Heartwood Place

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation, interview, and record review, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 1 of 1 sampled resident (# 1) who received assistance with toileting. Findings include, but are not limited to: Throughout the re-licensure survey, from 03/31/26 through 04/02/26, the following observations were made to determine adherence to universal precautions for infection control: Resident 1 was admitted to the facility in 12/2025 with diagnoses including vascular dementia. Per the service plan, dated 03/23/26, Resident 1 required two-person physical assistance with a gait belt and walker for transfer to the toilet, disposable briefs, and staff were to ensure perineal care (peri care) was provided. Two observations were made of caregivers transferring the resident to the toilet and providing peri care. On 03/31/26 at 11:05 am, Staff 14 (CG) assisted Resident 1 to the toilet, then removed the soiled gloves and placed them in her pocket. She then removed a clean brief from the closet, donned new gloves, and removed the soiled brief. Without changing gloves, she put the clean brief on the resident while s/he was sitting on the toilet. After providing peri care, she doffed her gloves and assisted the resident into the wheelchair, then into his/her recliner. She did not perform any hand hygiene between dirty and clean tasks. In an interview with Staff 14 on 03/31/26 at 11:14 am, she acknowledged placing the soiled gloves in her pocket was unsanitary. On 04/01/26 at 10:30am, Staff 10 (CG) and Staff 12 (CG) assisted Resident 1 to the bathroom then doffed their gloves without performing hand hygiene. Staff 10 remained in the room and Staff 12 left the room. Staff 12 returned to assist with transferring the resident from the toilet and did not perform hand hygiene prior to assisting. Staff 10 donned gloves without performing hand hygiene, then provided peri care. Both caregivers assisted the resident to ambulate to the sink. Staff 10 held the gait belt and guided the resident with his/her walker to the reclining chair, then doffed the soiled gloves. During both observations, Staff 10, Staff 12, and Staff 14 entered the resident’s room and donned gloves without first performing hand hygiene and did not perform hand hygiene between dirty and clean tasks. The need to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during ADL care was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/02/26 at 2:00 pm. They acknowledged the findings.

All direct care staff and med techs will be re-trained on donning and doffing of gloves between dirty and clean tasks handwashing and review of all infection control policies. Upon hire infection control courses are completed. Return demenstration of hand washing and donning and doffing of gloves will be observed. Current employees will receive on going monthly training/audits of all infection control requirements. Monthly audits and return demontration will be conducted to all direct care staff on hand washing and donning and doffing of gloves during resident care. Adminstrator, RN and RCC

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

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

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 4) whose MARs and physician orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 2017 with diagnoses including dementia and essential hypertension. Review of the resident’s 03/01/26 through 03/31/26 MAR and current physician orders identified the following: * The resident was prescribed amlodipine 10 mg tab, one tablet every night at bedtime. The order included parameters to notify the physician and hold the medication if the resident’s systolic blood pressure was less than 100 or the diastolic blood pressure was less than 60. There was no documented evidence the resident’s blood pressure was being taken prior to staff administering the amlodipine. In an interview on 04/01/26 at 1:05 pm, Staff 2 (RN) verified that staff had not been taking the resident’s blood pressure prior to administering amlodipine. The need to follow physician orders as written was discussed with Staff 1 (ED), Staff 3 (RCC), and Staff 8 (Director of Clinical Operations) on 04/02/26 at 3:45 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 12/2025 with diagnoses including vascular dementia. The resident was identified during the acuity interview to have skin issues (rash under breasts). Resident 1's current physician orders, dated 03/12/26, and MARs from 03/01/26 through 03/31/26 were reviewed, and the following was identified: The resident was prescribed nystatin 100,000 units/gram powder, topically apply twice a day until resolved for rash under breasts. The medication was not administered as prescribed on five occasions between 03/01/26 and 03/31/26. In an interview on 04/1/26 at 10:45 am, Staff 16 (MT) stated she held the treatment on those occasions as the rash appeared resolved. In an interview on 04/01/26 at 1:15 pm, Staff 2 (RN) confirmed the rash was not resolved, treatment was currently ongoing, and there was no order to hold the scheduled treatment. The need to ensure treatment orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RCC) on 04/02/26 at 1:00 pm. They acknowledged the findings.

Recording of blood pressure was added for Resident 4 to the order immediatley. The RN assesed resident #1 for the need to continue use of Nystain. A MAR audit was completed for all residents and medications/treatments. For all new medication/treatments a three check process will take place with Med Tech, RCC and RN. During this three check process all vitals and perameters will be put in place following doctors orders. On going MAR audits quarterly and with COC. A quarterly MAR audit will be done for each resident or with a COC. Monthly med tech meeting to be held for continuing education relating to medication policy and procedures. RN, RCC and Administrator will monitor.

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.

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.

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident’s Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan, for 3 of 4 sampled residents (#s 1, 2, and 4) whose ABST evaluations were reviewed. Findings include, but are not limited to: Resident 1, 2, and 4’s current service plans and ABST evaluations were reviewed during the survey. Observations were made of the residents, and staff were interviewed regarding each resident’s care needs. The following was identified: 1. Resident 1’s ABST evaluation did not reflect the care that was being provided to the resident as noted in their service plan or the time and frequency that was required to complete the ADL task was not accurate as follows: * No time was assigned for cueing or redirecting due to cognitive impairment or dementia. Interviews with staff indicated they spent approximately 10 minutes per occurrence redirecting the resident. * No time was assigned for providing treatments. Review of the resident’s MAR and interviews with staff indicated staff were providing a prescribed treatment BID. * No time was assigned for escorting to and from meals. During the survey, staff were observed escorting the resident to and from meals. * No time was assigned for supervising, cueing, or supporting while eating. During the survey, staff were observed needing to repeatedly provide verbal cueing to keep the resident focused on eating. * The time assigned for assisting with bathing (8 minutes) was not accurate. Staff interviewed stated it took between 15 and 20 minutes to complete the bathing task with Resident 1. * The time assigned for dressing/undressing (seven minutes) and grooming (four minutes) was not accurate. The resident recently sustained a hip fracture, and interviews with staff indicated it now took approximately 20 minutes each morning to assist the resident with dressing and grooming. The need to ensure each resident’s ABST evaluation accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 04/02/2026 at 1:00 pm. They acknowledged the inaccuracies in the ABST. 2. Resident 2’s ABST evaluation did not reflect the care that was being provided to the resident as noted in their service plan or the time and frequency that was required to complete the ADL task was not accurate as follows: Resident 2’s service plan and progress notes indicated staff were monitoring and documenting on the resident’s behavior frequently, and the resident was frequently displaying escalated verbal and physical behavior, for which staff were intervening and redirecting the resident to other activities. The resident’s ABST assigned no time for: * Monitoring behavioral conditions or symptoms; * Ensuring non-drug interventions for behaviors; or * Cueing or redirecting due to cognitive impairment or dementia. * Additionally, the time assigned for assisting with bathing (ten minutes) was not accurate. Staff interviewed stated it took between 25 and 45 minutes to complete the bathing task with Resident 2. The need to ensure each resident’s ABST evaluation accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was discussed with Staff 1 (ED), Staff 2 (RN) Staff 3 (RCC), Staff 8 (Director of Clinical Operations) on 04/02/2026 at 4:00 pm. They acknowledged the inaccuracies in the ABST. 3. Resident 4’s ABST evaluation did not reflect the care that was being provided to the resident as noted in their service plan or the time and frequency that was required to complete the ADL task was not accurate as follows: The time assigned for supervising, cueing, or supporting while eating (ten minutes, five times per day) was not accurate. Observations during the survey and interviews with staff indicated staff spent between 20 to 45 minutes assisting the resident with eating during meal and snack times. The need to ensure each resident’s ABST evaluation accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was discussed with Staff 1 (ED), Staff 3 (RCC), and Staff 8 (Director of Clinical Operations) on 04/02/2026 at 3:45 pm. They acknowledged the inaccuracies in the ABST.

The RCC updated the service plan for Residents 1, 2 an 4 to reflect the care being provided by direct care staff. A review and update of the ABST was completed to capture all 22 elements. Observation of care being provided for all residents then the ABST was updated to reflect the number of mintues identifed to complete services for each resident. Observation of care and mintues will be updated quarterly or with COC. Administrator, RN and RCC

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.

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.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C295.

Refer to C 295 and C 362

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.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

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 C303 and C362.

Refer to C303

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

Based on interview and record review, it was determined the facility failed to ensure the initial resident evaluation contained and addressed all required elements, for 1 of 1 sampled resident (#5) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 5 was admitted to the facility in 02/2023 with diagnoses including dementia. Review of the resident's admission evaluation identified the following deficiencies related to the required elements: * The item "...how a person copes with change or challenging situations" under "Personality" was not included on the evaluation form and not addressed; * The item "...how a person expresses pain or discomfort" under "Pain" was included on the form but was not addressed; and * The items "Memory, orientation...and decision-making abilities" under "Cognition" were addressed accurately in the resident's service plan but were documented incorrectly on the initial evaluation. Resident 5's initial evaluation was reviewed with Staff 1 (Administrator), Staff 2 (Corporate RN) and Staff 3 (RCC) on 06/01/23. They acknowledged the inaccuracies with the initial evaluation form.

This system has been corrected by updating the Resident Evalution/Assesment tool for missing elements. The Marketing Director and ED will assure that all elements of the initial evaluation upon assessment are addressed at assessment.. A New Resident Check off list has been updated to require the administrtor to audit the evaluation prior to move in. This will assure all elements have been captured. The area will be evaluated upon each asssessment and prior to move in. Administrator will be responsible for corrections.

2. Resident 2 was admitted to the facility in 06/2021 with diagnoses including dementia, malnutrition, and osteoporosis. Observations of the resident, interviews with staff, and review of the current service plan during the survey, from 05/30/23 thru 06/01/23, revealed Resident 2's service plan was not reflective of the resident's status and not implemented in the following area: * Home health recommendation to slightly tilt wheelchair and float heels to prevent skin breakdown. On 06/01/23, the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Corporate RN). They acknowledged the service plan was not reflective of the resident's status. 3. Resident 3 was admitted to the facility in 06/2015 with diagnoses including dementia and chronic kidney disease. Observations of the resident, interviews with staff, and review of the current service plan during the survey, from 05/30/23 thru 06/01/23, revealed Resident 3's service plan was not reflective of the resident's status and not implemented in the following area: * Resident preference to not use a straw for thickened liquids, who would provide nail trimming, and who would provide snacks and fluids. On 06/01/23, the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Corporate RN). They acknowledged the service plan was not reflective of the resident's status.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and services were implemented for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2021 with diagnoses including vascular dementia. Observations of the resident, interviews with staff, and review of the current service plan during the survey, from 05/30/23 thru 06/01/23, revealed Resident 1's service plan was not reflective of the resident's status and not implemented in the following areas: * Two-person assist with transfer; and * Use of the clipped call light. On 06/01/23, the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Corporate RN). They acknowledged the service plan was not reflective of the resident's status and was not being implemented.

Residents #1, 2, and 3 have had the missing service plan items added to their service plan. Outside provider notes will go through 3 step process to identify and implement orders.   RCM will use the service planning tool and review any TSP's in place to capture new baseline for the residents at quarterly review /assessment to assure service plans are reflective of resident needs. 1) Med tech will review HH/ HOSP documentaton and TSP will be completed if there is a change in services. RCC will review TSP's created and verify. RN will complete final review. 2) RCM will incorporate changes in service plans from assessments quarterly using service planning tool. Each service plan will update will have service plan tool submitted to the Admin by RCM showing use with date. The administrator, RCC and RN will be responsible for completion.

Based on interview and record review, it was determined the facility failed to ensure resident service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee, a licensed nurse if the resident needed or was receiving nursing services or experienced a significant change of condition, and at least one other staff person who was familiar with or who was going to provide services to the resident, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2 and 3's most recent quarterly service plans were reviewed during the survey. Each service plan lacked documented evidence it was developed and reviewed by the resident and other required members of his/her Service Planning Team. The need to ensure resident service plans were developed with a Service Planning Team was reviewed with Staff 1 (Administrator), Staff 2 (Corporate RN), and Staff 3 (RCC) on 05/31/23. They acknowledged the findings.

A service plan conference letter will be mailed to family POA or main contact prior to care conference date. This letter will be filed in the resident chart showing notification to the family. The signed service agreement completed by family will be signed by ED and RCC and placed in residents financial file. If family declines to attend progress note will be made in residents file. This will be evaluated monthly and quarterly. Administrator, RCC and RN will be responsible to see that the corrections are completed.

Based on observation, interview and record review, it was determined the facility failed to evaluate and monitor service planned interventions for 1 of 2 sampled resident (#1) who had repeated falls. Findings include, but are not limited to: Resident 1 was admitted to the memory care facility in 03/2021 with diagnoses including vascular dementia. Resident 1 required a wheelchair for mobility. During the acuity interview on 05/30/23, Staff 1 (Administrator), Staff 2 (Corporate RN) and Staff 3 (Resident Care Coordinator) reported the resident had fallen multiple times in the past 90 days when s/he attempted to transfer without staff assistance. Observations of the resident and staff interview from 05/30/23 to 06/01/23 showed the resident required hands on assistance at all transfers, bowel and bladder care management and supervision when the resident was on [his/her] wheelchair due to attempting self-transfer. A 04/18/23 service plan indicated the resident had right sided weakness and listed fall interventions including the use of clipped call light, nonskid socks, pool noodle under the mattress and the bed and the wheelchair in low position. Progress notes, incident reports and Temporary Service Plan (TSP) dated 03/08/23 through 05/30/23 indicated the resident experienced 14 falls. There was no documented evidence the facility consistently evaluated the pattern of the falls after each incident and determined if the service-planned interventions were implemented and/or continued to be effective. On 06/01/23, the findings were discussed with Staff 1 and Staff 2, including the need to evaluate the circumstances of falls and to monitor the effectiveness of the current service planned interventions. They acknowledged the findings.

All TSP's will be reviewed by RCC daily in clinical meeting to determine if they are effective or if further interventions are warranted. If resident has returned to baseline TSP will be resolved by a chart note to d/c TSP. If it is a change to the service plan and not temporary in nature it will be added to service plan at the quarterly reveiw. Any new interventions will be updated into the service plan once the TSP has been discontinued from alert charting if no longer temporary. This will be evaluated monthly, quarterly or upon COC. RCC and Administrator will be responsible for corrections to be completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure an Infection Control Specialist was trained by 07/01/22, as required in OAR 411-054-0050 and failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to: 1. In an interview on 05/30/23, Staff 1 (Administrator) was asked to provide training documentation for the facility's designated Infection Control Specialist. Staff 1 (Administrator) confirmed the facility designated an Infection Control Specialist had not yet completed the required training. The need to ensure the facility designated an individual to be the facility's Infection Control Specialist and completed the specialized training in infection prevention and control protocols within the required timeframe was reviewed with Staff 1 on 05/31/23. She acknowledged the findings. 2. Observations were made during the survey to determine adherence to universal precautions for infection control. On 05/31/23, approximately 9:20 am, the surveyor observed Staff 17 (RCF caregiver) provide incontinence care to Resident 1. During the observation, Staff 17 failed to change gloves after wiping urine and fecal matter from Resident 1's bottom area. Staff 17 touched the resident's shirts and pants and the resident's wheelchair while wearing the same soiled gloves. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Administrator) and Staff 2 (Corporate RN) on 06/01/23. They acknowledged the findings.

The system will be corrected by the administrator completing the four hour course of "Infection Control Specialist" within the next 30 days. Staff re-training was done by the RN and all staff were assigned an additional training module on universal precautions while providing resident care. Admin Infection Control Course will be completed online through Oregon Care Partners for Faciltity to be in compliance with  infection provention and control protocols. 2) Monthly audits will be conducted for staff to assure that staff are consistently use universal precautions while providing resident care. Admin or RCC will complete monthly audit tool to assue staff are in compliance with infection control protocols. This be evaluated each month by BOM auditing employee files for compliance. BOM and Administrator will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 direct care staff (#s 14 and 15) had documented evidence of First Aid certification training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 05/31/23. Staff 14 (CG) hired 03/20/23 and Staff 15 (CG) hired 04/11/23 lacked documented evidence they had completed First Aid certification training within 30 days of hire. The need for staff to complete all required training within 30 days of hire was discussed with Staff 1 (Administrator) on 06/01/23 at 10:15 am. She acknowledged the findings.

All staff charts will be audited to determine that First Aid/Abdominal thrust training has been completed.  BOM and Admin will audit all new employee training at the end of each month to verify they have their training completed. Administrator and BOM will audit new hire charts for compliance at the end of each month. This will be evaluated monthly for all new staff. The BOM and Administrator will be responsible to see that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C295 and C372.

This is a referral tag.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired staff (#s 12, 13, 14 and 15) completed all orientation training, 2 of 3 sampled direct care staff (#s 14 and 15) demonstrated competency in the required topics within 30 days of hire and 2 of 3 sampled direct care staff (#s 5 and 7) completed a minimum of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to: Staff training records were reviewed on 05/31/23. Staff 12 (Receptionist) was hired 02/06/23, Staff 13 (CG) was hired 02/21/23, Staff 14 (CG) was hired 03/20/23 and Staff 15 (CG) was hired 04/11/23. The following were identified: 1. There was no documented evidence Staff 12, Staff 13, Staff 14, and Staff 15 completed the required pre-service Infectious Disease Prevention training. 2. There was no documented evidence Staff 14 and Staff 15 demonstrated competency in the following areas within 30 days of hire: * Role of service plan; * Providing assist with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. 3. The following were identified related to annual in-service training: * Staff 5 (CG) was hired 09/17/19. For the annual period from 10/01/21 through 09/30/22, Staff 5 completed 2.5 hours of the required six hours of in-service training on topics related to dementia. * Staff 7 (CG) was hired 02/21/21. For the annual period from 03/01/22 through 02/28/23, Staff 7 completed 3.0 hours of the required six hours of in-service training on topics related to dementia and a total of 12.42 hours of total in-service training. The need to ensure staff completed all required pre-service training, direct care staff demonstrated competency in the required areas within 30 days of hire and staff completed the required annual in-service training was discussed with Staff 1 (Administrator) on 06/01/23. She acknowledged the findings.

Employees that are missing any training will be assigned the correct training and will complete within 30 days. BOM will do a monthy audit of the employee files for new employees to assure compliance. Any staff not completing training will be removed from regular schedule until compliance is met with training. This will be evaluated monthly by BOM or Administrator. The BOM and Administrator will be responsibe to see tht the corrections are completed and monitored.

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 C252, C260, C262 and C270.

This is a referral tag.

The findings of the re-licensure survey, conducted 05/30/23 through 06/01/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the re-licensure survey of 06/01/23, conducted 08/29/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to: The facility's ABST was reviewed on 05/17/23 and discussed with Staff 1 who explained the tool they used is Eldermark. S/He showed CS their acuity tool to determine care staff needed but was unable to demonstrate how the hours were calculated to determine the facility's staffing levels. The tool did not address all 22 ADLs for each resident and the amount of staff time needed to provide care. In an interview on 05/17/23 at 10:45am, Staff 1 explained the facility staffing per shift, stating that there are two wings of the building. On day and swing shift there are six CG with three on each side of the building and one shared MT. On NOC shift there are two CG, one on each side of the building and one shared MT. Staff 1 stated that the facility has 13 residents who require the assistance of two staff persons for transfers. CS observed the posted staffing plan to have been created on 12/20/22. The posted staffing plan indicated that for day and swing shift to schedule three-to-four CG and one MT. On NOC shift there is one CG, one MT, and one universal worker. The facility failed to implement and update an acuity-based staffing tool that addressed all the 22 activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care and, as a result, the facility's acuity-based staffing tool does not reflect the correct care time for each resident. On 05/17/23, the findings were reviewed with and acknowledged by Staff 1 (Executive Director). Verbal plan of correction: Not provided.

The findings of the on-site investigation, conducted 05/17/2023 through 05/17/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse Notes on Abbreviations: - The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. - Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate. - Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. - If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.