The Rawlin at Riverbend

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.

Based on interview and record review, it was determined the facility failed to immediately notify the local Senior and People with Disabilities (SPD) office when an incident of abuse, or suspected abuse, occurred, failed to report physical injuries of unknown cause to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, and failed to promptly investigate incidents for 3 of 3 sampled residents (#s 1, 2 and 6). Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 08/2024 with diagnoses including dementia and Parkinson’s disease. The resident's 01/15/25 through 04/15/25 progress notes, temporary service plans, outside provider notes, incident reports and incident investigations were reviewed, and interviews with staff were conducted. The following incidents were identified: *04/01/25: Resident was found on the floor with an injury to the right side of his/her head, left knee, and right upper arm. *04/10/25: At approximately 4:00 am the resident was found on the floor of his/her bedroom with a laceration to his/her right elbow. *04/10/25: A visiting hospice provider documented bandaging a right hip wound. There was no previous documentation as to the cause of the wound. *04/10/25: At approximately 10:40 pm the resident was found on the floor of his/her room with a laceration to his/her head. *04/14/25: The resident was found on the floor of his/her bedroom and had a left elbow wound which required treatment. There was no documented evidence the incidents of abuse, or suspected abuse, were immediately reported to the local SPD office or that the injuries of unknown cause were immediately investigated and abuse ruled out. The survey team requested that the above incidents be reported to the local SPD office immediately, and confirmation of reporting was provided by 5:48 pm on 04/17/25. The need to ensure abuse or suspected abuse was immediately reported to the local SPD office, and all injuries of unknown cause were immediately reported to the local SPD office, unless an immediate investigation reasonably concluded that the injury was not the result of abuse, was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 10/2022 with diagnoses including severe vascular dementia with mood disturbance, dissociative personality disorder, and history of traumatic brain injury. The resident’s current service plan, progress notes from 01/15/25 through 04/15/25, temporary service plans, and incidents were reviewed. Interviews with staff were conducted. The following was identified: * Resident 1 had five resident-to-resident altercations on: - 02/08/25 at 2:00 pm and another at 4:00 pm; - 02/12/25; and - 03/01/25 at 7:13 pm and another at 7:30 pm. * All of these resident-to-resident altercations were reported to the local Seniors & People with Disabilities (SPD) office two days after the events. * Investigations for the five altercations were conducted between two and five days following the incidents. In interview on 04/17/25 at 1:50 pm, Staff 1 (ED) reported she did sometimes call in reports of resident-to-resident altercations within 24 hours of the incident, especially if they occurred on a weekend, but didn’t email SPD until the next business day. The need to report incidents of abuse or suspected abuse to SPD immediately and to investigate incidents promptly was discussed with Staff 1 and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia. During the survey the resident was observed to be a one-person full assist for all mobility and ADL tasks. Interviews with staff, and review of the resident's 01/09/25 service plan and available temporary service plans, progress notes, and incident investigations from 01/19/25 through 04/15/25, were completed. The following was identified: * 1/19/25 - Bruise to left wrist found, measured approximately 2 inches long by 1 inch wide. During an interview with Staff 2 (RN) on 04/16/25 at 11:49 am. she reported there was no incident investigation completed to rule out abuse for the injury of unknown cause, and the incident had not been reported to the local SPD office. The need to ensure all injuries of unknown cause were immediately reported to the local SPD office unless an immediate investigation reasonably concluded that the injury was not the result of abuse was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. The facility was instructed to report the injury of unknown cause to the local SPD office on 04/16/25. Documentation of reporting requested was received from the facility by 4:00 pm.

1. All incidents listed in the SOD regarding residents #1, 2 & 6 were followed up on and reported to the local APS office upon education from the survey team. 2. When an incident is reported to APS, whether it is via phone call or email, the person doing the reporting will make a progress note in the resident chart to show what action has been taken. 3. ED and clinical leadership will review IR’s and incidents that need to be reported daily. 4. ED/LN/RCC’s

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.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

Based on observation, interview, and record review, it was determined the facility failed to ensure the evaluation described the resident's physical health status, mental status, and the environmental factors that helped the individual function at their optimal level, including data relevant to the residents' needs and current condition, and that move-in evaluations included all required elements, for 5 of 7 residents (#1, 4, 5, 6, and 7) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia and congestive heart failure. The resident’s most recent evaluation, dated 04/01/25, was reviewed. The quarterly evaluation was not relevant to the needs and current condition of the resident in the following areas: * Customary routines, dining location; * Recent medical concerns and hospitalizations; * Location of side rails; * Safety checks; * Strategies to reduce pressure on coccyx; and * Repetitive behaviors including skin picking. The need to ensure the evaluation described the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level, including data relevant to the residents' needs and current condition, was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 08/2024 with diagnoses including dementia and Parkinson’s disease. The resident’s most recent evaluation, dated 03/14/25, was reviewed. The quarterly evaluation was not relevant to the needs and current condition of the resident in the following areas: * Customary routines including dining; * Assistance required to attend meals, walk, and get in and out of bed; * Recent medical concerns and hospitalizations; * Chewing and swallowing difficulties; * Assistance required with eating; * Fall interventions; * Wandering outside; and * Behaviors including aggression toward family and staff. The need to ensure the evaluation described the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level, including data relevant to the residents' needs and current condition, was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 3. Resident 7 moved into the facility in 03/2025 with a diagnosis of dementia. The resident’s move-in evaluation dated 03/09/25 was reviewed and failed to address the following required elements: * Interests, hobbies, social, and leisure activities; * Mental health issues, including presence of depression, thought disorders or behavioral or mood problems; history of treatment, and effective non-drug interventions; * Personality, including how the person copes with change or challenging situations; * Activities of daily living, including use of wheelchair; * Pain, including non-pharmaceutical interventions and how a person expresses pain or discomfort; and * Nutrition habits and fluid preferences. The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 07/2024 with diagnoses including vascular dementia and diabetes. Review of the resident's quarterly evaluation, dated 04/08/25, progress notes, observations of the resident, and staff interviews were conducted, which revealed the most recent evaluation did not address all required elements to reflect the current needs and condition of the resident, to include the following: * Diet; * Skin condition; and * Treatments. The need to complete quarterly evaluations that addressed all required elements to reflect the needs and current condition of the resident was discussed with Staff 2 (RN) on 04/16/25, and Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. 5. Resident 1 was admitted to the facility in 10/2022 with diagnoses including severe vascular dementia with mood disturbance, dissociative personality disorder, and history of traumatic brain injury. Resident 1’s quarterly evaluation, dated 03/25/25, and his/her current service plan were reviewed, and staff were interviewed. The evaluation was not reflective of the resident’s current status and care needs in the following areas: * Smoking status; and * Shower assistance required. On 04/17/25, the need for evaluations to reflect the needs and current condition of residents was discussed with Staff 1 (ED) and Staff 3 (RCC). They acknowledged the findings.

1. Residents #1,4,5,6 & 7 all had discrepancies from the evaluation to service plan to reality of care being given. RN updated evaluations to reflect the current resident status and needs. This flowed through to corrections on the service plan. 2. Assessments will be done thoroughly and will include input from the floor staff as they are the ones who work closest with the residents. After the assessment is completed, the service plan will be updated as well to reflect current needs. 3. Upon admission, 30-days after admission, quarterly and as needed with change of condition. 4. ED/LN/RCC’s

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

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.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans reflected residents’ needs as identified in their evaluations and/or lacked clear directions to staff for 5 of 7 residents (#s 1, 2, 5, 6, and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2022 with diagnoses including severe vascular dementia with mood disturbance, dissociative personality disorder, and history of traumatic brain injury. The resident’s current service plan was reviewed, and staff were interviewed. The service plan was not reflective of the resident’s current needs in the following areas: * Smoking status; and * Shower assistance needed. The need for service plans to accurately reflect the residents’ needs was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia and congestive heart failure. The resident's current service plan available to staff, dated 04/01/25, and 01/15/25 through 04/15/25 progress notes and temporary service plans were reviewed, interviews with staff were conducted, and observations of the resident were completed. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas: * Location of side rails; * Frequency of safety checks; * Assist with evening toileting; * Pain and non-pharmacological interventions; * Oxygen use; * Hospice responsibilities; * Signs and symptoms to monitor for related to diagnoses including congestive heart failure and hyperglycemia; * Hearing; and * Repetitive skin picking. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 08/2024 with diagnoses including dementia and Parkinson’s disease. The resident's current service plan available to staff, dated 03/14/25, and 01/15/25 through 04/15/25 progress notes and temporary service plans were reviewed, interviews with staff were conducted, and observations of the resident were completed. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas: * Assistance provided by staff, hospice, and private caregiver; * Ability to use call light, swallow medications whole, ambulate, and transfer; * Assistance required with evacuation; * Assistance required with toileting; * Fall risk and fall interventions; * Pain; * Skin concerns; and * Behaviors including aggression toward family and staff. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 4. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 01/09/25, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Ambulation ability; * Pressure reducing cushion in recliner; * Air mattress on bed; * Back pain, non-drug interventions; * Straw in drinks; * Specific instructions for positioning using pillows in recliner and bed; and * Transfers. The need to ensure resident service plans were reflective of current care needs, were consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. Staff 3 updated the service plan to address the identified areas on 04/17/25. 5. Resident 7 moved into the facility in 03/2025 with a diagnosis of dementia. The resident's clinical record, including the service plan, dated 03/11/25, progress notes, dated 03/12/25 through 04/15/25, and temporary service plans were reviewed. Resident 7 was observed, and staff were interviewed. The service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Food and beverage preferences; * Weight loss including interventions to prevent further loss; * Level of assistance with use of wheelchair; * Behaviors and interventions; * Falls and current interventions; and * Level of assistance needed for ADLs, including toileting and incontinent care. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings.

1. There will be a complete audit of all service plans for the items in the OARS. Regarding residents #1,2,5,6 & 7- service plans will be revised to include the following information: #1- Smoking status and shower assistance needed #5- Location of side rails; Frequency of safety checks; Assist with evening toileting; Pain and non-pharmacological interventions; Oxygen use; Hospice responsibilities; Signs and symptoms to monitor for related to diagnoses including congestive heart failure and hyperglycemia; Hearing; and Repetitive skin picking. #6- Assistance provided by staff, hospice, and private caregiver; Ability to use call light, swallow medications whole, ambulate, and transfer; Assistance required with evacuation; Assistance required with toileting; Fall risk and fall interventions; Pain; Skin concerns; and Behaviors including aggression toward family and staff. #2- Ambulation ability; Pressure reducing cushion in recliner; Air mattress on bed; Back pain, non-drug interventions; Straw in drinks; Specific instructions for positioning using pillows in recliner and bed; and Transfers. #7- Food and beverage preferences; Weight loss including interventions to prevent further loss; Level of assistance with use of wheelchair; Behaviors and interventions; Falls and current interventions; and Level of assistance needed for ADLs, including toileting and incontinent care. 2. An outline of OAR specific details that are required for service plans will be provided to the RCC's for their reference with an emphasis on including all resident specific details that are important for care staff to provide person-centered care. During the 90 day period between service plan updates, we will be requiring the service plan to be revised if there are several updates or a change of condition, rather than just TSP updates. 3. LN will alert RCC's to official changes of condition as they occur. Service plans will be updated quarterly and as needed. 4. LN and ED will be responsible to ensure the corrections are kept up to date and completed.

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.

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.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific interventions were determined and documented, actions or interventions were communicated to staff on each shift, and the condition was monitored with progress noted at least weekly until resolution for 4 of 6 sampled residents (#s 1, 2, 5, and 6) who experienced short-term changes of conditions. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia. Observations of Resident 2, interviews with staff, and review of the resident's 01/09/25 service plan, 01/19/25 through 04/15/25 temporary service plans, progress notes, and incident investigations were conducted. The following was revealed: * 01/19/25 - Bruising to left wrist approximately 2 inches long by 1 inch wide; and * 02/11/25 – Emergency room transport for sudden leaning over in wheelchair, drooling, unable to move arms or legs. There was no documented evidence for the above short-term changes of condition that the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined actions or interventions to staff, and/or documented weekly progress until the condition resolved. The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and changes of condition were monitored with weekly progress noted through resolution was discussed with Staff 2 (RN) on 04/16/25, and Staff 1 (ED), and Staff 3 (RCC) on 04/17/25. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia and congestive heart failure. The resident's most recent evaluation and current service plan available to staff, dated 04/01/25, and 01/15/25 through 04/15/25 progress notes, outside provider notes, and temporary service plans were reviewed, interviews with staff were conducted, and observations of the resident were completed. 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/or monitoring at least weekly through resolution: * 01/22/25 – Coughing; * 02/14/25 – New medications, prednisone and senna; * 02/24/25 – Scratches on L arm; * 03/13/25 – Urinary tract infection and new medication nitrofurantoin; * 03/13/25 – New instructions for sacral wound dressing; * 04/14/25 – Diarrhea; and * Ongoing – Skin picking and open areas on arms. The need to ensure the facility determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 08/2024 with diagnoses including dementia and Parkinson’s disease. The resident's most recent evaluation and current service plan available to staff, dated 03/14/25, and 01/15/25 through 04/15/25 progress notes, outside provider notes, and temporary service plans were reviewed, interviews with staff were conducted, and observations of the resident were completed. 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/or monitoring at least weekly through resolution: * 01/21/25 - Increased aggression including “screaming into people’s faces and going into their rooms pacing back and forth”; * 01/27/25 – Eating with his/her hands; * 02/08/25 – Assistance required with eating; * 02/13/25 - Aggression with staff; * 03/18/25 – Loose stool; * 03/22/25 – New instructions from hospice to track bowel movements; * 04/01/25 – Skin injuries to right side of head, left knee, and right arm; * 04/09/25 – Altercation with private caregiver; * 04/10/25 – Skin injury to right elbow; * 04/10/25 – Abrasion to right hip; and * 04/10/25 – Laceration to right eyebrow. The need to ensure the facility determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 12:55 pm. They acknowledged the findings. 4. Resident 1 was admitted to the facility in 10/2022 with diagnoses including severe vascular dementia with mood disturbance, dissociative personality disorder, and history of traumatic brain injury. The resident’s progress notes from 01/15/25 through 04/15/25 were reviewed, as well as temporary service plans and incident reports. The following was identified: * Resident 1 was involved in resident-to-resident altercations on: - 02/08/25 at 2:00 pm and another at 4:00 pm; and - 03/01/25 at 7:13 pm. There was no documented evidence actions or interventions were determined, the determined interventions were communicated to staff on each shift, or that the interventions were monitored for effectiveness at least weekly through resolution for the resident-to-resident altercations. The need to determine actions or interventions for changes of condition, communicate those interventions to staff on all shifts, and to monitor the interventions for effectiveness, with progress noted at least weekly through resolution, was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25 at 1:50 pm. They acknowledged the findings. No additional information was provided.

1. Regarding residents #1,2, 5 & 6 and the monitoring of their changes of condition. #2- referencing bruising and information for a trip to the hospital. LN will educate Med Tech’s to not only progress note, but to also convey directly to LN/ED to allow for follow through on provisions of care. #5- referencing new medications, skin conditions, loose bowel movements. LN will document what action or interventions are needed for short-term changes of condition, how these interventions are communicated to staff on all shifts and monitor the short-term changes of condition at least weekly through resolution. #6- referencing his aggression, need for feed assistance, loose stool and skin injuries. LN will document what action or interventions are needed for short-term changes of condition, how these interventions are communicated to staff on all shifts and monitor the short-term changes of condition at least weekly through resolution. #1- referencing resident to resident altercations. LN will document what interventions that have worked in the past and what new interventions should be in place, then ensure staff on all shifts are communicated to regarding these interventions. LN will monitor at least weekly on effectiveness of interventions. 2. Before removing residents from alert-charting, sufficient evaluations need to be completed to ensure the interventions are effective. LN will progress note her findings of evaluation for Med Techs, RCC's and ED. 3. Alert charting monitored daily by LN or RCC. 4. LN/ED

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.

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 they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual care plan and service plan for 5 of 7 sampled residents (#s 1, 2, 4, 5, and 6) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to: The facility's ABST was reviewed during the survey, 04/15/25 through 04/17/25. Review of Residents 1, 2, 4, 5, and 6’s ABST revealed multiple ADLs were not reflective of the residents' evaluated care needs. The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 04/17/25. They acknowledged the findings.

1. Regarding the times entered on the ABST for ADLs being incorrect based on observation from the survey team. Times for residents #1,2,4,5 & 6 were not reflective of their individual needs. When change of condition or any assessment is done for a resident, the ABST will be updated to accurately reflect the time need to care for the resident. 2. LN/ED’s had training on ABST best practices and individual areas of concern on 4.30.25. There will be a form for care staff to accurately communicate times needed for ADL’s. This will be used as a resource during the resident’s assessments and service planning as well. LN will reflect any changes of condition as needed in the ABST. 3. This will be evaluated during a change of condition, quarterly or as needed with medication changes. 4. LN/ED/RCC’s

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 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 C231.

Refer to C231

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 C252, C260, C270 and C362.

Refer to C252, C260, C270 and C362

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

2. Resident 3 was admitted to the facility in 01/2023 with diagnoses including dementia and was receiving hospice services. Interviews with staff and observations identified Resident 3 had a fall mat under the bed. Staff indicated the mat was used while Resident 3 was in bed. Resident 3's current service plan, dated 03/23/24, did not provide clear direction regarding the use of the fall mat. The need to ensure service plans included clear instruction to staff for the delivery of care was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/03/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current status and care needs, and provided clear direction to staff regarding the delivery of services for 3 of  5 sampled residents (#s 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 02/2023 with diagnoses including Alzheimer's Disease, hypothyroidism, and heart failure. The resident's service plan, dated 01/11/24, was not reflective of the resident's current needs, or did not provide clear direction to staff in the following areas: * Assistance needed for activities; * Nutrition/ hydration, and eating assistance; * Side rails on bed; * Safety checks; and * Fall interventions. On 04/03/24, the need to ensure service plans were reflective of current status and provided clear directions for staff was discussed with Staff 1 (ED). She acknowledged the findings. 3. Resident 2 was admitted to the facility in 10/2022 with diagnoses including dementia with behavioral disturbance, pain, and hypertension. S/he was subsequently admitted to hospice in 4/2024 with admitting diagnosis of Alzheimer's disease with behavioral disturbance. Observation of care from 04/01/24 through 04/04/24, interviews with facility staff, and review of the current service plan, dated 03/19/24, revealed Resident 2's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Physician orders for life sustaining treatment status; * Number of staff needed to assist with grooming and eating; * Mobility equipment precautions and instructions for proper maintenance; * Skin integrity and instructions on skin care; * Instructions for signs and symptoms of infection to report when providing skin care; * Non-pharmaceutical interventions for pain, including how the resident expressed pain or discomfort; * Nutrition habits and fluid preferences; * Instructions on edema management; * Instructions on fall prevention; * Instructions on weight management; and * Social and leisure activities. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/04/24. They acknowledged the findings. No further information was provided.

1. Resident #5- Service plan will be updated with the following details: -Thorough life story details and current activity interests listed as well as detailed assistance measures to ensure safe participation in activites program. -Specified nutrition/hydration plan with preferences and scheduling expectations -Update level of assistance needed for meals- specifying when he's eating in the dining room vs. his apartment -Added side-rails on DME listing and their purpose for his bed mobility needs. -Clear parameters listed for safety check timing and observations needed -Fall interventions that are specified for resident #5 are listed. Resident #3- Service plan will be updated with the following details: -Fall mat listed on DME and instructions given to staff for delivery of care. Resident #2- Service plan will be updated with the following details: -POLST information verified and cross-referenced/updated on service plan. -Dining level of assistance detailed -Grooming level of assistance detailed -DME listed updated with precautions and instructions for proper maintenance. -Instructions on skin care and what to alert med-techs/management on. -When to report signs/symptoms of infection -Non-Pharm interventions for pain and how the resident expresses pain. -Specified nutrition/hydration plan with preferences and scheduling expectations. -Instructions on edema management -Fall prevention plan and detail -Monitoring for monthly weights and if any significent changes appear -Thorough life story details and current activity interests listed as well as detailed assistance measures to ensure safe participation in activities program. 2. After correcting these current residents listed, our internal guidelines with service plans will reflect the detail expecations given to use in this SOD moving forward. Each area will be given sufficent time and effort in providing the detail that will best support our care given. Service plans will be reviewed by RN or Administrator upon completion for support. 3. Evaluation of the details in Service Plans will be done upon significant change, new admit, quarterly and as needed. 4. Licensed nurse and/or ED during quarterly updates.

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 preferences and/or provided clear direction regarding the delivery of services for 4 of 4 sampled residents (#s 6, 7, 8, and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the facility in 04/2018 and had diagnoses including Alzheimer's Disease and rheumatoid arthritis. Observations of the resident, interviews with staff, review of temporary service plans, progress notes, and incident reports from 06/13/24 through 09/16/24, and review of the service plan, dated 08/13/24, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Fall risk; * Ability to communicate; * Ability to use call system; * Pain, to include location and non-pharmacological interventions; * Toileting assistance as needed, including instructions; * Dressing, grooming, and hygiene assistance; * Bathing; * Resistance to ADL cares with instructions; and * Use of eye glasses. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. The staff acknowledged the findings. 2. Resident 9 was admitted to the facility in 07/2023 with diagnoses including vascular dementia. Observations of the resident, interviews with staff, review of temporary service plans, progress notes, and incident reports from 06/13/24 through 09/16/24, and review of the service plan, dated 08/01/24, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * One- to two-person assist with dressing, grooming, hygiene, and bathing; * Resistance to ADL cares with instructions for staff; * Sleep area of preference; * Communication; * Staff to anticipate needs; and * Ability to use call system. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. The staff acknowledged the findings. 3. Resident 6 was admitted to the MCC in 07/2023 with diagnoses including Alzheimer's disease. Review of the resident's current service plan, updated 09/12/24, and interviews with staff revealed it was not reflective and/or did not provide clear direction to staff in the following areas: * Recent fall history; * Ability to use the call light; and * Hearing aid care. The need to ensure resident service plans were reflective of residents' current status and care needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings. 4. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia. Review of the resident's current service plan, updated 06/08/24, and interviews with staff revealed it was not reflective of the resident's current status and care needs in the following areas: * Fall history; and * Ability to use the call light. The need for service plans to be reflective of residents' current status and care needs and provide clear direction to staff regarding the delivery of services was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

1. There will be a complete audit of all service plans for the items in the OARS. Regarding resident #8, #9, #6 and #7- service plans will be revised to include the following information: #8- fall risk, ability to communicate; ability to use call system; her pain (including location and non-pharmological interventions); toileting assistance as needed, including instructions; dressing, grooming and hygiene assistance; bathing; resistance to ADL cares with instructions; use of eye glasses. #9- their one- or two-person assist with dressing, grooming, hygiene and bathing; resistance to ADL cares with instructions for staff; sleep area of preference; communication; staff to anticipate needs; ability to use call-system. #6- recent fall history; ability to use the call-light; hearing aid care #7- resident passed away on 9/23/24 2. An outline of OAR specific details that are required for service plans will be provided to the RCC's for their reference with an emphasis on including all resident specific details that are important for care staff to provide person-centered care. During the 90 day period between service plan updates, we will be requiring the service plan to be revised if there are several updates or a change of condition, rather than just TSP updates. 3. LN will alert RCC's to official changes of condition as they occur. Service plans will be updated quarterly or as needed. 4. LN and ED will be responsible to ensure the corrections are kept up to date and completed.

Based on interview and record review, it was determined the facility failed to monitor resident injuries with weekly progress noted until the condition resolved, for 2 of 3 sampled residents (#s 1 and 4) with skin wounds. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia. The resident's record was reviewed and interviews were conducted with the resident and staff during the survey. On 02/09/24 a facility Progress Note indicated "Resident has a very small cut on [his/her] right hand. The cut is about less than a [centimeters] long in the shape of a C..." A Temporary Service Plan dated 02/09/24 was created for the injury and noted "Inner wrist right hand. About 2 cm long in the  shape of the letter C." There was no documented evidence the injury was evaluated to determine the accurate size. There was no documented evidence the injury had been monitored weekly to resolution. The need to ensure the changes in condition were evaluated and monitored with weekly progress noted until the condition was determined to be resolved was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings. 2. Resident 1 moved into the facility in 10/2022 with diagnoses including dementia. The resident's clinical record was reviewed and interviews were conducted with the resident and care staff during the survey. A review of progress notes indicated the following: a. 01/30/24: "no pain from skin tear, no signs of infection, skin tear not bleeding..." A temporary service plan (TSP) dated 01/29/24 documented "3 cm long skin tear on left shoulder. Ask PRN for pain pill if needed." There was no further documentation the skin tear had been monitored with weekly progress noted until the condition resolved. b. 03/14/24: "on alert for picking sites on both upper arms..." and on 03/16/24, "sores are present but not actively bleeding..." A TSP dated 03/12/24 documented "skin tear, abrasion, picking sites to both upper arms. Staff was instructed to "encourage to apply lotion or ointment. Apply lotion after shower or when needed." The record lacked documentation the wounds had been monitored with weekly progress noted until the condition resolved. The need to ensure the short term changes in condition were monitored with weekly progress noted until the conditions were resolved was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/04/24. They acknowledged the findings.

1. Regarding #4 -IR and APS self-report completed on 4/2/24 Regarding #1 -IR completed on 1/29/24. Abuse/neglect ruled out as resident had been able to tell what had happened. 2. Med-tech meeting on 4/10/24. There was significant discussion and education on placing residents on alert and notifying nurse in addition to progress noting new findings or skin concerns. 3. Alert charting monitored daily by LN or RCC. 4. LN & ED

3. Resident 8 was admitted to the facility in 04/2018 with diagnoses including Alzheimer's disease and rheumatoid arthritis. The resident's clinical record, including progress notes, dated 06/03/24 through 09/16/24, and incident reports were reviewed, and interviews with staff were conducted. The following was identified: * 07/03/24 - Fall with bump and bruising to forehead. Intervention implemented was safety checks eight times a shift or as often as possible; and * 08/25/24 - Fall with head strike with hematoma and bleeding from left side of the forehead. The intervention implemented was to increase safety checks to six times a shift. There was no documented evidence the interventions in place after the resident's 07/03/24 fall were evaluated for effectiveness and determined if further actions/interventions were indicated. In addition, the following was identified: * 07/06/34 - Resident-to-resident altercation. The intervention implemented was to redirect Resident 8 when near rooms close to the other resident involved; and * 08/13/24 - Resident-to-resident altercation with the same unsampled resident. Interventions implemented were to re-direct Resident 8 from entering the involved resident's room and offer snacks and/or drinks to decrease agitation. There was no documented evidence the intervention in place after the resident's 08/13/24 altercation was evaluated for effectiveness. The need to monitor determined actions or interventions for effectiveness and determine new interventions if they were not effective was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure actions and interventions were determined and monitored for effectiveness for all short-term changes of condition for 3 of 4 sampled residents (#s 6, 7, and 8) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia. The resident's 06/19/24 through 09/16/24 progress notes, temporary service plans, incident reports, investigations, and current service plan were reviewed, and interviews were conducted. The following was identified: * 07/08/24 - Resident 7 fell and interventions were implemented, including performing safety checks and anticipating needs, toileting schedule, and habits; and * 09/06/24 - The resident experienced another fall and no new interventions were implemented. There was no documented evidence the interventions implemented after the resident's 07/08/24 fall were evaluated for effectiveness or that new interventions were determined and implemented after his/her fall on  09/06/24. The need to monitor determined actions or interventions for effectiveness and determine new interventions if they were not effective was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings. 2. Resident 6 was admitted to the MCC in 07/2023 with diagnoses including Alzheimer's disease. The resident's 06/21/24 through 09/16/24 progress notes, temporary service plans, incident reports, investigations, and current service plan were reviewed, and interviews were conducted. The following was identified: * 08/18/24 - The resident experienced a non-injury fall. The interventions listed on the investigation were for ". . . staff to increase toileting rounds to 6 times a shift and ask [the resident] if [s/he] needs anything before leaving [his/her] apartment." These interventions were on the service plan with an effective date of 07/15/23. There was no documented evidence previous interventions were evaluated for effectiveness or new interventions were determined and implemented after the resident's 08/18/24 fall. The need to monitor determined actions or interventions for effectiveness and determine new interventions if they were not effective was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

1. Regarding residents #7, #6, #8 and the monitoring of their changes of condition. #7- resident passed away on 9/23/24. #6- referencing falls: LN will evaluate the interventions in place for effectiveness and determine whether new interventions are needed. #8- referencing falls and res to res altercations: LN will evaluate the interventions in place for effectiveness and determine whether new interventions are needed. 2. Before removing residents from alert-charting, sufficient evaluations need to be completed to ensure the interventions are effective. LN will progress note her findings of evaluation for Med Techs, RCC's and ED. We will also hold a Med Tech meeting where the focus will be on change of condition and the role the Med Tech's communication to the LN and RCC's plays. 3. Alert charting monitored daily by LN or RCC. 4. LN & ED

Based on interview and record review, it was determined the facility failed to ensure physicians orders were carried out as prescribed for 3 of 5 sampled residents (#s 2, 4, and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia and high blood pressure. Resident 4's MARs for 03/01/24 and physician's orders were reviewed. Resident 4 had physician's orders for Metoprolol Tartrate 25 mg twice daily, to be held for systolic blood pressure less than 100. Resident 4's systolic blood pressure was documented to be below 100 in the morning on March 5th and 9th, and below 100 in the afternoon on March 9th and 19th. The Metoprolol Tartrate was not held as ordered. The need to ensure physician's orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (RN). They Acknowledged the findings. 2. Resident 5 was admitted to the facility in 02/2023, with diagnoses including Alzheimer's Disease, heart failure, and atrial fibrillation. Review of Resident 5's MAR, dated 03/01/24 through 04/01/24, and physician orders, dated 03/25/24, identified the following deficiencies: There was an order for monthly vital signs, which included instructions to "Fax primary care provider and RN if: blood pressure top number is greater than 140 or less than 100, if blood pressure bottom number is greater than 90". On 03/01/24, the monthly blood pressure was recorded as 147/96, indicating both values were above the acceptable range. There was no documented evidence the physician was informed the blood pressure values were above the acceptable parameters. On 04/03/24, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED). She acknowledged the findings. 3. Resident 2 was admitted to the facility in 10/2022 with diagnoses including dementia with behavioral disturbance, pain, and hypertension. S/he was subsequently admitted to hospice in 4/2024 with admitting diagnosis of Alzheimer's disease with behavioral disturbance. Resident 2's current physician orders and MARs from 03/01/24 through 04/01/24 were reviewed. Interviews with facility staff were conducted. The following was revealed: * Hospice admission orders contained instructions to administer hydromorphone 10 mg/ml oral solution every hour as needed for pain. However, there was no documented evidence the order was included in the MAR, or the medication was administered as ordered; and * Hydromorphone 20mg was ordered to be administered one tablet every hour as needed for "moderate-severe pain, dyspnea." The resident also had a concurrent order for oxycodone 5 mg to be administered every hour as needed for pain with a instructions to "give oxycodone before giving hydromorphone for pain." The MAR indicated hydromorphone was administered prior to oxycodone on 03/20/24, 03/25/24, and 03/26/24. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/04/24. They acknowledged the findings. No further information was provided.

1. Regarding #4 -Med error IR completed and reported to APS Regarding #5 -Education was given to staff on 4/11/24 regarding the importance of monthly vitals and the communication that is expected moving forward. Regarding #2 -Medications have been reviewed and the med listed has been discontinued on 3/27/24. 2. #4-Med-tech meeting on 4/10/24 reviewed/educated staff on following hold parameters. #5-Med-tech's educated on 4/11/24 to notify providers after monthly vitals if BP readings are outside of paramenters noted in MAR. #2-LN or RCC to review orders during hospice admit to ensure no duplicates of narcotics or other meds. 3. #4- #5-Monthly #2- Upon hospice admission and as needed 4. #4- LN & ED #5- LN & ED #2- LN & ED

Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 2 of 4 sampled residents (#s 6 and 7) whose MAR and physician orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the MCC in 07/2023 with diagnoses including Alzheimer's disease. A review of the resident's 09/01/24 through 09/16/24 MAR and current signed physician orders revealed the following: The resident had a signed physician order for mirtazapine 15 mg, one tab nightly, effective 08/28/24, which was an increase of his/her previous dose of 7.5 mg nightly. The MAR indicated the following: * 09/01/24 - resident refused; * 09/02/24 - med not available; * 09/05/24 - resident refused; and * 09/08/24 - resident refused. On 09/03/24, 09/04/24, 09/06/24, 09/07/24, and 09/09/24 through 09/13/24 the MAR indicates the medication was administered. On 09/15/24 a MT noted on the MAR that the "wrong dosage" was in the medication cart. In an interview on 09/17/24 at 12:50 pm, Staff 2 (RN) reported she was not sure what dosage was actually administered to the resident. She stated she would investigate the matter further. At 1:21 pm the same day, Staff 2 reported she had looked at the resident's mirtazapine medication card and the MAR. She stated it appeared the resident was administered 7.5 mg on some days and 15 mg on other days, but she wasn't able to determine when the incorrect dose of 7.5 mg was administered versus the correct dose of 15 mg. Staff 2 reported she would create an incident report for a medication error. A copy of the incident report was provided on 09/18/24. There was no documented evidence the resident received the prescribed dose of 15 mg of mirtazapine each night. The need to ensure physician orders were carried out as written was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings. 2. Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia. The resident's 09/01/24 through 09/16/24 MAR, physician orders, and 06/19/24 through 09/16/24 progress notes were reviewed. The following was identified: * The resident was admitted to hospice services on 09/09/24. * Resident 7 had an order for haloperidol 0.5 ml every hour as needed for delirium, nausea, and/or vomiting. * The resident also had an order for lorazepam 0.5 mg every hour as needed for anxiety or dyspnea. * A MT documented on 09/14/24 speaking with hospice about the resident being very aggressive during care. The MT wrote, "hospice asked med techs to please utilize PRN's for aggression and agitation. every [sic] 30 mins- 1 hour before [resident] gets [his/her] depend [sic] changed." * The MAR shows that the resident was administered haloperidol five times on 09/14/24 and one time on 09/15/24. Staff documented the reason for administration was "Delirium." In an interview with Staff 2 (RN) on 09/17/24 at 12:57 pm, she reported there was no signed physician order to administer a PRN psychotropic medication to the resident prior to brief changes. She provided documentation of parameters for both the PRN haloperidol and the PRN lorazepam, which did not include administration of either medication prior to providing care to the resident. The need to carry out physician and other legally recognized practitioner orders as written was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

1. Regarding the physician's orders are carried out as written for residents #6 and #7. #6- Med error IR was created and given to survey team. There were no negative affects from this med error. #7- resident passed away 9/23/24. 2. LN spoke with Med Techs that had hands in this situation, individually about the importance of asking questions when they are unsure of dosage or the physician orders. 3. Daily reports on missed or held medications will be reviewed by the RCC's, LN or ED and any concerns will be brought to attention. 4. LN & ED

Based on interview and record review, it was determined the facility failed to ensure resident MARs included specific parameters and instructions for PRN medications, for 4 of 5 sampled residents (#s 2, 3, 4 and 5) whose MARs included multiple PRN medications used to treat the same condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 01/2023 with diagnoses which included dementia and anxiety. Residents 3's orders and 03/01/24 through 04/01/24 MARs were reviewed. Resident 3 had orders for: * Acetaminophen 500 mg as needed for moderate pain; * Morphine Sulfate solution 5 mg as needed for pain; * Buspirone 5 mg as needed for anxiety; and * Lorazepam 0.5 mg as needed for anxiety. There were no resident specific parameters and instructions for which PRN medication to use first. The need to ensure there were clear parameters for unlicensed staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/02/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia. Residents 4's orders and 03/01/24 through 04/01/24 MARs were reviewed. Resident 4 had orders for: * Biofreeze gel 5%, apply to lower back as needed for low back pain; and * Voltaren gel 1%, APPLY 2 grams to lower back as needed for pain. There were no resident specific parameters and instructions for which PRN medication to use first. The need to ensure there were clear parameters for unlicensed staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/02/24. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 02/2023, with diagnoses including Alzheimer's Disease, atrial fibrillation, and heart disease. Review of Resident 5's MAR, dated 03/01/24 through 04/01/24, and physician orders, dated 03/25/24, identified the following deficiencies: a. Resident 5 was prescribed the following PRN medications for constipation: * Bisacodyl 10 mg suppository "daily as needed for constipation"; * Enema (phosphate/saline) "daily as needed for constipation"; * Glycerin adult 2 GM supp (fleet) "daily as needed for constipation; and * Milk of Magnesia 473 mL "daily as needed for constipation. b. Resident 5 was prescribed the following PRN medications for pain: * Acetaminophen 650 mg supp "every four hours as needed for fever or mild pain"; * Diclofenac gel 1% "four times daily as needed for pain"; * Morphine sulfate 20mg/mL "every hour as needed for moderate to severe pain or dyspnea"; * Tramadol HCL 50 mg "every eight hours as needed for moderate or severe pain"; and * Tylenol 325 mg gel caps "every six hours as needed for mild pain". There were no resident-specific parameters for any of the PRN medications listed above, regarding the sequential order of use. On 04/03/24, the need to ensure clear parameters for unlicensed staff, when multiple PRN medications were prescribed for the same condition was discussed with Staff 1 (ED). She acknowledged the findings. 4. Resident 2 was admitted to the facility in 10/2022 with diagnoses including dementia with behavioral disturbance, pain, and hypertension. S/he was subsequently admitted to hospice in 4/2024 with admitting diagnosis of Alzheimer's disease with behavioral disturbance. Resident 2's MAR from 03/01/24 through 04/01/24 and physician orders were reviewed and revealed the following: a. The following PRN medications lacked instructions for sequential order of use:   * Acetaminophen 500 mg (for pain); * Acetaminophen 650 mg suppository (for mild pain); * Hydromorphone 20mg (for moderate-severe pain); and * Oxycodone 5 mg (for pain). b. The following PRN medications lacked resident specific parameters for use: * Haloperidol 20mg/ml (for delirium, nausea and/or vomiting); * Hydromorphone 20mg (for dyspnea); * Lorazepam 20mg/ml (for anxiety, restlessness, shortness of breath); and * Seroquel 25 mg (for anxiety and agitation). The need to ensure MARs were accurate, contained medication specific instructions, and provided resident specific parameters and instructions for PRN medications was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/04/24. They acknowledged the findings. No further information was provided.

1. Regarding #3- Added verbiage for signs of anxiety and we have faxed hospice for request to DC one of the PRN anxiety meds. For the morphine- parameters were added to give for severe pain. #4- Faxed for DC order on one of the PRN back pain meds. RN put parameters for which one to use first. #5- Updated bowel meds with parameters on order of use. Also faxed to DC some of the bowel meds. Orders updated to clarify order of use for pain management meds. Also faxed to DC some of the pain management. #2- Updated MAR with parameters for which order to give PRN pain medications. Added resident specific signs of anxiety/delirium . Faxed to DC one of the anxiety PRN's. 2. LN/RCC will be the only ones approving pending order review in order to ensure all parameters and details are accurately depicted. 3. Orders reviewed quarterly by pharmicist and quarterly when physician orders are faxed. As needed when orders change. 4. LN & ED

Based on interview and record review, it was determined the facility failed to ensure resident MARs included resident-specific parameters and instructions for PRN medications, for 2 of 4 sampled residents (#s 6 and 8) whose MARs included multiple PRN medications used to treat the same condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 04/2018. Residents 8's MARs were reviewed from 09/01/24 through 09/16/24, and the following was noted: * Acetaminophen 500 mg every four hours as needed for mild to moderate pain and/or fever; and * Hydrocodone/APAP 5/325 mg every 12 hours as needed for pain. There were no documented parameters for when to administer the hydrocodone and/or which medication to administer first for pain. The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings. 2. Resident 6 was admitted to the MCC in 07/2023 with diagnoses including Alzheimer's disease. Review of the resident's 09/01/24 through 09/16/24 MAR and physician orders revealed the resident had the following PRN pain medications: * Acetaminophen 325 mg, two tables every four hours as needed for mild pain or fever over 100 degrees; * Acetaminophen 500 mg, one tablet every six hours as needed for mild pain or fever; * Ibuprofen 400 mg, one tablet every eight hours as needed for moderate to severe pain; and * Morphine 20 mg/ml, 0.25 ml (5 mg) every hour as needed for pain or shortness of breath. There were no documented parameters instructing staff in which order to administer the PRN pain medications. The need to ensure all PRN medications had resident-specific parameters and instructions was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), Staff 11 (RCC), and Staff 12 (RCC/LPN) on 09/18/24. They acknowledged the findings.

1. MARs needing revision or added instruction for the following residents: #8 & #6 #8- Parameters were added to MAR for her acetaminophen and hydrocodone. #6- Parameters for all listed pain meds were specified. A DC request (2 times) was made for the duplicate orders of Tylenol. 2. PRN med audits will be completed every week by LN. 3. Every week. 4. LN & ED

2. Resident 3 was admitted to the facility in 01/2023 with diagnoses including dementia and was receiving hospice services. Resident 3's 03/2024 and 02/2024 MARs and orders were reviewed. Resident 3 had orders for Buspirone 5 mg and Lorazepam 0.5 mg, both to be given as needed for anxiety. Written, resident-specific parameters and the specific reasons for the use of the psychotropic medication for Resident 3, how anxiety was expressed, were not documented. The need to ensure clear resident specific reasons for use and parameters were available to guide non-licensed, non-certified staff in the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/02/24 and 04/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all direct care staff administering psychotropic medications knew the specific reasons for the use of the psychotropic medication for that resident, medications had written, resident-specific parameters, and non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 3 of 3 sampled residents (#s 1, 2, and 3) who had received psychotropic medications. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 10/2022 with diagnoses including dementia with behavioral disturbance, pain, and hypertension. S/he was subsequently admitted to hospice in 4/2024 with admitting diagnosis of Alzheimer's disease with behavioral disturbance. Review of Resident 2's clinical record indicated the following: * Resident 2 was prescribed haloperidol 0.5 ml as needed for delirium, nausea, and/or vomiting, and lorazepam 0.25 ml as needed for anxiety, restlessness, and shortness of breath; and * The MAR from 03/01/24 through 04/01/24 indicated staff administered four doses of PRN lorazepam and one dose of PRN haloperidol. There was no documented evidence the staff attempted and documented non-pharmacological interventions with ineffective results prior to administering the medication. The need to ensure non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/04/24. They acknowledged the findings. No further information was provided. 3. Resident 1 moved into the facility in 10/2022 with diagnoses including dementia and had a behavior support plan, dated 11/17/23 that included resident-specific interventions for behaviors. The resident's 03/01/24 to 03/31/24 MAR and physician's orders were reviewed. The following was identified: Resident 1 had an order for PRN Haldol to be administered as needed for agitation. Review of the MAR showed staff administered the medication on two occasions on 03/22/24. There was no documented evidence the PRN medication was used only after documented, non-pharmacological interventions had been tried with ineffective results. The need to ensure non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medications was discussed with Staff 1 (ED) Staff 2 (RN) and Staff 3 (RCC) on 04/04/24. They acknowledged the findings.

1. Regarding resident #2 & #1- Med-tech's instructed to progress note or write a comment in the MAR that prior non-med interventions were ineffective before administering the PRN. #3- Entered in resident's specific signs of anxiety. 2. Training med-tech's to prog note or write a comment in the MAR that prior non-med interventions were ineffective before administering the PRN. 3. RCC's to check daily when they review PRN's given. 4. LN monthly at QAPI review completed with ED.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired direct care staff (#s 7, 8, 9 and 10) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 6 (Business Office Director) on 04/02/24. Staff 7 (CG), hired 12/14/23, Staff 8 (CG), hired on 02/16/24, Staff 9 (CG), hired 02/23/24, and Staff 10 (CG), hired 02/22/24, lacked documented evidence they had completed first aid and abdominal thrust training within 30 days of hire. Staff 6 acknowledged the staff had not been trained in First Aid or abdominal thrust. The need to ensure staff completed the required training within 30 days was reviewed with Staff 1 (ED) on 04/02/24. She acknowledged the findings.

1. Regarding staff #7,8,9,10 Staff members were given the deadline of 4/15/24 to complete their First Aid and abdominal thrust training. 2. All members of staff will have their pre-service/first 30-day training records reviewed by the Business Office Director before they complete their first week of training. 3. Records will be checked before the staff hit the on-the-floor training and verified at their 30-day mark for completion. 4. Business Office Director & ED

Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of facility records on 04/02/24 identified the following deficiencies: There was no documented evidence that annual training on fire safety was provided to residents. On 04/02/24, the need to provide and document fire safety instruction to residents, at least annually, in accordance with the OFC was discussed with Staff 1 (ED). She acknowledged the findings.

1. We will be requiring new residents to be instructed within 24 hrs of admission and re-instructed annually, in general safety procedures. 2. Our Maintenance Director's move-in checklist will include the instruction on general safety procedures. Our MD will have a resident census kept on file with admission dates to give the annual training. Annually, there will be documentation on the completed education. 3. Upon admission and annually thereafter. 4. Maintenance Director & ED

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 372 and C 422.

Refer to C 372 and C 422

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 555.

Refer to C555

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 260, C 270, C 303, C 310 and C 330.

Refer to C 260, C 270, C 303, C 310 and C 330

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. This is a repeat citation. Findings include, but are not limited to: Refer to C 260, C 270, C 303, and C 310.

Refer to C260, C270, C303 and C310

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in service plans for 2 of 5 sampled residents (#s 2 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 02/2023, with diagnoses including Alzheimer's Disease, heart failure, and atrial fibrillation. In an acuity interview on 04/01/24, the resident was identified as needing physical assistance with eating. Review of Resident 5's service plan, dated 01/11/24, observations, and interviews with staff identified the following deficiencies: The dining portion of Resident 5's service plan lacked the following information: * Food and fluid preferences; * Individual needs or adaptations, to allow the resident the greatest independence possible; and * A set process or program, to provide hydration and nutrition to the resident between meals. On 04/03/24, the need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED). She acknowledged the findings. 2. Resident 2 was admitted to the facility in 10/2022 with diagnoses including dementia with behavioral disturbance, pain, and hypertension. S/he was subsequently admitted to hospice in 4/2024 with admitting diagnosis of Alzheimer's disease with behavioral disturbance. Observations of lunch on 04/02/24 and 04/03/24 and breakfast on 04/03/24 and 04/04/24 indicated Resident 2 needed cueing and encouragement from staff with fluid intake. Resident 2's service plan dated 03/19/24 was reviewed. The resident's service plan lacked information regarding a daily program for hydration based upon the resident's preferences and needs. The facility provided snack carts including beverages to residents in the common area who participated in facility activities. Resident 2 was not part of the activities and therefore did not have access to the beverages on the snack carts, nor did facility staff offer any hydration options to the resident during his/her waking hours. The need to provide a daily program for hydration based upon the resident's preferences and needs throughout the resident's waking hours was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/04/24. They acknowledged the findings. No further information was provided.

1. Regarding residents #5, #2- service plan will be updated with food and fluid preferences with processes of implementation and delivery detailed for staff. This will include detail for meal times, snack times and will contain resident specific needs and adaptations. 2. Upon admission and significant changes service plans will be updated to include a resident specific nutrition/hydration strategy. 3. Upon admission, significant change and quarterly as needed. 4. RCC, LN & ED

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose activity plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3, 4, and 5'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 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 which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities. The need to evaluate and develop individualized activity plans, including all required components for each memory care resident, was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/02/24 and 04/03/24. They acknowledged the findings.

1. Regarding residents #1, #2, #3, #4, #5- Individualized activities plans will be written into the service plans detailing: -what, when, how and how often -resident current preferences, abilities and skills -emotional and social needs and patterns -physcial abilities and limitations, adaptations needed for resident participation -indentification of activities needed for behavioral interventions 2. Upon admission, at 30-day new admit assessment and significant changes the individualized activities plans will be updated reflecting the currrent needs of each resident. 3. 30-day new admit assessment, upon significant change and quarterly as needed. 4. Life Enrichment Director, RCC & ED.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 6, 7, 8, and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Residents 6, 7, 8, and 9's records were reviewed during the survey. There was no documented evidence activity evaluations had been completed that addressed the following elements: * Current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate in activities; and * Identified activities for behavior interventions. There were no specific individualized activity plans which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities. On 09/18/24 at 1:10 pm, the need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC), and Staff 12 (RCC/LPN). The staff acknowledged the findings.

1. Regarding residents #6, #7, #8 & #9- Individualized activities plans will be written into the service plans detailing: -what, when, how and how often -resident current preferences, abilities and skills -emotional and social needs and patterns -physcial abilities and limitations, adaptations needed for resident participation -indentification of activities needed for behavioral interventions 2. Upon admission, at 30-day new admit assessment and significant changes the individualized activities plans will be updated reflecting the current needs of each resident. 3. 30-day new admit assessment, upon significant change and quarterly as needed. 4. Life Enrichment Director, RCC & ED.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 2 sampled residents (#4) with documented behaviors. Findings include, but are not limited to: Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia. Resident 4's record documented behaviors including physical altercations with other residents. The resident's service plan, dated 01/04/24, did not address the behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 04/02/24 and 04/03/24, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED) and Staff 3 (RCC). They acknowledged the findings.

1. Regarding resident #4- service plan will be updated to reflect the specifc behaviors and interventions to be utlized to minimize the behaviors and their negative impact on the resident and the community. Known triggers for the resident will also be noted. 2. As behaviors arise, we will update service plans with appropriate interventions specific to the resident in order to minimize. 3. Quarterly and as needed. 4. RCC, LN & ED

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 260, C 270, C 303, C 310, and Z 164.

Refer to C260, C270, C303, C310 and Z 164

Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers. The current call system did not have a way to consistently alert caregiving staff when a call light was activated, which constituted a threat to the health, safety, and welfare of residents. Findings include, but are not limited to: During an interview on 09/17/24 at 11:00 am, Resident 10 revealed his/her call system in his/her room failed to work, and s/he used a wooden clapper to get the staff's attention because the call lights went unanswered. On 09/17/24 at 11:30 am, the pull cord in Resident 10's room was pulled.  At 12:15 pm the surveyor asked staff how they were alerted to resident call lights. Staff reported when a resident pulled a cord for assistance, the notification went to a call light panel located behind a locked door, and the MTs informed the caregivers of the call through their walkie talkies. When staff were asked if they had received notification Resident 10 had activated his/her call light, they stated no. No one responded to the call from 11:30 am to 1:00 pm. In an interview about the call system 09/17/24 at 12:25 pm, Staff 16 reported when she was near the call light panel, she would alert the caregivers of the room numbers that needed assistance. On 09/17/24 at 2:18 pm, surveyors discussed the call light system with Staff 1 (Executive Director). She reported tablets had been ordered for each neighborhood and they were "supposed to be able to download" an app to the tablets connecting them to the call system. She said that app would cue staff on each neighborhood that a resident's call light had been activated. Staff 1 stated the tablets were "enroute," and the system should be "up and running by the end of the week." She indicated some of the residents had call buttons worn on their wrist and some had call pendants, and that these devices were part of a "stand-alone system." Surveyors requested a list of all residents who had a wrist button or call pendant. Staff 1 reported the current call system had no way of tracking response time to call lights. She said the new system using the tablets would be able to track response time. Staff 1 indicated "someone was at the front" desk during "business hours," and it was part of the receptionist's duties to monitor the call panel and notify staff of call lights and follow-up to ensure they were answered. She said "all staff" should have walkie talkies so the MT, RCC, and receptionist could reach care staff to alert them to call lights. On 09/17/24, an observation of the call light panel showed that thirteen resident room emergency pull cords had been activated. There was no evidence the call system panel was being consistently monitored to alert staff when call lights went off. Call lights left unanswered placed the residents' health, safety, and welfare at risk. At 2:40 pm on 09/17/24 the facility was asked to provide an invoice or other documentation to show the tablets had been purchased. At 3:30 pm, Staff 1 reported she would have the list of residents with call buttons independent from the main system, as well as the documentation the tablets had been purchased, on the morning of 09/18/24. On 09/18/24 at 9:30 am a list of 10 of the 64 residents in the facility with call buttons independent from the main system was received, as well as an invoice for the tablets. The facility also provided an email from the corporate IT specialist, who wrote they would "have the ability to add more applications such as the call-light system in the future." When asked what "in the future" meant, Staff 1 said the app would be installed as soon as the tablets were received. She indicated that in the meantime hourly checks on every resident had been implemented. Surveyors requested a plan regarding how the facility would ensure residents' needs were met until the call system was consistently connected to the care staff center or staff pagers. A plan to have one staff responsible to check on all residents every 15 minutes, as well as scheduling the vendor to make the current call system audible on 09/23/24, was received on 09/18/24 at 12:47 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failures(s) associated with the licensing violation. The need to ensure the facility provided a call system that consistently connected resident units to the care staff center or staff pagers was discussed with Resident 1 (Executive Director) and Resident 13 (Asset Manager) on 09/18/24. They acknowledged the findings.

1. The system was repaired on September 23rd and is in good working condition. 2. Any issues that arise will be directed to the installation company for immediate assistance. The Rawlin will implement a "Fire Watch" system where residents will have eyes-on safety checks every 15 minutes if the call-light system has a failure. 3. Call-light system will be checked continuously for operation. Maintenance Director will do weekly panel inspection. 4. Maintenance Director and ED.

The findings of the relicensure survey conducted 04/01/24 through 04/04/24 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 re-visit to the re-licensure survey of 04/04/24, conducted 09/16/24 through 09/18/24, are documented in this report. The survey was conducted to determine 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. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home & Community-Based Services 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 A situation was identified where there was a failure of the facility to comply with the Department's rules that was likely to cause a resident serious harm. An Immediate Plan of Correction was requested in the following area: OAR 411-054-0300 (11-13): Call System The facility put an Immediate Plan of Correction in place during the survey.

The findings of the second revisit, to the re- licensure survey of 04/04/24, conducted 12/30/24 to 12/31/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

The findings of the on-site investigation, conducted 01/10/24, 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

The findings of the on-site investigation, conducted 01/10/24, 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

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:   Observation of the facility kitchen areas were reviewed on 9/8/23 from 10:45 am through 2:30 pm and found the following:   a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:   * Fans blades and cages in cooler; * Ceiling in walk in cooler; * Ceiling vents and ceiling surrounding vents; * Industrial mixer; * Interior of unit microwaves; * Unit reach in refrigerators/freezers; * Half walls of unit dining areas; * Cupboards where food stored in activity space; * Oven in activity space; * Areas around facets in all kitchenettes with mold like residue; and * Carpet rug in one of kitchenettes was dirty.   b. The following areas were in need of repair:   * Walk in freezer door, ceiling and racks with ice build up; * Unit kitchenettes and dining area walls with pealing/scratched/scuffed paint; * Janitor closet in kitchen with pealing/missing paint, small hole in wall; * Unit reach in refrigerators with damage to inside. One with door seal detached; * Caulking around handwashing sink damaged/missing/in need replacement. c. Multiple cutting boards, plastic storage containers with damage or heavy scoring and staining rendering items not to be smooth and cleanable as required. Oven mitts in kitchen found with rips and tears exposing cloth padding. Small fry pan damaged and in need of replacement. d. Microwaves in kitchen and multiple kitchenettes with staining, rusting and protective coating pealing. e. Ready To Eat (RTE) food items (Rice Krispy treat and cookie) found stored in unit drawer uncovered and exposed to potential contamination. Drawer with visible food debris. f. Multiple unit refrigerators without thermometers to monitor temperatures to ensure food items stored at 41 degrees F or less. Fridge in Daisy unit had a thermometer but when checked was at 48 degrees F. Milk stored in that refrigerator was checked and temperature was at 45 degrees F. Facility did not have a process for staff to monitor temperatures of unit refrigerators to ensure cold food items were stored at appropriate temperatures. Items in that refrigerator were discarded. Staff 2 (Dietary Manager) toured the kitchen areas with the surveyor and acknowledged the findings. At approximately 2:00 pm, the surveyor reviewed above areas with Staff 1 (Executive Director) who acknowledged the findings.

A. 1. A detailed cleaning checklist including the following areas will be created for the Dining Services team to complete: Fan blades and cages in cooler, ceiling vents and ceiling surrounding the vents, the industrial mixer, interiors of kitchen and unit microwaves, interiors of kitchen and unit refrigerators and freezers, half walls of unit dining areas, cupboards where food is stored in the activity space, the oven in the activity space, areas surrounding the faucets in the kitchen and units and the carpet rugs in the unit kitchenettes. 2. Training of current and new members of the Dining Services team will include a review of the cleaning checklists as a building procedure. Employees will be required to sign the cleaning checklist as an ackowledgement of the expectations. 3.The areas that have been listed that need correction will be evaluated on a weekly basis moving forward. 4. The Dietary Services Director and Maintenance Director will monitor the completion of the corrections listed. B. 1. Repair of the following areas will be tasked to the Maintenance Director: Walk-in freezer door, ceiling and racks ice build-up- call to manufacturer of walk-in freezer seeking local repair assistance. Thorough removal of existing ice build-up. Unit kitchenettes and dining area walls that have pealing/scratches/scuffed paint- Fresh paint and kick-guard will be installed to prevent further damage. Janitor closet in kitchen with pealing/missing paint, also with a small hole in the wall- All items will be removed from the closet for a fresh coat of paint and repair/patch for the hole. When items are put back in the closet they will be well-organized. Unit reach-in refrigerators with damage- All unit refrigerators will be replaced. Caulking around handwashing sink is damaged/missing- Kitchenette sinks will be deep cleaned and re-caulked. 2. The areas that were in violation will be added to TELS (tracking software for maintenance/upkeep of community) as a task/review for the Maintenance Director. 3. The TELS tasks will be scheduled monthly. 4. The Executive Director will review completion of the tasks with the Maintenance Director. C. 1. Inventory of kitchen food preparation products will be completed and will note the specific items needing repair. Items that were listed included: cutting boards, plastic storage containers, oven mitts, small fry pans. Once items inventoried, replacements will be ordered. 2. Preparation product inventory will be implemented as a standard practice moving forward. 3. Product inventory will be evaluated monthly. 4. The Dining Services Director will review needs and order with Executive Director. D. 1. Unit microwaves as well as microwave in the kitchen will be ordered and replaced. 2. Review/evaluation of the microwaves will be added to TELS for the Maintenance Director to complete. 3. The TELS task will be scheduled monthly. 4. The Executive Director will review completion of th etask with the Maintenance Director. E. 1. Unit kitchenettes will receive a deep clean. 2. A review of where/how food items are to be stored will be completed at our next All-Staff Meeting, 10/19/2023. Our NOC team will be tasked with a Weekly Deep Clean checklist for the unit kitchenettes. 3. The Weekly Deep Clean checklist will be evaluated weekly as a TELS task. 4. The Maintenance Director will monitor the Weekly Deep Clean checklist in the TELS program. F. 1. Unit refrigerators will have a thermometer installed to ensure food items are stored at 41 degrees F or less. 2. The Dining Services team will be responsible for taking/recording temperatures of the unit refrigerators daily. 3. Temperatures will be logged daily. The temperature logs will be reconciled on a monthly basis. 4. The Dining Services Director will present the temperature logs to the Executive Director for review.

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

Refer to C 240 POC

The findings of the kitchen inspection, conducted 9/8/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit to the kitchen re-licensure survey of 09/08/23, conducted on 11/08/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review, conducted during a site visit on 08/08/23, it was confirmed the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse for 1 of 1 sampled resident (#8). Findings include, but are not limited to: A review of Resident 8's progress notes revealed on 04/03/23, s/he was on alert for a resident-to-resident altercation resulting in a "possible head injury" from another resident headbutting him/her. There was no other documentation provided regarding the incident or evidence of an internal investigation. A review of an email sent to the Licensing Complaint Unit on 07/05/23 by APS confirmed the incident had not been reported. In an interview on 08/08/23 Staff 1 (Business Office Manager) stated anytime a resident puts hands on another resident, there should have been an incident report filled out and an internal investigation done. Staff 3 (Resident Care Coordinator) stated it had been reported to the ED. The above information was shared with Staff 1 (Business Office Manager) on 08/08/23. S/he acknowledged the findings. It was determined the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse. Verbal pan of correction: Re-training for RCCs and Nurses on Abuse reporting will be done within 30 days. The ED and Business office manager will be responsible for auditing incidents to ensure that resident to resident altercations and any suspected abuse/neglect is being reported to APS.

The findings of the on-site investigation, conducted 08/08/23, 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.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/08/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/08/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/08/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/08/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/08/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/08/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview and record review, it was confirmed that the facility failed to have a system in place to track controlled substances. Findings include: CS reviewed Narcotic logs dated March-June 2022 for Resident #1, Internal incident report that was reported on 05/19/22, and policy and procedure for counting and disposal of controlled substances. Resident #1 had a narcotic documented as  "not here"  or  "not found"  from 05/10/22-05/19/22 which was not reported to the nurse right away per their policy and procedures. There was also no documentation of a police report being filed or reporting to APS. In separate interviews on 12/01/22, Staff #1-3 stated that the narcotics count is done at the beginning and end of each shift. If the count is off, the nurse would be notified immediately. The above information was shared with Staff #1 on 12/08/22 via phone call, who acknowledged the findings. Plan of Correction: The facility has had ongoing training regarding narcotics count and documentation in the book. Reminders that the nurse will be immediately notified if the count is off. Also went over reporting to the police and APS.

Based on interview and record review, it was confirmed that the facility failed to administer medications as prescribed. Findings include: In an interview with Staff #1 on 12/01/22, Staff #1 stated that they have not seen or heard of any staff withholding medications from residents. They stated that they are reviewing the missed medications and progress notes daily. CS reviewed Resident #1-4s medication administration records (MARs) and progress notes for June-August 2022. Resident #2 did not receive multiple medications as prescribed in August 2022 due to not having the medication available or awaiting delivery from pharmacy. The above information was shared with Staff #1 on 12/08/22, via phone conversation, who acknowledged the findings. Facility plans of correction: Ongoing re-training to staff regarding medication re-ordering process. Contacting the pharmacy as needed. Facility may move to cycle fill in the future.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 12/01/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 10/04/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to: During the survey, conducted 10/11/21 through 10/13/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19, and made available to all facilities, were not being followed by the facility. * Upon arrival to the facility on 10/11/21, staff were observed working with residents without required eye protection; * Staff were observed removing their eye protection equipment at the end of shifts and during breaks without properly disinfecting and storing the equipment; and * There was no designated staff member to complete screening of all staff and visitors for signs and symptoms of COVID-19. Additionally, there were no supplies or instructions for disinfecting the screening equipment (thermometers/pens) between each use. The need to ensure the facility implemented proper infection control practices to protect residents and staff from the COVID-19 virus was discussed with Staff 1 (ED) on 10/13/21. She acknowledged the findings.

C160: OAR 411-054-0025 (Reasonable precautions) Covid infection control will be followed. All visitors entering the facility will be screened by the receptionist/Staff. Staff will also assure that pens will have 2 containers one for clean and one for dirty. Sign in area will also have hand sanitizer and or wipes to sanitize used pens and table area during hourly cleaning. Receptionist will also hand out mask and shield at time of visit to assure Covid rules are being followed and initial after each screening to assure for consistency. Med Tech on duty will do screening and document temperatures and initial after taking temps of oncoming staff. Staff will also sanitize and sterilize thermometer. Staff will also assure that pens will have 2 containers one for clean and one for dirty. Sign in area will also have hand sanitizer and or wipes to sanitize used pens and table area. Med Tech will check staff has all proper PPE for their shift and routine checks to assure staff is wearing PPE correctly during their shift. Sanitizing tables/Area will be set up by Housekeeper for the front lobby and in the breakroom to be able to sanitize shields/goggles between usage. Proper containers with labeled names for staff on tables in the lobby and step by step instructions for storage and disinfecting/sanitizing. Business Office Manager to review screening logs daily.

6. Resident 6 was admitted to the MCC in 2018 with diagnoses which included Alzheimer's disease, atherosclerotic heart disease and chronic pain. The resident was receiving hospice services at the time of the survey, spent a majority of the day in bed and was being treated for several skin conditions. Observations of the resident during the survey indicated the resident was minimally verbal and could not reliably respond to questions. Progress notes between 7/10/21 and 10/10/21 were reviewed, along with Resident 6's current service plan, Temporary Service Plans (TSPs) and hospice visit notes. The following issues were identified: * On 08/03/21, a MT documented "I am adding [resident] to alert [charting] for a small skin tear to [his/her] left elbow." * On 10/06/21, A MT documented "Placing resident on alert [charting] due to [s/he] got a skin tear on [his/her] left elbow its a silver dollar size skin tear [MT] bandage it and will call family and hospice [resident] also has a small bump on the back of [her/his] head was draining a little bit will continue to monitor." The two skin tears to the left elbow and the bump to the back of the head represented injuries of unknown cause. There was no documented evidence the facility either conducted an immediate investigation of the injuries which reasonably concluded and documented that the injuries were not the result of abuse, or reported the injuries to the local SPD office as suspected abuse. The injuries of unknown cause were reviewed with Staff 1 (ED) on 10/13/21 at 12:00 pm. She acknowledged the injuries represented injuries of unknown cause, acknowledged no investigation to rule out abuse had been conducted and confirmed the injuries had not been reported to the local SPD office as suspected abuse. Staff 1 was instructed by the surveyor to report the injuries of unknown cause to the local SPD office. Confirmation the incidents had been reported was received on 10/14/21. 3. Resident 3 was admitted to the facility in June 2020 with diagnoses including Alzheimer's Disease. A review of the resident's records during the survey revealed the following: * An incident report dated 7/20/21 indicated staff had witnessed Resident 3 and another resident "inappropriately touching" each other. The residents were separated, and both went back to their separate halls. Resident 3 was unable to say what happened. There was no further documentation. There was no documented evidence the facility conducted a thorough investigation of the incident to rule out abuse. The facility lacked documentation of required investigative components, including individuals present, a description of the inappropriate touching, follow-up action, and the administrator review. The need to ensure the facility investigated all incidents and documented all required investigative components was discussed with Staff 1 (ED) on 10/13/21. She acknowledged the findings. 4. Resident 4 was admitted to the facility in 6/2021 with diagnoses including dementia. Interviews with staff and review of progress notes, temporary service plans and incident reports were conducted during the survey and identified the following reportable incidents: * Incident reports dated 07/20, 08/07, 08/25, 08/26, 08/27, 08/31, 09/07, and 09/18, indicated Resident 4 expressed unwanted sexualized behaviors towards other residents; and * Progress notes dated 08/05, 08/28, 09/04, 09/15, 10/01, 10/05, 10/06, 10/07, and 10/10, indicated Resident 4 displayed unwanted sexualized behaviors towards other residents. There was no documented evidence the facility reported the incidents to the local SPD office as abuse, immediately conducted an investigation, took measures to prevent reoccurrence of the abuse and the facility administrator reviewed the incidents. On 10/13/21, the need to ensure all allegations of abuse and neglect were immediately investigated and reviewed by the facility administrator, and incidents were reported to the local SPD office was discussed with Staff 1 (ED). She acknowledged the findings. The surveyor directed the facility to self-report the incidents. Confirmation the incidents had been reported was received on 10/14/21. 5. Resident 5 was admitted to the facility in 8/2020 with diagnoses including dementia. Interviews with staff and review of progress notes, temporary service plans and incident reports were conducted during the survey and identified the following reportable incidents: * An incident report dated 10/02, indicated Resident 5 kicked an unsampled resident in the leg; and * A progress note dated 08/20, indicated Resident 5 was found with a cut on their shin. There was no documented evidence the facility reported the kicking incident to the local SPD office as suspected abuse. There was no documented evidence the facility either conducted an immediate investigation of the shin injury which reasonably concluded and documented that it was not the result of abuse, or reported the injury to the local SPD office as suspected abuse. On 10/13/21, the need to ensure all allegations of abuse and neglect were immediately investigated and reviewed by the facility administrator, and incidents were reported to the local SPD office was discussed with Staff 1 (ED). She acknowledged the findings. The surveyor directed the facility to self-report the incidents. Confirmation the incidents had been reported was received on 10/14/21.

Based on interview and record review, it was determined the facility failed to conduct an immediate investigation of an allegation of abuse and injury of unknown cause to rule-out abuse or report the injury as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 6 of 7 sampled residents (#s 1, 3, 4, 5, 6, 7). Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 6/2019 with diagnosis including Alzheimer's disease. Interviews with staff and review of progress notes, temporary service plans and incident reports were conducted during the survey and identified the following reportable incidents: * Temporary service plans dated 6/22/21 and 6/30/21 indicated Resident 1 was exposed to inappropriate sexual behavior and inappropriate sexual gestures from another resident; * A progress note dated 7/17/21 indicated Resident 1 was on alert for inappropriate behaviors with a known resident. An incident report was initiated on 7/16/21, that documented "they were holding hands, near the other resident's private parts."; and * An incident report dated 8/25/21 indicated another resident came up and started to push Resident 1 and grabbed his/her walker and threw it. Resident 1 lost his/her balance as s/he was being shoved and fell on the floor. These incidents represented instances of sexual and physical abuse. There was no documented evidence the facility immediately reported the instances of abuse to the local SPD office. The facility failed to immediately investigate and take measures to prevent reoccurrence of the abuse that occurred on 8/25/21. * Progress notes dated 8/23/21 and 10/3/21 indicated a half dollar size skin tear to the right leg and bruising on the right side of the face, respectively. These represented injuries of unknown cause. There was no documented evidence the facility either conducted an immediate investigation of the injuries which reasonably concluded and documented that the injuries were not the result of abuse, or reported the injuries to the local SPD office as suspected abuse. 2. Resident 7 was admitted to the facility in 7/2019 with diagnoses including Alzheimer's disease - late onset and dementia with behavioral disturbance. Interviews with staff and review of progress notes, temporary service plans and incident reports were conducted during the survey and identified the following reportable incidents: * A progress note dated 9/14/21 indicated Resident 7 was sitting in the living room when another resident was seen kissing his/her hand, arm, and mouth. This incident represented an instance of sexual abuse. There was no documented evidence the facility immediately reported the instance of abuse to the local SPD office. The facility failed to immediately investigate and take measures to prevent reoccurrence of the abuse. * A progress note dated 10/9/21 indicated Resident 7 had a black left eye, goose egg above the left eye and bruising on both forearms. These represented injuries of unknown cause. There was no documented evidence the facility either conducted an immediate investigation of the injuries which reasonably concluded and documented that the injuries were not the result of abuse, or reported the injuries to the local SPD office as suspected abuse. The need to ensure allegations of abuse and injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/13/21. Staff 1 did not provide any documentation the allegations and injuries were investigated, and abuse was ruled out. The surveyor directed the facility to self-report the incidents. Confirmation the incidents had been reported was received on 10/14/21.

C231 OAR 411-054-0028 Abuse Reporting.   Instances when abuse could not be ruled out were reported at the time of survey.                                                                                Inservice with APS on Documentation/Investigation for reporting on 10/28/21 by Geoff Clark. Inservice was recorded for future training and or as needed for All Staff training.      RN/RCC/Med Tech will have Clinical meeting daily to review IR, Alert charting, review previous progress notes, Medication administration, Medication given/PRN'S, Medication exemptions. Clinical meeting will be done daily, ED will be in charge to monitor to assure daily compliance. Incident Reports (IR) will be initiated by Med Tech (MT) at time of any incident: Res to Res, Skin issues (bruises, skin tears, skin discoloration, bumps). The MT will gather witness statements and notification for Primary, Family, RN, RCC, ED and detailed documentation entered regarding Incident. MT will also have TSP in place.  RCC will review and continue investigation at that time if needed to Self-Report and send Face Sheet, Progress note, Care Plan, TSP pertaining to the IR. RN will monitor for compliance. Executive Director be notified of all Incident Reports to be reviewed/signed off and will verify self- report(s) this will be done daily.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required care/service elements for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed. Findings include but are not limited to: Resident 2 was admitted to the facility in 09/2021, with diagnoses including dementia. Resident 2's move-in evaluation was reviewed during survey and lacked information related to the following required elements: * Fall risk; * Pain including non-pharmacological interventions; and * Elopement risk. The need to ensure move-in evaluations addressed all required care/service elements was discussed with Staff 1 (ED) on 10/13/21. She acknowledged the findings.

C252 OAR 411-054-0034 Resident Evaluation New Move-in evaluations will be done prior to moving in. RCC will be the designated person to assure all elements are answered as stated in the rule. RN will review all Evaluations. Executive Director will review new move in evaluations for required elements. RCC is designated to update 30- day evaluations/quarterly Evaluations/Change of conditions; these are updated with TSP's and updates from Care-partners, Med Techs, New orders from primary, outside services, Family, RN, ED, RCC, Resident, Case Manager. Family Care conferences are scheduled to review and sign updates. All care team are invited to Care Conferences. Family, POA have options to attend or participate via phone, email, zoom. Family/Resident will be offered a copy of Updated Care Plan. Care Conferences will be documented. All updated Care Plan will have signatures of the Care Team involved, Family, RN, RCC, ED. Resident #2 Care Plan will be reviewed and updated for Fall risk, Pain including non-Pharmacological interventions; and elopement risk. RCC will update and RN will Review medications and to have interventions when needed.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 5 of 7 sampled residents (#s 1, 2, 4, 5 and 6) whose service plans were reviewed.  Findings include, but are not limited to: Resident 1, 2, 4, 5 and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. On 10/13/21, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED). She acknowledged the findings.

C262 OAR 411-054-0036 Service Plan: Service Planning Team Refer to C252: RCC is designated to update 30- day evaluations/quarterly Evaluations/Change of conditions; these are updated with TSP's and updates from Care-partners, Med Techs, New orders from primary, outside services, Family, RN, ED, RCC, Resident, Case Manager. Family Care conferences are scheduled to review and sign updates. All care team are invited to Care Conferences. Family, POA have options to attend or participate via phone, email, zoom. Family/Resident will be offered a copy of Updated Care Plan. Care Conferences will be documented. All updated Care Plan will have signatures of the Care Team involved, Family, RN, RCC, ED.

Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for the resident following a change of condition, monitor and document on the progress of the condition at least weekly until resolved and monitor the resident consistent with his/her evaluated needs and service plan, for 3 of 7 sampled residents (#s 4, 6 and 7) who had resident altercations, skin issues and falls. Findings include, but are not limited to: 1. Resident 6 was admitted to the MCC in 2018 with diagnoses which included Alzheimer's disease, atherosclerotic heart disease and chronic pain. The resident was receiving hospice services at the time of the survey, spent a majority of the day in bed and was being treated for several skin conditions. Review of Resident 6's progress notes between 7/10/21 and 10/10/21, current service plan, Temporary Service Plans (TSPs) and incident reports indicated the following deficiencies related to changes of condition: a. On 07/05/21 the resident was found on the floor of his/her room. The resident sustained a laceration to the head. The resident was placed on Alert Charting and staff documented on the progress of the wound until 7/20/21. There was no documentation as to whether the wound was healed and considered resolved. Additionally, there was no documented facility review of service-planned fall interventions to determine whether they were being followed at the time of the fall, were effective or whether additional interventions needed to be developed to minimize the risk for further falls. b. On 8/13/21, a MT documented the resident was being placed on Alert Charting for "open site to coccyx." MTs documented on 8/15/21, 8/16/21 and 8/17/21 that treatments were being administered and the area was "healing." There was no further documented monitoring of the wound by the facility until Staff 2 (RN) documented on 9/10/21, per hospice, the wound was resolved. c. On 10/6/21, a MT documented the resident was being placed on Alert Charting for a skin tear to the left elbow and a bump on the back of the head. No written instructions for monitoring of the bump were provided to staff, and there was no documented monitoring of the bump by the facility. The need to ensure actions/interventions were documented and communicated to staff, changes of condition were monitored at least weekly until resolved and existing interventions were monitored for effectiveness was discussed with Staff 1 (ED) and Staff 2 (RN) on 10/13/21. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 6/2021 with diagnoses including dementia. Resident 4's record was reviewed for changes of condition and identified the following: * Between 7/15/21 and 10/11/21, Resident 4's record indicated the resident had 17 incidents of unwanted sexualized behaviors towards other residents. There was no documented evidence the facility reviewed service-planned interventions to determine whether they were effective. The facility failed to implement additional interventions to try to minimize further behavior toward other residents. On 10/13/21, the need to monitor the effectiveness of interventions and develop new interventions as needed was discussed with Staff 1 (ED). She acknowledged the findings. Refer to Z165. 3. Resident 7 was admitted to the facility in 7/2019 with a diagnosis of Alzheimer's disease. During the acuity interview on 10/11/21, Resident 7 was identified as a fall risk who had a history of falls with a fracture. Progress notes, incident reports, service plans and temporary service plans were reviewed during the survey. The facility failed to adequately determine and document what actions or interventions were needed for the resident and communicate the interventions to staff in response to repeated falls, exposure to inappropriate sexual behavior and an injury of unknown cause. Additionally, the facility failed to monitor service-planned interventions for effectiveness in response to the following incidents: * On 7/9/21, the resident was found on the floor in the shower; * On 7/31/21, staff documented the resident was being added to alert for a non-injury fall; * On 8/4/21, staff documented the resident was found on floor in bedroom. Resident was lying on the right side on top of the fall mat; * On 8/9/21, staff documented the resident was found on floor in bedroom. The resident was lying on right side in the fetal position by chair that s/he was previously sleeping in; * On 9/13/21, staff documented the resident was kissed on the hand, arm and mouth by another resident; and * On 10/9/21, staff documented the resident had a left black eye, goose egg above the left eye and bruising on both forearms. The need to ensure interventions were developed in response to changes of condition, the interventions were communicated to staff on all shifts, and the interventions were monitored for effectiveness was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 5 (RCC) on 10/13/21. They acknowledged the findings.

C270 OAR 411-054-0040 Change of Condition monitoring refer to C231 RN/RCC/Med Tech will have Clinical meeting daily to review IR, Alert charting, review previous progress notes, Medication administration, Medication given/PRN'S, Medication exemptions. Clinical meeting will be done daily, ED will monitor to assure daily compliance. MT are aware to place any resident on Alert for any changes of Medications, Falls, Skin issues, illness, Behaviors, RES to RES, Any incidents. MT are aware to notify the RN/RCC/ED of these changes or issues. Alert Charting will be reviewed daily and RN to assess Resident and document findings as needed and will instruct Med Tech's of what is needed to monitor and document. RN will at that time initiate if needed a Change of condition status. RN will instruct RCC to Update Care Plan and ISP of instructions for staff of what to monitor and report. RN will notify family/Primary of changes of condition. Monthly MT meeting and All Staff meeting for education/training.  RCC will review Charts and Audit for #4,6,7. This Audit will be completed by 12/12/21.

Based on interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed for residents with a significant change of condition, for 2 of 2 sampled residents (#s 6 and 7) who experienced pressure ulcers and a hip fracture. Findings include, but are not limited to: 1. Resident 6 was admitted to the MCC in 2018 with diagnoses which included Alzheimer's disease, atherosclerotic heart disease and chronic pain. The resident was receiving hospice services at the time of the survey, spent a majority of the day in bed and was being treated for several skin conditions. Progress notes between 07/10/21 and 10/10/21 were reviewed along with Resident 6's current service plan, Temporary Service Plans (TSPs), physician orders, MAR and hospice visit notes. The following issues were identified: * A "Hospice Physician Order" dated 08/09/21 indicated "Right coccyx pressure injury. Apply calmazine BID and PRN." * Staff 2 (RN) documented in a "Skin/Wound Note" dated 09/23/21 "Resident has reddened buttock with an approximately 7 cm x 2 cm wide area, outer skin deep, area washed covered with foam." These documented skin conditions represented pressure ulcers, which are considered significant changes of condition. There was no documented evidence the facility RN conducted a thorough assessment of each of the conditions and documented her findings. In an interview on 10/13/21, Staff 2 (RN) acknowledged no assessments of the skin conditions had been completed. The need to ensure conditions that represent significant changes of condition are assessed by the facility RN was discussed with Staff 1 (ED) on 10/13/21. She acknowledged the findings. 2. Resident 7 was admitted to the facility in 07/2019 with diagnoses of Alzheimer's disease and dementia with behavioral disturbance. The resident was admitted to the hospital on 07/21/21 for left hip replacement surgery. Progress notes and temporary service plans were reviewed during the survey. Progress notes identified the resident returned to the facility on 07/27/21. A temporary service plan dated 07/30/21 noted the resident had experienced a decline in ADL functioning related to the hip replacement in the following areas: * Ambulation; * Two person transfers with a gait belt; * Pain with transfers; and * Toileting assistance every two hours. The overall decline in health and changes in ADL needs constituted a significant change in condition for which an RN assessment was required. There was no documented evidence the facility RN completed a significant change of condition assessment for the decline in ADL functioning which included documented findings and resident status. The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/13/21. They acknowledged the findings.

C280 OAR 411-054-0045 Resident Health Services Significant changes of condition for sampled residents have been completed. RN/RCC/Med Tech will have Clinical meeting daily to review IR, Alert charting, review previous progress notes, Medication administration, Medication given/PRN'S, Medication exemptions. Clinical meeting will be done daily, ED or their designee will monitor  daily for compliance. Med tech to initiate TSPs for all changes in condition. RN to determine if change in condition is short term or signficant and consult with ED or RCC. Residents with significant changes of condition to be monitored by RN. This monitoring to take place during daily reviews of electronic health record system's dashboard. The RN will conduct and document an assessment of the significant change of condition and update the service plan based on his/her findings. RN is responsible for reviewing system weekly.

3. Resident 6 was admitted to the MCC in 2018 with diagnoses which included Alzheimer's disease, atherosclerotic heart disease and chronic pain. The resident was receiving hospice services at the time of the survey and was being treated for several skin conditions. Review of the most recent set of signed physician orders, dated 08/04/21, indicated the resident was prescribed three PRN medications to treat constipation. Instructions on the MAR directed staff to administer the medications in the following order: * Milk of magnesia - "Try 1st. If ineffective after 24 hours may give suppository." * Bisacodyl suppository - "Try 2nd. If ineffective after 24 hours may give Fleets." * Fleet enema - Try 3rd. Hospice to initiate fleets." Review of medication administration notes between 07/10/21 and 10/10/21 indicated the facility failed to administer the medications as ordered on five occasions. The suppository was administered on 08/4/21, 08/31/21, 09/11/21, 09/18/21 and 09/23/21 without the milk of magnesia (MOM) first being administered and noted as ineffective. The facility's failure to follow the orders was reviewed with Staff 2 (RN) on 10/13/21 at 9:00 am. She stated the MTs may have been instructed by a hospice nurse to administer the suppository without trying the MOM first. At 9:30 am, Staff 2 informed the surveyor she had reviewed the MARs and found no documented evidence the MOM had been administered first, or that a hospice nurse had instructed the MTs to administer the suppository. The facility's failure to ensure physician orders were followed was reviewed with Staff 1 (ED) on 12/13/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed and signed physician orders were documented in the resident's record for all medications and treatments the facility was responsible to administer for 3 of 5 sampled residents (#s 3, 5 and 6) whose MARs and physician orders were reviewed. Findings include, but are not limited to: 1. Resident 3's physician orders, 09/01/21 through 10/12/21 MARs and progress notes dated 7/11/21 through 10/12/21, were reviewed and identified the following: a. The resident was prescribed two PRN psychotropic medications for anxiety and restlessness: haloperidol and lorazepam. The order for haloperidol included instructions to administer first and "if haloperidol ineffective in 30 minutes, use lorazepam." The 09/2021 MAR indicated lorazepam had been administered on 09/7/21 first, with no documented evidence the haloperidol had been administered prior with ineffective results. b. The resident was prescribed two PRN pain medications for moderate to severe pain and osteoarthritis: acetaminophen and morphine. The orders for acetaminophen included instructions to administer first, and the morphine had instructions to administer second if the acetaminophen was ineffective. The 09/2021 MAR indicated the morphine had been administered on 09/11/21 first, with no documented evidence the acetaminophen had been administered prior with ineffective results. An interview on 10/13/21 at 11:30 am, Staff 15 (MT) confirmed that on 09/07/21 and 09/11/21, the MT had not followed the order of administration for the PRN medications. The need to ensure orders were administered as prescribed was discussed with Staff 1 (ED) on 10/13/21. She acknowledged the findings. 2. Resident 5's signed physician orders and 10/01/21 through 10/11/21 MAR were reviewed, and the following deficiencies were identified: a. The resident had a signed physician order for citalopram 40 mg 1 time daily. However, the MAR indicated the resident was receiving citalopram 20 mg one time daily. Observation of the citalopram drug card confirmed that the resident was receiving the 20 mg dose one time daily. b. Resident 5's MAR displayed loperamide 2mg, magnesium hydroxide 1200 mg/15 ml, calcium carbonate 500mg, and acetaminophen 500mg as PRN medications. There were no signed physician orders for these medications found in the resident record. On 10/13/21, the need to ensure orders were carried out as prescribed, and signed provider orders were documented in the resident's record for all medications, was discussed with Staff 1 (ED). She acknowledged the findings.

C303 Refer to C231, C252, C262, C270 Medications for sampled residents reviewed and reconciled with primary care physician. RN/RCC/Med Tech will have Clinical meeting daily to review IR, Alert charting, review previous progress notes, Medication administration, Medication given/PRN'S, Medication exemptions. Clinical meeting will be done daily, ED or their designee will monitor to assure daily compliance. Inservice to be held for med techs related to documentation, following nursing parameters, and The 6 Rights of Medication Administration. System of triple checks with stamped step by step instructions check off for person to initial after task is completed First check: Med Tech that receives any order(s) must send to pharmacy, progress note, Alert Charting/TSP in place if applicable. Second Check: RCC to review to assure the first check was completed and accurate. Third Check: RN to review and document for accuracy in Progress note. RN will review medications Quarterly. Chart Review audit will be conducted every quarter to assure all medications have current orders. RCC/RN will review/Audit charts for residents #1, 2,3,4,5,6, 7 this will be completed 12/12/21. Executive Director to monitor for compliance

Based on interview and record review, it was determined the facility failed to ensure a written fire drill record was maintained and included all required components in accordance to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records for April through September 2021 were reviewed during survey. The following required components were not consistently documented in fire drill records: * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. The need to ensure a written fire drill record was maintained and included all components in accordance to the Oregon Fire Code (OFC) was discussed with Staff 1 (ED) and Staff 9 (Maintenance Director) on 10/13/21. They acknowledged the findings.

C420 OAR 411-054-0090 Fire and Life Safety: Drills/Instruction The following additions were made to our existing fire drill logs; escape route used, residents evacuated, special circumstance training, problems encountered and comments relating to residents who resisted or failed to participate in the drills, actions taken to overcome the problems, evacuation time period (begin and end time), and number of occupants evacuated. Care staff will be expected to explain the escape route used based on our evacuation map. Care staff will be escorting at least one resident on fire drills (every other month minimum) beyond at least the first set of fire doors of the fire sector involved in the drill and questioned about problems or issues that arose during the evacuation and actions they took to overcome the problems. Information will be given on what to do for residents who refuse. Refusals to participate in drills or actual emergencies are dealt with as such; When we evacuate, we evacuate most able bodied people first then least able bodied. If a resident refuses after all non-physical persuasion methods, they become least able bodied. It is the responsibility of all staff to use non-physical methods to get residents evacuated first (motivation, encouragement, persuasion, change of face, and diversion), then if those tactics are unsuccessful, we move to physical techniques (using a wheelchair to escort them, multiple person assisted walking, and as a last resort using bedsheets or fall mats to assist the resident out of danger). Care staff will be given special circumstances (i.e. natural disasters, equipment failures, building failures, and other unique scenarios) for each fire drill and be educated/questioned on how to react to those situations. Care staff will be timed on response time, total time of the drill, and evacuation time of each resident.

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 C160, C231 and C420.

Z142 OAR 411-057-0140 Administration Compliance Refer to C160, C231, C420

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, C262, C270, C280 and C303.

Z162 OAR 411-057-0160 Compliance with Health Rules. Refer to C252, C262, C270, C280, C303

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 5 of 6 sampled residents (#s 1, 2, 3, 5 and 6) whose activity plans were reviewed and failed to provide meaningful activities to all residents. Findings include, but are not limited to: 1. Residents 1, 2, 3, 5 and 6's service plans were reviewed during the survey. The facility was documenting quarterly activity evaluations, however, the evaluations lacked one or more of the following required components and were not included on the residents' service plan:   * 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 individualized activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. 2. The facility was divided into four neighborhoods. Observations in each of the neighborhoods during the survey revealed there were some residents who were either in their rooms or not engaged in any activities. Observations in the Walnut neighborhood on 10/11/21 through 10/13/21 identified multiple non-sampled residents seated in front of a TV in the common area. No other activities were observed in the Walnut neighborhood. On 10/11/21 and 10/12/21, a non-sampled resident approached the surveyor stating, "Can you help me find something to do" and " I need something productive to do." Each time the resident approached the surveyor there were no direct care staff in the immediate area. The surveyor went to find a staff member to relay the information. Staff approached the resident, gave him/her some paper and coloring pencils and walked away from the resident. Observations of Resident 1 on 10/11/21 through 10/13/21, identified Resident 1 was wheelchair bound and unable to successfully propel the wheelchair without staff assistance. Staff were not observed to offer to escort the resident to and from group activities occurring in other areas of the community and nor were staff observed to engage the resident with 1:1 activity during the survey. The only activity offered to the resident was watching TV in his/her room, alone. In an interview on 10/13/21, Staff 6 (Activities Director) reported she was usually the only person available for activities. She stated the care partners try to help, but they were usually busy and would help when an activity involved food because she was not familiar with each resident and their ability to independently eat. Staff 6 reported the facility was still in the process of developing the activity program and she recently started working with Staff 5 (RCC) on activity evaluations for new admissions, but had not gone through each resident's service plan. On 10/13/2021, the need to evaluate and develop individualized activity plans was discussed with Staff 1 (ED), Staff 2 (RN), Staff 5 and Staff 6. They acknowledged the findings.

Z164 OAR 411-057-0160 Activities RCC and Activities will review up-coming care plans and update to add missing components to all care plans to assure all Service Plans are reflective and followed. Audits to be done monthly. ED to monitor for compliance. Activities will reflect likes/dislikes, limitations, level of participation, tools if needed.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted 1 of 2 sampled residents (#4) and others in the community. Resident 4 exhibited repeated sexually abusive behaviors towards other residents which posed an immediate jeopardy situation that could threaten the health, safety or welfare of residents. Findings include, but are not limited to: Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia and major depressive disorder. Resident progress notes and incident reports from 07/15/21 through 10/11/21 indicated the resident had at least 17 documented incidents of sexualized behaviors on 07/16, 07/20, 08/05, 08/07, 08/25, 08/26, 08/27, 08/28, 08/31, 09/04, 09/07, 09/15, 09/18, 10/01, 10/05, 10/06, 10/07, and 10/10 toward other residents. Those incidents included pulling down his/her pants and showing other residents his/her genitalia, putting his/her genitalia in other resident's faces and/or up to their mouths, looking at other residents near him/her and touching his/her own genitalia, and taking other residents' hands and placing their hands on his/her genitalia. On 10/12/21, the surveyor witnessed Resident 4 sit next to an unsampled resident on the couch unsupervised. Resident 4 proceeded to place his/her hand on the unsampled resident's upper thigh and/or groin area four different times, with the unsampled resident moving Resident 4's hand off each time. The surveyor asked Staff 1 (ED) to separate Resident 4 and the unsampled resident. Resident 4's most recent service plan, dated 08/24/21, did not address the resident's sexualized behaviors towards other residents and include effective resident-specific interventions or approaches for staff to utilize for the behaviors. The facility's failure to evaluate and develop an individualized behavior plan to address Resident 4's behaviors resulted in continuation of the behaviors and exposed other residents to sexual abuse. On 10/12/21, at 2:15 pm, the survey team requested an immediate plan of correction addressing the Resident 4's behaviors. At approximately 5:45 pm, the survey team received and accepted the plan of correction. On 10/13/21, the need to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted residents and others in the community was discussed with Staff 1. She acknowledged the findings.

Z165 OAR 411-057-0160 Behaviors Resident #4 continues to have a companion. APS have made surprise visits to assure that this is accurate and is maintained. Executive Director working with Policy Analyst Debbie Concidine for contacts for All Male facilities. Requested assistance from Referral contacts for placement. All Upcoming Care Plans will be reviewed and Audit quarterly or as needed by RCC to meet the rule. Executive Director will monitor for compliance. This Audit will be done every 3 months

Based on observation, interview and record review, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Findings include, but are not limited to: The building consisted of four units or "neighborhoods." There were two separate outdoor courtyards, each shared by two neighborhoods. There were doors in each neighborhood which allowed access to the courtyards. There was also a common living/activity area, central to the building, that allowed access to each of the courtyards. The facility was toured on 10/11/21 at 12:50 pm. The doors to the courtyards from three of the four neighborhoods and from the common area were locked. Staff 14 (CG) acknowledged the doors were locked and stated that if a resident wanted to go outside, staff opened the door for them. Another CG stated the doors were locked when the weather was cold or rainy but didn't know why the doors were currently locked because the weather was sunny and mild. On 10/12/21 at 9:00 am, the courtyard doors were all observed locked. In an interview at 10:35 am, Staff 1 (ED) was informed the courtyard doors had been locked the previous day, and was asked for the facility's policy regarding when the courtyard doors were to be locked and unlocked. Following the interview, the courtyard doors were observed to be unlocked. The facility's "Courtyard Door Policy" stated the doors were to be unlocked between 8:00 am and 6:00 pm except in situations of snow, ice and extreme heat. On 10/13/21 at 10:05 am, the doors were, again, observed to be locked, preventing residents free access to and from the courtyards. The need to ensure residents had access to an outdoor space which allowed them to enter and return without staff assistance was reviewed with Staff 1 on 10/13/21 at 12:00 pm. She acknowledged the findings.

Z168 OAR 411-057-0160 Outside Area Outdoor Policy revised for Residents to access courtyard. Outdoor Policy states: Courtyard Door Policy- 02/14/2020 Courtyard Doors will be unlocked at 8:00am and re-locked at 6:00pm to allow residents to allow residents direct access to a secure outdoor recreation area. Staff must do a visual check of each courtyard before locking/securing courtyard door to ensure that no residents or staff are currently occupying the courtyards. The paging system is connected to all outdoor recreation door sensors to alert staff when a resident enters or exits the outdoor space. This schedule may vary based on inclement weather conditions such as; Snow, Frost /Ice, Extreme Heat above 75 degrees or heavy rain.

The findings of the re-licensure survey conducted 10/11/21 through 10/13/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 A situation was identified where there was a failure of the facility to comply with the Department's rules that caused residents serious harm. An immediate plan of correction was requested in the following area: OAR 411-057-0160 Behaviors. The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the revisit to the re-licensure survey of 10/13/21, conducted 02/22/22 through 02/23/22 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 and OARs 411 Division 57 for Memory Care Communities.