07/25, interviews with the resident and facility staff were conducted, and the service plan dated 02/14/25 was reviewed.

1. Resident 3's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Instructions to staff on blood glucose monitoring protocol when resident skips meals;
* Instructions on signs and symptoms of hypo- and hyperglycemia to report;
* Instructions on signs and symptoms of depression to report while on anti-depressant therapy;
* Instructions for proper maintenance of blood sugar monitor on left upper extremity and how to monitor for malfunctions;
* Instructions on to whom to report skin impairments;
* How side rails were to be used and monitored for safety;
* Hearing and a need for assistive devices;
* Transfers;
* Ambulation and use of assistive devices;
* Behavioral problems;
* Presence of depression, thought disorders, behavioral and mood problems;
* How a person expresses pain or discomfort;
* Personality, including how the person copes with change or challenging situations;
* Instructions on compression therapy;
* Number of staff needed to assist with activities of daily living;
* Number of staff needed to assist with grooming and eating;
* Number of staff needed to assist with emergency evacuations;
* Instructions for bleeding precautions and interventions while on anticoagulation therapy (Eliquis);
* Instructions on to whom to report weight gain or loss, and changes in appetite;
* Instructions on fall prevention;
* Instructions on peri and skin care; and
* Instructions on edema management.

The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Director of Nursing), Staff 2 (ED), and Witness 1 (Consultant) on 05/08/25 at 2:46 pm. They acknowledged the findings.


2. Resident 1 moved into the facility in 12/2020 with diagnoses including Alzheimer’s disease and generalized weakness.

The resident's current service plan, dated 02/06/25, progress notes dated 02/06/25 through 05/06/25, and corresponding incident reports were reviewed. Observations of the resident and interviews with staff were completed between 05/06/25 and 05/08/25. The following was identified:

Resident 1's service plan was not reflective of the resident's current needs and lacked clear direction to staff in the following areas:

* Recent emergency room visit with nasal fractures and lacerations;
* Behavior triggers regarding male friendship;
* Assistance required for emergency evacuations;
* Number of staff and amount of assistance for grooming, bathing, dressing, toileting, transfers, and ambulation;
* Escorts to dining room;
* Use of wheelchair;
* Frequency of safety checks;
* Instructions on to whom to report skin impairments;
* Fall interventions; and
* Weight loss.

The need to ensure service plans reflected residents' current needs and provided clear direction to staff regarding the delivery of services was reviewed with Staff 1 (Director of Nursing) and Staff 2 (ED) on 05/08/25 at 12:50 pm. 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 determine and document actions or interventions for short term changes of condition, provide written communication of a resident's change of condition and any required interventions to staff on all shifts, and ensure documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced short term changes of condition, and failed to document and update the service plan as needed after a resident experienced a significant change of condition for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

1. Resident 1 moved into the facility in 12/2020 with diagnoses including Alzheimer’s disease and generalized weakness.

The resident's current service plan dated 02/06/25, progress notes dated 02/06/25 through 05/06/25, and corresponding incident reports were reviewed. Observations of the resident and interviews with caregivers were completed between 05/06/25 and 05/08/25.

a. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted at least weekly through resolution:

* 03/12/25 – Redness to chest area and abdominal folds; and
* 03/12/25 – Urinalysis showed bacterial growth.

b. The following significant change of condition lacked documentation of the change and updates to the service plan as needed:

* 05/02/25 – Return from emergency room with a nasal fractures and lacerations.

During an interview on 05/07/25 at 1:55 pm, Staff 1 (Director of Nursing) confirmed there were no temporary service plans or skin logs completed for Resident 1 in the last 90 days.

The need to ensure a significant change of condition was documented and the service plan was updated as needed after a resident experienced a significant change of condition, and actions or interventions were determined and documented for short term changes of condition, written communication of a resident's change of condition and any required interventions to staff on all shifts, and documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 1 and Staff 2 (ED) on 05/08/25 at 12:55 pm. The findings were acknowledged.

2. Resident 3 was admitted to the facility in 04/2024 with diagnoses including type 2 diabetes mellitus, cellulitis of left lower limb, and paroxysmal atrial fibrillation.

Resident 3's progress notes, dated 02/08/25 through 05/05/25, and service plan dated 02/14/25, were reviewed.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 02/09/25 - “…Lantus ordered to be decreased from 18 units to 16 units.”;
* 02/10/25 - “reported blood sugars were low and the concern was that resident was purposefully avoiding food.”;
* 02/15/25 -“…PRN Tramadol was given instead of Oxy…”;
* 02/16/25 - “…residents recent behaviors, caregivers stated that they did notice some change in him at times…”;
* 02/17/25 - “…missing glucometer and resident refusing finger sticks…”;
* 02/23/25 - Resident refused CBG at 5:00 pm and 8:00 pm, no insulin was administered;
* 02/24/25 - Resident refused CBG at 5:00 pm, no insulin was administered;
* 03/03/25 - Resident refused CBG at 5:00 pm and 8:00 pm, no insulin was administered;
* 03/10/25 - Started new dose of furosemide 20mg to control edema;
* 04/7/25 - “…burning pain with urination, blood from his urine.”;
* 04/16/25 - Diarrhea;
* 04/16/25 - “..pain in urination..”;
* 04/20/25- ER visit;
* 04/21/25 - “Patches of blanch able redness noted to bilateral buttocks.”;
* 05/3/25 - Resident was on alert for “loose bowl movement and vomiting all night”;
* 05/3/25 - “ Resident refused all AM, PM Medications not feeling well had 4 times loose bowel movement had Imodium time 2”; and
* 05/4/25 - “Resident still have diarrhea and vomiting all night…. Today will be the third day of the same symptoms without any changes even after taking the medications…”.

The need to ensure the facility had a system in place to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved was reviewed with Staff 1 (Director of Nursing), Staff 2 (ED), and Witness 1 (Consultant) on 05/08/25 at 2:46 pm. They acknowledged the findings.

3. Resident 2 moved into the facility in 1/2022 with diagnoses including vascular dementia and Parkinson’s disease.
The current service plan dated 02/06/25 and progress notes dated 02/06/25 through 05/06/25 were reviewed. Observations and interviews with staff were completed between 05/06/25 and 05/08/25.

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

* 04/07/25 – Medication change (routine lorazepam); and
* 05/01/25 – New medication (baclofen).

The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 1 (Director of Nursing), Staff 2 (ED), and Witness 1 (Consultant) on 05/08/25. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (#3) who received subcutaneous injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to:

Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant to OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client.

During the acuity interview on 05/06/25, Resident 3 was identified to be administered a subcutaneous injection four times daily by a facility UAP.

Resident 3's MARs from 04/01/25 through 05/06/25 revealed subcutaneous injections had been given by Staff 8 (MT), Staff 9 (MT), and Staff 15 (MT).

Review of the nursing delegation binder found no documented evidence all elements of the initial delegation were completed for Staff 8.

Additionally, the RN comprehensive assessment to determine Resident’s 3 condition was stable and predictable, one of the criteria for delegation of a nursing procedure, was not completed and/or documented.

Staff 1 (Director of Nursing) assumed nursing oversight at the facility on 05/05/25. During the interview on 05/06/25, she stated the delegated RN was no longer employed by the facility.

The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was reviewed with Staff 1, Staff 2 (ED), and Witness 1 (Consultant) on 05/08/25 at 2:46 pm. They acknowledged the findings.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

(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:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure medication and treatment 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 3 was admitted to the facility in 04/2024 with diagnoses including type 2 diabetes mellitus, cellulitis of left lower limb, and paroxysmal atrial fibrillation.

Facility staff administered insulin to the resident four times daily.

Review of Resident 5's current physician orders and MARs from 04/01/25 through 05/06/25 revealed the following:

a. Humalog 100 U/ml insulin sliding scale for diabetes was ordered for administration before each meal and at bedtime based on Resident 3's blood glucose level. Based on review of the MARs, an incorrect dose of insulin was administered on twelve occasions. The administration of incorrect dose had no negative outcome to Resident 3.

b. Pregabalin 50mg was ordered to be administered one capsule by mouth twice daily for neuropathic pain. Based on review of the MARS, two capsules by mouth twice daily were administered on 04/30/25, 05/01/25, 05/02/25, and 05/05/25.

c. Insulin Lantus 100 U/ml was ordered to be discontinued on 04/15/25 and insulin Semglee 100 u/ml was ordered to start on 04/15/25. Both insulin injections were administered on 04/15/25.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Director of Nursing), Staff 2 (ED), and Witness 1 (Consultant) on 05/08/25 at 2:46 pm. They acknowledged the findings.

2. Resident 1 moved into the facility in 12/2020 with diagnoses including Alzheimer’s disease and generalized weakness.

Resident 1's physician's orders, MARs, dated 04/01/25 through 05/06/25, were reviewed and revealed the following:

a. The MAR was blank for the following medications or treatments:

* 04/18/25 - acetaminophen 500 mg (for pain) 08:00 pm dose; and
* 04/18/25 – donepezil 5 mg (for Alzheimer’s disease) 08:00 pm dose.

On 05/07/25 at 12:14 pm, Staff 7 (MT) confirmed the above medications were missed on the electronic MARs.

b. Resident 1 had a physician's order, dated 11/27/24, for melatonin 3 mg (for sleep disturbance), one tablet at bedtime.

* On 04/05/25 the medication was entered as “not available”; and
* On 05/01/25 and 05/02/25, an “X” was entered on the MAR.

During an interview on 05/07/25 at 12:14 pm, Staff 7 confirmed that the medication was not administered on the above dates.

The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (Director of Nursing) and Staff 2 (ED) on 05/08/25 at 12:55 pm. The findings were acknowledged.
3. Resident 2 moved into the facility in 01/2022 with diagnoses including vascular dementia and Parkinson’s disease.
The resident's MARs dated 04/01/25 to 05/06/25 and current physician's orders were reviewed. There was no documented evidence of signed physician orders in the resident's facility record for the following medication:

* Baclofen 5 mg - Give 1 tablet by mouth every six hours as needed for muscle spasms.

In an interview on 05/08/25, Staff 2 (ED) was unable to locate the physician's orders for this medication.

The need to ensure written, signed physician orders were in the residents' facility record was discussed with Staff 1 (Director of Nursing), Staff 2, and Witness 1 (Consultant) on 05/08/25. They 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 notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#2 and 3) who had documented medication and treatment refusals. Findings include, but are not limited to:

1. Resident 2's MARs were reviewed for the time period of 04/01/25 through 05/08/25.

Staff documented Resident 2 refused:

* Carbidopa/levodopa 25mg/100mg (for Parkinson’s disease) three times;
* Lorazepam 0.5mg (for anxiety) twice;
* Acetaminophen 500mg (for Parkinson’s disease) twice;
* Metformin 500mg (for diabetes) once; and
* Quetiapine 25mg (for essential tremor) once.

There was no documented evidence the facility notified Resident 2's physician of the refusals.
The need to ensure the facility had a system to notify the physician/practitioner of medication refusals was discussed with Staff 1 (Director of Nursing), Staff 2 (ED) and Witness 1 (Consultant) on 05/08/25. They acknowledged the findings.



2. Resident 3 was admitted to the facility in 04/2024 with diagnoses including type 2 diabetes mellitus, cellulitis of left lower limb, and paroxysmal atrial fibrillation.

Resident 3's MARs from 04/01/25 through 05/06/25 and corresponding progress notes were reviewed. The resident's records showed the following medication and treatment refusals:

* Acetaminophen 500mg (for pain) on three occasions;
* Aquaphor Ointment (skin health) on six occasions;
* Carvedilol 12.5mg on two occasions;
* Gabapentin 600mg (for neuropathy) on seven occasions;
* Duloxetine 30mg (for depression) on three occasions;
* Duloxetine 60mg (for depression) on seven occasions;
* Eliquis 5mg (blood thinner) on ten occasions;
* Finasteride (for bladder dysfunction) on ten occasions;
* Furosemide 20mg (diuretic) on eight occasions;
* Insulin Humalog on eight occasions;
* Insulin Glargine on three occasions;
* Jardiance 10mg (for blood sugar control) on six occasions;
* Lidocaine patch 4% (for pain) on 27 occasions;
* Losartan 50mg (for blood pressure) on eleven occasions;
* Potassium Chloride 20mEq (supplement) on ten occasions;
* Pregabalin 50mg (for pain) on four occasions;
* Spironolactone 25mg (diuretic) on ten occasions; and
* Daily weights.

There was no documented evidence the facility notified the physician or other practitioner each time the resident refused to consent to the orders.

The need to ensure the facility notified the physician or other practitioner of medication and treatment refusals was reviewed with Staff 1 (Director of Nursing), Staff 2 (ED), and Witness 1 (Consultant) on 05/08/25 at 2:46 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

(j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to instruct caregivers on the correct use of and precautions related to the supportive device, document use of the device in the resident's service plan, and/or evaluate the device on a quarterly basis for 2 of 2 sampled residents (# 2 and 3) who used a supportive device with restraining qualities. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 01/2022 with diagnoses including vascular dementia and Parkinson’s disease.
On 05/06/25, the surveyor observed side rails in the up position on both sides of the resident's bed, which represented devices with restraining qualities. The rails were securely attached.

A review of the resident's current service plan, dated 02/06/25, indicated the resident had "siderails." The service plan did not have instructions to caregivers on the correct use of the side rail and precautions related to the supportive device.

There was no documented evidence a quarterly evaluation of the side rails was completed.

The need to ensure staff were instructed on the use of and precautions related to the devices, use of supportive devices were included on residents' service plans and evaluated quarterly was discussed with Staff 1 (Director of Nursing), Staff 2 (ED), and Witness 1 (Consultant) on 05/08/25. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 04/2024 with diagnoses including type 2 diabetes mellitus, cellulitis of left lower limb, and paroxysmal atrial fibrillation.

During the acuity interview on 05/06/25, Resident 3 was identified as having a side rail. Upon observation on 05/07/25, Resident 3's hospital bed was noted to have two half-length side rails in the up position, representing devices with restraining qualities.

During the interview on 05/07/25, Resident 3 stated s/he was aware of the side rail use and had agreed to it as a bed mobility measure.

The resident’s service plan, dated 02/14/25, did not provide information relating to the side rails and their correct use. Resident’s last Side Rail Use Assessment form was completed on 12/20/24.

The need to ensure documentation of the use of supporting devices with restraining qualities is included in the resident service plan and evaluated on a quarterly basis was reviewed with Staff 1 (Director of Nursing), Staff 2 (ED), and Witness 1 (Consultant) on 05/08/25 at 2:46 pm. They acknowledged the findings.

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 interview, observation, and record review, it was determined the facility’s Acuity-Based Staffing Tool (ABST) did not accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to:

A review of ABST documentation, the posted staffing plan, the staffing schedule for 04/27/25 through 05/03/25, and the specific needs contract staffing requirements were reviewed. The following was identified:

* The minutes recorded on the ABST did not match services provided by staff in multiple areas for Residents 1 and 2.

The need for the ABST to accurately capture care time and care elements that staff were providing to each resident was discussed with Staff 1 (Director of Nursing), Staff 2 (ED), and Witness 1 on 05/08/25. 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 interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated no less than quarterly for 32 of 33 residents. Findings include, but are not limited to:

During the acuity interview at 9:30 am on 05/06/25, Staff 7 (MT) and Staff 11 (CG) confirmed the facility census was at 33 residents.

The facility’s ABST data was reviewed at 11:31 am on 05/06/25. The ABST data for 32 of 33 residents did not show documented evidence of being updated at least quarterly.

During an interview on 05/08/25 at 1:45 pm, Staff 2 (ED) stated the facility process for updating the ABST included to update it at the same time the service plan was being updated and/or with significant changes of condition. No additional documentation was provided to show the ABST for the above residents had been updated at least quarterly.

The need to ensure residents’ ABST was updated no less than quarterly was discussed with Staff 1 (Director of Nursing), Staff 2, and Witness 1 (Consultant) on 05/08/25. They acknowledged the findings.

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 interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternate months, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 05/07/25 at 1:45 pm.

In 12/2024, staff were instructed on Workplace Violence. There was no documented evidence staff were instructed on fire and life safety on alternating months from fire drills.

During an interview on 05/08/25 Staff 2 (ED) indicated fire and life safety instruction to staff only occurred in 12/2024 over the last six months.

The need to ensure staff instruction was provided according to the OFC was discussed with Staff 1 (Director of Nursing), Staff 2, and Witness 1 (Consultant) on 05/08/25 at 1:44 pm. They acknowledged the findings and no further information was provided.

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

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

This Rule is not met as evidenced by:

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

Refer to Z 155

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:

During a tour of the interior of the facility on 05/06/25 at 9:55 am, the majority of the dining room chair cushions in the MCC had scuffs, tears, or scrapes on the surface.

The surveyor toured the environment with Staff 18 (Facilities Manager) on 05/08/25 at 9:50 am. He acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

In an interview at 1:00 pm on 05/08/25, Staff 2 (ED) confirmed two resident units in the RCF had a shared pocket door with a shared bathroom/shower room.

Observations of the shared bathrooms on 05/08/25 revealed sliding pocket doors from the resident units with no method to ensure resident privacy during use of the bathroom.

The need to ensure privacy in individual resident units was discussed with Staff 1 (Director of Nursing) and Staff 2 on 05/08/25. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on record review and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to:

Review of records for Residents 1 and 2, who resided in the MCC, revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms.

During an interview on 05/08/25 at 1:10 pm, Staff 2 (ED) stated that residents in the MCC were not provided a key unless they requested it.

The need to ensure all residents were provided keys to their units was discussed with Staff 1 (Director of Nursing) and Staff 2 on 05/08/25 at 1:15 pm. The findings were acknowledged.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access

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

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 C150, C152, C231, C362, C363, C420, and C513.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 5, 6, 14, and 12) completed all required pre-service orientation and dementia training within the required time frames; failed to ensure 3 of 3 newly hired staff (#s 4, 5, and 6) demonstrated competency in all assigned job duties within 30 days of hire; and failed to ensure 2 of 2 long-term employees (#s 7 and 11) completed the required LGBTQIA2S+ training. Findings include, but are not limited to:

Staff training records were reviewed on 05/06/25 at 10:00 am with Staff 17 (Business Office Manager).

a. There was no documented evidence Staff 5 (CG/MT), Staff 6 (MT), Staff 12 (Housekeeper), and Staff 13 (Activities Assistant), hired 03/18/25, 04/02/25, and 03/31/25, and 04/07/25, respectively, completed one or more of the following pre-service orientation elements:

* Resident rights and values of CBC care;
* Abuse reporting requirements;
* Fire safety and emergency procedures;
* Written job description;
* Infectious disease prevention;
* Approved HCBS course; and
* Approved LGBTQIA2S+ course.

b. There was no documented evidence Staff 6 and Staff 14 completed pre-service dementia training prior to beginning their job duties.

c. There was no documented evidence Staff 5 completed one or more of the following pre-service dementia training topics:

* Environmental Factors that are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); and
* Use of supportive devices with restraining qualities in memory care communities.

d. There was no documented evidence Staff 4 (CG), hired 03/03/25, Staff 5, and Staff 6 demonstrated competency in all assigned job duties, including the following:

* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting;
* General food safety, serving and sanitation; and
* Other duties as applicable (Med pass, treatments).

On 05/07/25, at approximately 3:35 pm, Staff 1 (Director of Nursing) was informed all MTs must demonstrate competency in their assigned job duties before they could pass medications again, including those on duty at the time. She acknowledged this and reported she would be completing competency checklists with staff on duty at the time, as well as the morning shift for the following day, as the night shift MTs were agency staff.

Copies of completed medication technician competencies for four MTs was received on 05/08/25 at 11:58 am.

d. There was no documented evidence Staff 7 (MT), hired 12/05/22, and Staff 11 (CG), hired 09/12/22, had completed the required LGBTQIA2s+ training.

The need to ensure all staff complete required training in the specific timeframes required by rules was discussed with Staff 1 and Staff 2 (ED) on 05/08/25 at 12:55 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure 5 of 5 newly hired staff (#s 23, 24, 25, 26, and 27) completed all required pre-service orientation prior to beginning any job duties, completed pre-service training in all required training areas, and demonstrated competency in all assigned job duties within 30 days of hire and failed to ensure 1 of 2 long-term employees (# 21) completed the required LGBTQIA2S+ training. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 08/20/25 at 11:53 am. The following was identified:

a. There was no documented evidence Staff 23 (MT), Staff 24 (CG), Staff 25 (MT), Staff 26 (CG), and Staff 27 (MT), hired 07/10/25, 07/14/25, 07/07/25 , 07/0725 and 07/15/25, respectively, completed one or more of the following pre-service orientation training areas:

* Resident rights and values of CBC care;
* Abuse reporting requirements;
* Fire safety and emergency procedures; and
* Written job description.

b. There was no documented evidence Staff 5 completed one or more of the following additional pre-service training topics:

* Environmental Factors that are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.);
* Family Support and the role the family may have in the care of the resident; and
* Use of supportive devices with restraining qualities in memory care communities.

c. There was no documented evidence Staff 23 (MT), Staff 24 (CG), Staff 25 (MT), Staff 26 (CG), and Staff 27 (MT) demonstrated competency in all assigned job duties, including one or more of the following:

* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* General food safety, serving and sanitation.

d. There was no documented evidence Staff 21 (CG), hired 07/15/20, had completed the required LGBTQIA2s+ training.

The need to ensure all new staff completed all training within the required timeframes and all long-term staff completed all required annual training was discussed with Staff 1 (Director of Nursing), Staff 17 (Business Office Manager), and Staff 19 (ED) on 08/21/25 at approximately 11:00 am. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to 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, C270, C282, C303, C305, 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 ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 and 2’s current service plans were reviewed during survey and interviews were conducted with staff. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.

The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Director of Nursing) and Staff 2 (ED) on 05/08/25 at 12:55 pm. The findings were acknowledged.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration

(c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed for 2 of 2 sampled residents (#s 1 and 2) whose activity plans were reviewed. Findings include, but are not limited to:

Resident 1 and 2’s records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect one or more of the following required components:

* Residents' current preferences;
* Abilities and skills;
* Emotional/social needs and patterns;
* Physical abilities and limitations;
* Adaptations necessary for the resident to participate; and
* Identification of activities for behavioral interventions.

There was no specific activity plan, reflecting the residents' activity preferences and needs, which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.

During an interview on 05/08/25 at 10:58 am, Staff 12 (Activities Director) confirmed all of the components were not addressed in the current individualized activity plans for Residents 1 and 2.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Director of Nursing) and Staff 2 (ED) on 05/08/25 at 12:55 pm. The findings were acknowledged.

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:

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation areas were no less than six feet in height, and to ensure outdoor furniture was of sufficient weight, stability and design, to prevent resident injury or aid in elopement. Findings include, but are not limited to:

The facility was endorsed as a secure MCC for residents with a diagnosis of dementia. The building and its residents had access to an outdoor recreation area. The outdoor recreation area was toured on 05/05/25 and 05/06/25 and the following was identified:

a. One section of fencing, which included a gate, did not meet the six-foot height requirement. On 05/06/25 at 2:00 pm, the surveyor and Staff 18 (Facilities Manager) measured the section of the fence, and measurements included areas as low as 69.5 inches.

b. Outdoor furniture was observed in the courtyard, to which residents had free access. The furniture was movable, and not of sufficient weight to prevent injury or elopement.

The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height and to ensure outdoor furniture was of sufficient weight, stability and design, to prevent resident injury or aid in elopement was discussed with Staff 1 (Director of Nursing) and Staff 2 (ED) on 05/08/25. The findings were acknowledged.

OAR 411-057-0170(6) Secure Outdoor Recreation Area

(6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted on 05/10/24 and 05/13/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection of 05/13/24, conducted 09/19/24, 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 maintain the kitchen in good repair in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observation of the main kitchen, basement and refrigerator room outside of the main kitchen on 05/10/24 at 11:18 am identified the following:The following areas were in need of repair:* Multiple floor tiles and grout were broken, including a corner baseboard tile behind the turbofan appliance;* There was a leaking pipe beneath the three compartment sink;* Commercial refrigerator in the main kitchen had rusted shelves and a broken door seal; * The upright side-by-side residential style refrigerator/freezer combo located in a room outside of the main kitchen was not cooling/maintaining temperatures;* Two upright freezers located in a room outside of the main kitchen had a build-up of ice and frost on the interior walls;* One white upright freezer located in a room outside of the main kitchen had a damaged door seal;* The floor inside the refrigerator room located outside of the main kitchen had multiple areas of torn floor covering which exposed the wood floor beneath;* Two dorm room size refrigerators in the basement were not cooling/maintaining temperatures; and* Two chest style freezers in the basement had a build-up of ice and frost around the interior walls.The need to ensure the kitchen was maintained in good repair in accordance with the Food Sanitation Rules was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Culinary Director) on 05/13/24. They acknowledged the findings.

The findings of the Change of Owner re-licensure survey conducted 03/08/22 through 03/10/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 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 revisit to the re-licensure survey of 03/10/22, conducted 05/09/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose records were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 02/2022. Resident 2's move-in evaluation failed to address the following:* Visits to health practitioners, ER, hospital or nursing facility in the past year;* Mental health issues including behavior or mood problems, history of treatment and effective non-drug interventions;* Cognition, including memory, confusion, and decision making;* Personality, including how the person copes with change or challenging situations; * Ability to use the call system;* Pain: pharmaceutical and non-pharmaceutical interventions including how a person expresses pain or discomfort;* Nutrition habits, fluid preferences and weight if indicated;* Emergency evacuation ability;* Recent losses;* Unsuccessful prior placements; and* Environmental factors that impact the residents behavior.The need to ensure the facility completed all required elements on Resident 2's new move-in evaluation was discussed with Staff 1 (Administrator) and Staff 2 (VP of Operations) on 03/09/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of the resident's status and provided clear instruction to staff for 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 05/2020 with a history of multiple back surgeries and chronic pain.The current service plan dated 01/04/22 noted the resident required one person assist with toileting, was "bed bound", and would become restless related to pain and anxiety. The service plan directed staff to offer non-drug interventions before as needed medication for pain.During interviews on 03/10/22 with Staff 4 (MT), Staff 5 (MT/CG) and Staff 10 (CG) they stated the following:*Resident 1 required 2-3 people to provide incontinent care;*S/he experienced increased pain and anxiety in the evening hours;*The resident would use the call light more frequently when anxious or in pain; *When his/her beard was trimmed s/he "feels better about himself"; and*S/he preferred one to one companionship when restless.Resident 1's service plan was not reflective related to number of staff needed to provide incontinent care, there was no description of how the resident demonstrated pain or restlessness, and there were no non-drug interventions identified to help with pain and anxiety.Resident 1's service plan was reviewed with Staff 1 (Administrator) on 03/10/22 at 1:00 pm. Staff 1 acknowledged the finding.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 2 of 2 sampled residents (#s 2 and 4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:During the acuity interview on 03/08/22, Resident's 2 and 4 were identified to be administered insulin injections by non-licensed staff.1. Resident 2's MARs, reviewed from 02/11/22 through 03/08/22, revealed weekly insulin had been administered by Staff 3, 11 and 17 (MTs).Initial delegations for Staff 3 (MT) completed 02/21/22 and Staff 17 (MT) completed 02/14/22, lacked documentation in the following areas:* A rationale that the task could be safely delegated;* Frequency the resident should be reassessed, including rationale; * Frequency the MT should be supervised and reevaluated, including rationale; and* Staff 11 (MT) was not delegated and had administered insulin on 03/07/22.2. Resident 4's MARs, reviewed from 02/01/22 through 03/08/22, revealed insulin had been administered by Staff 4, 5 and 11 (MTs).Initial delegations for Staff 4 (MT) completed 02/07/22, Staff 5 (MT) completed 02/07/22 and Staff 11 completed on 02/18/22, lacked documentation in the following areas:* A rationale that the task could be safely delegated;* Frequency the resident should be reassessed, including rationale; and* Frequency the MT should be supervised and reevaluated, including rationale.The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Administrator), Staff 2 (VP of Operations) and Staff 16 (RN) on 03/09/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the facility record and that orders were followed for 2 of 2 sampled residents (#s 1 and 2) whose physician orders were reviewed. Findings include, but are not limited to:1 a. Resident 1's 02/01/22 through 02/28/22 MAR was reviewed and noted the following medications were documented as administered:* Duloxetine (for depression);* Melatonin (for sleep);* Omeprazole (for reflux);* Oxycodone (for pain);* Polyethylene (for bowel care);* Potassium (Supplement);* Pregabalin (for pain)* Metamucil (for bowel care);* Simvastatin (for cholesterol); and* Torsemide (diuretic).There was no documented evidence written signed physician orders for the medications were in the resident's record. The facility faxed the physician and received signed orders on 3/10/22 at the time of the survey.b. Resident 1 had orders for warfarin (to prevent blood clots) 2.5 mg to be administered on 2/15/22 and no warfarin was to be administered 02/16 through 02/20/22. The MAR dated 02/16 through 02/20/22 noted the medication was not held as ordered.Following medication and treatment orders as prescribed was reviewed with Staff 1 (Administrator) on 03/10/22 at 1:00 pm. At the time of the survey, Resident 1's physician's orders related to warfarin were being followed.
2. Resident 2 was admitted to the facility in 02/2022 with diagnoses including celiac disease. Resident 2's 03/01/22 through 03/08/22 MAR was reviewed and noted the following:* From 03/04/22- 03/08/22 CertaVite Senior (supplement) was not available and was not administered as prescribed. During an interview with Staff 16 (RN) on 03/09/22, she reported the medication was still not available. Staff 16 reported she would need to follow up with MT who should have faxed the pharmacy. The need to ensure medication orders were followed as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (VP of Operations) on 03/09/22. The acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were complete, accurate, provided clear instruction and parameters for administration of scheduled and PRN medications for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 1's MAR dated 02/01/22 through 02/28/22 noted the following:* Reguloid Orange Powder (Metamucil) one to three times daily for constipation. There were no instructions to staff regarding when or how much to administer; and* Diazepam as needed for spasm/anxiety without clear instruction about when and for what to administer the medication.Resident 1's MARs were reviewed with Staff 1 (Administrator) on 03/10/22 at 1:00 pm. Staff acknowledged the findings.
2. Resident 2's MAR dated 03/01/22 through 03/08/22 noted the following:* PRN Milk of Magnesia and PRN Docusate Sodium lacked parameters for the sequence of administration; and* CBG checks prior to insulin administration lacked clear parameters for when to hold the insulin.The need to ensure MAR's had clear instructions and parameters for unlicensed staff was reviewed with Staff 1 (Administrator), Staff 2 (VP of Operations) and Staff 16 (RN) on 03/09/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT prior to use, documented evidence the resident was informed of the risks and benefits associated with the device, documentation of less restrictive alternatives prior to use, and documented instructions to caregivers on the correct use and precautions of the device for 2 of 2 sampled residents (#s 1 and 2) who had half-length side rails on their bed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 05/2020 with diagnoses including a history of back surgeries and chronic pain. Observations during the survey on 03/10/22 revealed Resident 1 had a hospital bed. Bilateral side rails were observed on the bed in the down position. Resident 1 was not in the bed during the observation. There was no documented evidence the following required elements were completed:* Assessment by an RN, PT or OT; * Documentation of less restrictive alternatives prior to use of the device; * Documentation the resident was informed of risks and benefits associated with the device; and * Instruction provided to staff on the correct use and precautions of use of the device.The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT or OT and completion of all required elements was discussed with Staff 1 (Administrator) on 03/10/22. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 02/2022 with diagnoses including Parkinson's disease. Observations during the survey on 03/09/22 revealed Resident 2 had a hospital bed with a quarter length side rail on one side of the bed. The side rail was in the up position. Resident 2 was seated in a recliner chair during the observation. There was no documented evidence the following required elements were completed: * Assessment by facility RN, PT or OT;* Documentation the resident requested or approved of the device; * The facility had informed the individual of the risks and benefits associated with the device; * Documented other less restrictive alternatives evaluated prior to the use of the device;* Instructed caregivers on the correct use and precautions related to use of the device; and* Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan.The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT or OT and completion of all required elements was discussed with Staff 1 (Administrator), Staff 2 VP of Operations) and Staff 16 (RN) on 03/09/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:Review of fire drill and fire and life safety records for 07/2021 through 03/2022 identified the following deficiencies:* Fire and life safety instruction for staff was not conducted and documented on alternate months of the fire drills; and* There was no documentation of the following required components:- Escape route used;- Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and- Number of occupants evacuated.The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (Administrator) and Staff 2 (VP of Operations) on 03/09/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:Fire and life safety records, reviewed between 07/2021 through 03/2022, revealed the facility lacked documented evidence of the following:* Alternate exit routes were used during fire drills;* Fire and life safety training for residents at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire;* A written record of fire safety training, including content of the training sessions and the residents attending; and* There was no documented evidence the facility identified residents who were unable or unwilling to participate in the fire drills therefore, there was no documented evidence immediate changes were made to ensure the evacuation standard was met. The need to ensure alternate exit routes were used during fire drills, fire and life safety instruction was provided to residents at least annually, and documentation of residents who declined to participate in fire drills with the changes made to ensure the facility was able to maintain the evacuation standard was discussed with Staff 1 (Administrator) and Staff 2 (VP of Operations) on 03/09/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to:The exterior of the facility was toured on 03/08/22. Exterior pathways in the courtyard and around the perimeter of the building contained multiple drop offs up to four inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents. On 03/08/22, the building's exterior was toured with Staff 1 (Administrator), Staff 2 (Vice President of Operations), and Staff 15 (Maintenance Director). They acknowledged the findings.

Based on interview and observation it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include the following:During an unannounced site visit on 12/31/2021 Compliance Specialist (CS) observed 2 rooms with signs on the doors stating not to disturb, staff sleeping.In an interview with Staff #1 (S1) it was stated that they had to bring their child with them into work one day. They had been rapid tested for COVID-19 and brought into one of the rooms designated for agency staff.