The Rawlin at Riverbend

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.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure 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.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN.
(a) The facility must determine whether a potential resident meets the facility's admission requirements.
(b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability.
(c) Each resident record must, before move-in and when updated, include the following information:
(A) Legal name for billing purposes.
(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding:
(i) Name.
(ii) Pronouns.
(iii) Gender identity.
(C) Prior living arrangements;
(D) Emergency contacts;
(E) Service plan involvement - resident, family, and social supports;
(F) Financial and other legal relationships, if applicable, including, but not limited to:
(i) Advance directives;
(ii) Guardianship; (iii) Conservatorship; and
(iv) Power of attorney.
(G) Primary language;
(H) Community connections; and
(I) Health and social service providers.

(2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.
(a) Resident evaluations must be:
(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and
(B) Performed at least quarterly, to correspond with the quarterly service plan updates.
(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.
(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.
(E) Documented, dated, and indicate who was involved in the evaluation process.
(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.

(3) EVALUATION REQUIREMENTS AT MOVE-IN.
(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.
(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.
(c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs.
(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.
(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.

(4) QUARTERLY EVALUATION REQUIREMENTS.
(a) Resident evaluations must be performed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.
(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.

(5) The resident evaluation must address the following elements:
(a) For service planning purposes, if indicated by the resident,
(A) Name.
(B) Pronouns.
(C) Gender identity.
(b) Resident routines and preferences including:
(A) Customary routines, such as those related to sleeping, eating, and bathing;
(B) Interests, hobbies, and social and leisure activities;
(C) Spiritual and cultural preferences and traditions; and
(D) Additional elements as listed in 411-054-0027(2).
(c) Physical health status including:
(A) List of current diagnoses;
(B) List of medications and PRN use;
(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and
(D) Vital signs if indicated by diagnoses, health problems, or medications.
(d) Mental health issues including:
(A) Presence of depression, thought disorders, or behavioral or mood problems;
(B) History of treatment; and (C) Effective non-drug interventions.
(e) Cognition, including:
(A) Memory;
(B) Orientation;
(C) Confusion; and
(D) Decision-making abilities.
(f) Personality, including how the person copes with change or challenging situations.
(g) Communication and sensory abilities including:
(A) Hearing;
(B) Vision;
(C) Speech;
(D) Use of assistive devices; and
(E) Ability to understand and be understood.
(h) Activities of daily living including:
(A) Toileting, bowel, and bladder management;
(B) Dressing, grooming, bathing, and personal hygiene;
(C) Mobility - ambulation, transfers, and assistive devices; and
(D) Eating, dental status, and assistive devices.
(i) Independent activities of daily living including:
(A) Ability to manage medications; (B) Ability to use call system;
(C) Housework and laundry; and
(D) Transportation.
(j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.
(k) Skin condition.
(l) Nutrition habits, fluid preferences, and weight if indicated.
(m) List of treatments - type, frequency, and level of assistance needed.
(n) Indicators of nursing needs, including potential for delegated nursing tasks.
(o) Review of risk indicators including:
(A) Fall risk or history;
(B) Emergency evacuation ability;
(C) Complex medication regimen;
(D) History of dehydration or unexplained weight loss or gain;
(E) Recent losses;
(F) Unsuccessful prior placements;
(G) Elopement risk or history;
(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and
(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.
(p) Environmental factors that impact the resident's behavior including, but not limited to:
(A) Noise.
(B) Lighting.
(C) Room temperature.
(6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.

Stat. Auth.: ORS 410.070, 441.122, 443.450
Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure service plans 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.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure 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.

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

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

This Rule is not met as evidenced by:

Based on 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.

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

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

This Rule is not met as evidenced by:

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

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.

This Rule is not met as evidenced by:

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

Refer to 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.

This Rule is not met as evidenced by:

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a dayA 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 SystemThe 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.

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.

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 9/23/242. 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.

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.



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.
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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

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 livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

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 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.

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.

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.

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.

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

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 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day