Village at Valley View

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

Based on interview and record review, it was determined the facility failed to ensure staff were informed of new interventions recommended by outside providers and the service plan was adjusted, if necessary, for 1 of 1 sampled resident (# 1) who received home health services. Findings include, but are not limited to: Resident 2 moved into the MCC in 07/2025 with diagnoses including mild dementia and congestive heart failure. During the acuity interview on 04/06/26 at 1:45 pm, Resident 2 was identified to have a pressure ulcer and a foley catheter and as receiving home health services. The resident's clinical record, from 01/06/26 through 04/06/26, was reviewed, and staff were interviewed. The following was identified: Resident 2 was receiving home health services due to having a pressure wound and foley catheter. The following transcriptions of the outside provider’s recommendations were identified in the residents’ progress notes: * 01/08/26: New wound care orders, drink Ensure three to four times daily, and offload at all times; * 01/20/26 and 01/30/26: Encourage the resident to lay in bed to relieve pressure to wounds; * 01/29/26: Absolutely no shearing forces or sliding of any sort, lift and transfer resident; * 02/06/26: Encourage the resident to elevate lower extremities when able; * 02/18/26: Monitor temperature to ensure it comes down, keep wound covered, when left open in brief with incontinence, it increases risk of infection; and *02/20/26: Keep dressing intact and not get wet, provide bed baths to maintain the dressing dry. Documentation revealed staff reviewed the above recommendations; however, there was no documented evidence direct care staff were informed of the recommendations or that the service plan was adjusted. In an interview on 04/08/26 at 9:08 am, Staff 3 (LPN) confirmed the interventions recommended by the outside provider were not communicated to staff, and the service plan was not updated. The need to ensure staff were informed of new interventions and the service plan was adjusted as necessary after receiving outside provider services were provided recommendations was discussed with Staff 1 (Administrator) on 04/09/26 at 1:45 pm. He acknowledged the findings.

1. Change to a wall box for all outside provider notes. Med Tech's retrained on transcription of outside provider notes. 2.The RCC checks daily to assure documentation and any changes to care plan are followed timely. The nurse reviews weekly for coordination of care. For outside community providers an envelope with a provider communication form, face sheet, and current med list will be sent. Any concerns from the community will be noted for the outside provider to see. When the resident returns these are reviewed for any changes to medications or plan of care. 3. At least monthly review of systems to assure adequacy and efficiency in the system. 4. RCC, RN, and Administrator

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and recorded every other month at different times of the day, evening, and night shifts, and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: On 04/08/26 at 10:00 am, fire drill records from 10/2025 through 03/2026 were reviewed with Staff 5 (Facilities Services Director). He confirmed the facility had not conducted a fire drill during evening or night shifts. On 04/08/26 at 1:00 pm, Staff 6 (Business Office Manager) confirmed there was no documentation of fire and life safety instruction to staff on alternate months of fire drills. The need to ensure fire drills were conducted and recorded every other month at different times of the day, evening, and night shifts, and fire and life safety instruction was provided to staff on alternate months was reviewed with Staff 1 (Administrator), Staff 2 (Regional RN), Staff 3 (LPN), Staff 4 (Resident Care Manager), Staff 5, Staff 6, and Staff 9 (Lead MT) on 04/08/26 at 3:15 pm. They acknowledged the findings.

1.Fire Drills are held every other month and Fire Safety Training at All Staff meeting on the alternate months. Alternating shifts implemented for fire drills. Fire Safety done 3/15/2026. Fire Drill Scheduled for NOC shift on 5/14/2026. Updated forms in use. Designated safety point is the front parking lot. or the side parking lot depending on fire location. Orientation checklist has fire safety and fire locations performed by the Maintenance director for all new staff. 2. The system is corrected to follow the above plan for fire drills and twice yearly emergency drills. 3. At least monthly review of Fire and Life safety Drills. 4. Maintenance director is responisble to ensure fire and emergency drills are completed on alternative months. Administrator to assure oversight.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C420.

Refer to C420

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

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

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C290.

Refer to C290

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

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

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: 1. On 10/22/25, from 9:55 am thru 12:40 pm, the facility main kitchen was observed. a. The following areas needed cleaning: * Janitor’s wall and floor had a build-up of black residue; * Drain next to the ice machine had a build-up of black residue; * Slicer was not covered when not in use; * Exterior of the microwave had food debris; * Commercial can opener had a build-up of food debris; * In the dry food storage area, bulk food containers, including beans and rice, had spills on the shelf; * Commercial mixer was not covered when not in use and had accumulated food debris; * Bulk food containers, both outside and lids, had accumulated food debris; * A residential mixer had food residue on the exterior; * A rack used to store clean dishes and equipment had visible dust; * All trash can exteriors and bases had accumulated debris; * Wall around the dishwasher and below the handwashing sink had spills; * Sprinkler heads had layers of dust; * Light fixture covers on the sides had grease buildup and visible dust; * Vents throughout the kitchen had accumulated dust; * Ceiling around vents and above the prep station had layers of dust and grease build-up; * Three tiers of the plastic food-holding cart had accumulated food debris; * The vent in the walk-in cooler had accumulated dust; *Rack in the walk-in cooler, used to store raw meat, had a build-up of dust and food residue; * Handwashing sink pipe next to the prep station had layers of dust; and * An electric wire hanging on the wall above the prep station had layers of dust. b. The following areas needed repair: * The edges of the white shelving in the dry food storage were worn. 2. On 10/22/25, at 12:04 pm, the Rose Cottage kitchenette was observed, and the following was noted: * Cabinet contained multiple opened syrup bottles that were undated and had spills; and * Cabinet under the two-compartment sink had water damage and brown residue. 3. On 10/22/25, at 12:10 pm, the Daisy Cottage kitchenette was observed, and the following was noted: * The cabinet next to the oven had spills and food debris; and * Cabinet under the two-compartment sink had water damage. 4. On 10/22/25, at 12:20 pm, the Lily Cottage kitchenette was observed and the following was noted: * A cabinet drawer had significant paint chipping; and * Cabinet under the sink had brown residue and water damage, with paper and tape being used to secure the area. 5. Improper food storage: * A bag of cocoa powder, in the dry food storage, was undated; * The walk-in cooler contained multiple undated cheese items and several sauce and dressing containers had spills and were undated; * Multiple packages of raw meat were not in containers to prevent drips; and * In the walk-in freezer, a box of cheesy garlic bread was undated and not completely covered or sealed. 6. Other areas of concern include: * Colored cutting boards were heavily scored; * All kitchen staff did not properly restrain their hair or beards; * At 11:40 am, Staff 2 (Executive Chef) prepared a pureed diet using peeled potato, peas, and chopped turkey, placing all three items into a blender and blending them. After blending, potato skins were visible in the pureed diet. The surveyor directed Staff 2 to remove the potato skins when preparing the pureed diet; and * Combining all three food times in one blender made the pureed diet unpalatable. The areas of concern were observed and discussed with Staff 2 on 10/22/25 at 12:30 pm and Staff 1 (ED) at 12:40 pm. The findings were acknowledged.

a. Janitor sink and wall has been scrubbed and cleaned and will be maintained daily after usage b. All floor drains have been cleaned and will be added to the weekly cleaning list c. All appliances will be kept covered after being cleaned and finished being used d. Microwave has been cleaned and is added to the dialy cleaning list e. Can opener was removed from table and thoroughly cleaned and reattached. The actual opener piece is cleaned daily and added to the cleaning list f. Dry storage shelves have all been wiped down and added to daily cleaning list g. Both mixers have been cleaned completely and added to the daily cleaning list h. Flour and Sugar bins were both emptied and cleaned inside and out. Both added to the weekly cleaning list i. All shelves were wiped down, both in the walk in and in the kitchen. Those have been added to the daily cleaning list. j. All trash cans were cleaned inside and out and added to the weekly cleaning list k. Used a pressure washer to clean the walls in the dish area and are on the daily cleaning list to be attended to daily l. All light fixtures, sprinkler heads and the ceiling were cleaned and will be added to the weekly cleaning list m. All vents in the ceiling were removed and cleaned and will be added to the weekly cleaning list n. Food carts have been cleaned and added to the daily cleaning list o. Pressure washer was used to clean the pipes under the hand washing sink and will be added to the weekly cleaning list p. Electrical cords that are over the prep table were wiped down and sanitized and will be added to the weekly cleaning list q. The dry storage shelves are planned to be repainted to meet compliance r. Carestaff have been retrained to ensure that all containers in the cottages are to remain closed when not in use and date after opening s. The areas under the sinks in all cottages are currently under repair and will be finished before date of compliance t. Kitchen staff have been retrained to date all products that have been opened and cleaned u. Kitchen staff have been retrained to keep raw meat products on or in a designated container on the bottom shelf of the meat rack v. All cutting boards have been replaced with new ones w. Hair nets and beard nets have been purchased and will be worn daily These corrective actions will be monitored by the Executive Chef

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to C240.

Myself, Josh Hamik the Executive Director and Tony the Executive Chef will be monitoring these areas weekly, monthly and as needed to make sure we stay on top of these items listed below. Tony has created checklists, updated checklists to include daily, weekly and monhtly duties for his staff. a. Janitor sink and wall has been scrubbed and cleaned and will be maintained daily after usage b. All floor drains have been cleaned and will be added to the weekly cleaning list c. All appliances will be kept covered after being cleaned and finished being used d. Microwave has been cleaned and is added to the dialy cleaning list e. Can opener was removed from table and thoroughly cleaned and reattached. The actual opener piece is cleaned daily and added to the cleaning list f. Dry storage shelves have all been wiped down and added to daily cleaning list g. Both mixers have been cleaned completely and added to the daily cleaning list h. Flour and Sugar bins were both emptied and cleaned inside and out. Both added to the weekly cleaning list i. All shelves were wiped down, both in the walk in and in the kitchen. Those have been added to the daily cleaning list. j. All trash cans were cleaned inside and out and added to the weekly cleaning list k. Used a pressure washer to clean the walls in the dish area and are on the daily cleaning list to be attended to daily l. All light fixtures, sprinkler heads and the ceiling were cleaned and will be added to the weekly cleaning list m. All vents in the ceiling were removed and cleaned and will be added to the weekly cleaning list n. Food carts have been cleaned and added to the daily cleaning list o. Pressure washer was used to clean the pipes under the hand washing sink and will be added to the weekly cleaning list p. Electrical cords that are over the prep table were wiped down and sanitized and will be added to the weekly cleaning list q. The dry storage shelves are planned to be repainted to meet compliance r. Carestaff have been retrained to ensure that all containers in the cottages are to remain closed when not in use and date after opening s. The areas under the sinks in all cottages are currently under repair and will be finished before date of compliance t. Kitchen staff have been retrained to date all products that have been opened and cleaned u. Kitchen staff have been retrained to keep raw meat products on or in a designated container on the bottom shelf of the meat rack v. All cutting boards have been replaced with new ones w. Hair nets and beard nets have been purchased and will be worn daily These corrective actions will be monitored by the Executive Chef

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

Based on observation, interview, and record review, it was determined the licensee failed to provide administrative oversight to ensure the quality of care and services rendered in the facility. Findings include, but are not limited to: During the re-licensure survey, conducted 02/10/25 through 02/14/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations. Refer to deficiencies in the report.

1. The Administrator or designee oversees the daily operations of the community and ensures the quality of care and services are being rendered in the community including the supervisions and training on staff. 2. The Administrator or designee holds daily stand up meetings with department directors to discuss needs, goals, and oversight of operations. Daily stand up meetings include review of the electronic health records "dashboard" ensure review of changes of condition, incident reports and other clinical components. Administrator or designee also attends daily shift change reports with care staff to commicate and provide direction to staff on care needs. The Administrator reports at least weekly to the executive COO and VP of Health Services key quality indicators such as staffing, incident reports, care concerns and other quality improvement metrix. This information is reviewed at least weekly during a Quality Assurance (QA) meeting with the executive team to ensure compliance. 3. The Administrator or Designee is to oversee these processes daily. 4. The Administrator is to ensure that the above is occuring with oversight of the COO and VP of Health Services.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to: During the survey, conducted 02/10/25 through 02/14/25, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective. In an interview on 02/12/25 at 3:00 pm, Staff 1 (Administrator) and Staff 2 (Executive Nurse) confirmed that ongoing quality improvement programs were not being conducted. The need to ensure the facility developed and conducted ongoing quality improvement programs was reviewed with Staff 1 and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings. Refer to the deficiencies in the report.

1. The VP of Health Services has re-inserviced the Administrator and department supervisors on the company Quality Assurance Program according to company and licensing approved policies and procedures. 2. Administator and department supervisors have signed acknowlegement of understanding policy and procedures regarding quality assurance pertaining to such metrics as resident and family satisfaction, employee satisfaction, grievance processes, using the "Dashboard" in the electronic medical records (EMR) for incident reporting and medication quality assurance and other associated policies. The Administrator meets with department supervisors at least weekly to review and solve issues identified and reported. There is a record of these meetings to track progress and follow up as needed. The Administrator also leads a monthly Quality Improvement meeting per company policy. 3. The COO meets at least monthly with the Administrator to assure ongoing quality assurance processes are followed. 4. The VP of Health Services (RN) meeting at least monthly with the community nurse to assure ongoing quality assurance process are followed.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required wound care. Findings include, but are not limited to: Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. The resident’s clinical chart including the service plan available to caregiving staff dated 04/30/24, Interim Service Plans (ISPs), dated 11/01/24 through 02/14/25, Observation notes, dated 11/10/24 through 02/14/25, and signed physician orders were reviewed. Observations of the resident and interviews with the staff were completed. On 02/11/25 at 10:00 am, an observation of the resident during ADL care was completed. Resident 3 was observed to have an intact blood blister on his/her left calf that was unbandaged. On 02/11/25 at 11:15 am, Staff 3 (Wellness Director/LPN) confirmed the facility had no documentation of the presence of the blood blister, including instructions to staff for monitoring or care of the blood blister. A telehealth assessment of the intact blood blister was completed by Staff 2 (Executive Nurse) on 02/11/25 at 3:15 pm. Staff were instructed to monitor the blood blister. On 02/12/25 at 4:15 pm, Staff 2 documented in Observation notes that the resident’s blister remained intact, and she covered the blister with loose fitting gauze and gauze wrap. There was no documented evidence provided to survey of instructions to staff for care or monitoring of the newly wrapped blister. On 02/12/25 at 12:35 pm, Staff 2 stated the intact blood blister alone did not constitute a significant change of condition; however, if it were to open then it would be followed as a wound by the RN. On 02/13/25 at 10:11 am, Resident 3 was visualized with a soiled bandage on his/her left lower leg. This surveyor asked Staff 16 (MT) what happened to the resident, and she stated she needed to change the bandage. There was no documented evidence of instructions to the MT on how to perform a dressing change for the skin injury. The MT unwrapped the bandage from the resident’s leg with skin and/or residue pulled from the open area as the bandage was removed. This constituted a change in the skin injury from a blister to an open wound which required a nursing assessment. There was no audible or physical indication the resident was in pain during the removal of the bandage. The MT continued to treat the newly opened area by spraying the wound with wound cleanser. She prepared to dress the wound with a bandage, but the surveyor stopped the process and requested a nurse be called to assess the open area first. At 10:36 am, Staff 2 entered the resident’s room and told Staff 16 that MTs could only perform First Aid and not wound care without directions from a nurse. Staff 2 proceeded to complete a skin assessment, and she dressed the resident’s wound. The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents when an unlicensed staff member exercised her own independent judgment in how to care for an open wound without instructions from a licensed professional. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who required wound care. Findings include, but are not limited to: Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. The resident’s clinical chart including the service plan available to caregiving staff dated 04/30/24, Interim Service Plans (ISPs), dated 11/01/24 through 02/14/25, Observation notes, dated 11/10/24 through 02/14/25, and signed physician orders were reviewed. Observations of the resident and interviews with the staff were completed. On 02/11/25 at 10:00 am, an observation of the resident during ADL care was completed. Resident 3 was observed to have an intact blood blister on his/her left calf that was unbandaged. On 02/11/25 at 11:15 am, Staff 3 (Wellness Director/LPN) confirmed the facility had no documentation of the presence of the blood blister, including instructions to staff for monitoring or care of the blood blister. A telehealth assessment of the intact blood blister was completed by Staff 2 (Executive Nurse) on 02/11/25 at 3:15 pm. Staff were instructed to monitor the blood blister. On 02/12/25 at 4:15 pm, Staff 2 documented in Observation notes that the resident’s blister remained intact, and she covered the blister with loose fitting gauze and gauze wrap. There was no documented evidence provided to survey of instructions to staff for care or monitoring of the newly wrapped blister. On 02/12/25 at 12:35 pm, Staff 2 stated the intact blood blister alone did not constitute a significant change of condition; however, if it were to open then it would be followed as a wound by the RN. On 02/13/25 at 10:11 am, Resident 3 was visualized with a soiled bandage on his/her left lower leg. This surveyor asked Staff 16 (MT) what happened to the resident, and she stated she needed to change the bandage. There was no documented evidence of instructions to the MT on how to perform a dressing change for the skin injury. The MT unwrapped the bandage from the resident’s leg with skin and/or residue pulled from the open area as the bandage was removed. This constituted a change in the skin injury from a blister to an open wound which required a nursing assessment. There was no audible or physical indication the resident was in pain during the removal of the bandage. The MT continued to treat the newly opened area by spraying the wound with wound cleanser. She prepared to dress the wound with a bandage, but the surveyor stopped the process and requested a nurse be called to assess the open area first. At 10:36 am, Staff 2 entered the resident’s room and told Staff 16 that MTs could only perform First Aid and not wound care without directions from a nurse. Staff 2 proceeded to complete a skin assessment, and she dressed the resident’s wound. The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents when an unlicensed staff member exercised her own independent judgment in how to care for an open wound without instructions from a licensed professional. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided.

1. The resident was immediately assessed and care provided by the VP of Health Services(RN) at the time of the needed wound care. Instruction was given to the Med Tech at the time of the incident regarding appropriate first aid care versus wound care orders and skilled wound care. Providence Hospice Director was called for coordination and understanding from hospice nurses that they may not "delegate" community Med techs to provide wound care. Education done regarding the actual RN delegation process for Oregon. This was completed by VP of Health Services. Audit performed on first aid kits to ensure appropriate products in use and that specialized wound care supplies were not for general use. Paper In-service with signature conducted with all Med Techs. 2. Monthly Med Room audit by RN includes review of appropriate supplies for first aid. Added to Med Tech competency understanding of first aid versus skilled wound care. 3. Monthly Monitoring with Med Room Audit 4. Resident Care Coordinator (RCC ) and RN with Administrator oversight.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' rights to be treated with dignity and respect and to be free from physical restraints for 1 of 1 sampled resident (#3) who had a full-length bed rail and received feeding assistance and for an unsampled resident who required feeding assistance. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. The resident’s clinical chart including the service plan available to caregiving staff dated 04/30/24, Interim Service Plans (ISPs), dated 11/01/24 through 02/14/25, outside provider notes, dated 11/01/24 through 12/31/24, “Lenity Oregon Device Assessment,” dated 08/21/24, and signed physician orders were reviewed. Observations of the resident and interviews with the staff and resident’s family were completed. a. During the acuity interview on 02/10/25 at approximately 2:30 pm, Resident 3 was identified to have side rails on his/her hospital bed. The resident’s service plan indicated the resident required full assistance with transferring and ADL care including toileting and had a history of falls requiring fall interventions. On 11/01/24, the hospice RN documented that a “signed MD order was faxed to the facility for a full rail on [his/her] hospital bed to help with [Resident 3’s] safety, protection and comfort.” This intervention was put into place because the half rail hospice installed previously was allowing for Resident 3 to “get the trunk of [his/her] body upright” and then s/he would fall out of bed. On 11/01/24, an ISP identified the use of full bed rails which directed staff to ensure the rails were in the up position while the resident was in bed. On 02/11/25 at 10:00 am, this surveyor entered Resident 3’s room with caregiving staff to make observations of ADL care. The resident’s bed was observed to have a full bed rail that extended the length of the left side of the hospital bed. The right side of the hospital bed was pushed against the wall. The rail was in the elevated position and Resident 3 was positioned diagonally with his/her left leg draped over the rail. The resident was yelling for help. The caregivers lowered the rail and assisted the resident out of bed and with his/her ADL needs. On 02/12/25 at 10:48 am, Staff 18 (CG) was asked how the resident used the bed rail. Staff 18 confirmed the resident did not use the rail for mobility, and acknowledged Resident 3 was trying but could not get out of bed during the observation on 02/11/25. The full-length bed rail was seen as a restraint because it was limiting Resident 3’s independent mobility by restricting him/her to the bed unless assisted out by caregivers. The facility failed to ensure Resident 3’s right to be free of physical restraint was maintained. b. During the acuity interview on 02/10/25 at approximately 2:30 pm, Resident 3 and multiple unsampled residents were identified to need feeding assistance. Meal observations were conducted on 02/10/25 through 02/14/25. Two caregivers were observed providing feeding assistance for Resident 3 and an unsampled resident over the course of two meals. Staff were standing over the residents instead of sitting next to them while providing assistance. On 02/13/25 at 12:16 pm, Staff 16 (MT) was asked why she stood while assisting residents with eating. Staff 16 reported standing made her appear like she was doing something. If she sat, it looked like she wasn’t doing anything. The need to ensure residents’ rights to be treated with dignity and respect and to be free from physical restraint was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

1. Administrator or designee ensures all resident's rights are being followed and implemented. Policy is followed for restraint free community unless Individual Based Limitation Policy is followed. The resident identified has an IBL in place signed by her HCPOA. Staff have been in-serviced on standing while feeding residents verbally by RCC in real time during the week of 2/18/25 and further training of resident dignity and these particular concerns will addressed during formal training scheduled 3/21 and 3/24/2025 by RN Trainer. 2. Policy and Procedure for assistive devices with restraining quality reviewed with Providence Hospice and their associated supplier. All staff retrained on supportive devices with restraining qualities and notification to Administrator if a new device is seen within resident apartments without associated service planning. All future staff continue to be trained on Supportive Devices with restrating qualities and Resident dignity. 3. Administrator or designee to do at least weekly walkthrough to determine any new devices that may have come into the community unbeknownst to management staff. 4. Administrator, Licensed Nurse or Designee will oversee the corrections are being followed at least weekly.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

Based on observation, interview and record review, it was determined the facility failed to notify the local Senior and People with Disabilities (SPD) office when an incident of abuse, or suspected abuse, occurred and 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 ensure investigations included all required components including Administrator review, for 4 of 4 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to: 1. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia. The resident’s Observation notes, dated 11/12/24 through 02/10/25, Interim Service Plans (ISPs), dated 09/18/24 through 02/08/25, incidents report, dated 11/09/24 through 02/09/25, Care History (alert charting documentation), dated 11/10/24 through 02/13/25, and Outside Services Documentation, dated 11/03/24 through 02/07/25, were reviewed and the following incidents were identified: * 11/09/24: Unwitnessed fall in the resident’s private bathroom; * 11/15/24: Staff documented on an ISP relating to a rash on Resident 1’s private areas, bottom, and thigh reporting the rash occurred due to “[Bowel movement and] sitting in a wet brief”; * 11/26/24: Unwitnessed fall with injury; * 12/18/24: Skin tear on left arm; * 01/09/25: Left second finger bruising and blister; and * 01/31/25: Resident to resident altercation. There was no documented evidence the incidents of abuse, or suspected abuse, were immediately reported to the local SPD office or that the physical injuries of unknown cause were immediately investigated to conclude the injury was not the result of abuse. Additionally, there was no documented evidence that the incidents that were investigated by the facility included documentation of the Administrator’s review. Documentation was received on 02/12/25 at 3:10 pm and on 02/14/25 at 11:08 am that the above incidents were reported to the local SPD office. The need to ensure all incidents of abuse, or suspected abuse, were reported to the local SPD office, injuries of unknow cause were immediately investigated and reported to the local SPD office when abuse, or suspected abuse, could not be ruled out, and included documentation of the Administrator’s review was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings. 2. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease. The resident’s Observation notes, dated from 12/21/24 through 02/10/25, Interim Service Plans, dated from 12/21/24 through 01/31/25, and incident reports, dated from 12/24/24 through 01/31/25, were reviewed and the following was identified: * 01/31/25: Resident to resident altercation. There was no documented evidence the facility reported the incident to the local SPD office or that the Administrator reviewed the investigation. Documentation was received on 02/12/25 at 3:10 pm that resident to resident altercation was reported to the local SPD office. The need to ensure all incidents of abuse were immediately reported to the local SPD office and investigations had documented evidence of the Administrator’s review was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings. 3. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia. The resident's 11/10/24 to 02/10/25 Observation notes, Interim Service Plans, incident reports, and Incident Investigations were reviewed, and interviews with staff were conducted. a. On 11/19/24, the resident’s Observation notes stated, “Care staff found big bruise size of a soft ball ish on [Resident 4’s] ride [sic] side of [his/her] ribs” and “[I]nformed the Nurse.” There was no documented evidence an immediate investigation was completed to rule out abuse or that the injury was immediately reported to the local Seniors and People with Disabilities (SPD) office. During an interview on 02/11/25 at 12:20 pm, Staff 3 (Wellness Director/LPN) stated she had not been informed of this injury, and no investigation or reporting had occurred at the time of injury. The survey team requested the injury be reported to the local SPD office, and confirmation was provided on 02/11/25 at 1:57 pm. b. On 01/22/25, the resident experienced an unwitnessed fall which resulted in an injury to his/her head. The incident was immediately investigated by Staff 3, and the investigation concluded that abuse or suspected abuse could be ruled out and did not need to be reported to the local SPD office. The investigation did not include all required components, including administrator review. The need to ensure all injuries of unknown cause were immediately reported to the local SPD unless an immediate investigation reasonably concluded that the injury was not the result of abuse, and that all investigations included all required components, was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings. 4. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. The resident's 11/10/24 to 02/12/25 Observation notes, Interim Service Plans, incident reports, and Incident Investigations were reviewed. Observations of the resident and interviews with staff were completed. a. The resident's Observation notes indicated the resident experienced the following injuries of unknown cause: * 12/02/24 - "[C]are staff found bruise on [his/her] left arm bigger than a quarter"; * 12/08/24 - "[R]esident [had] a small/medium bruise on [his/her] left calf”; and * 02/12/25 – “[R]esident had a non-injury fall…I did not find any visible [injuries], just a new small skin tear.” During an ADL observation on 02/11/25, a blood blister was visualized by this surveyor on the resident’s left calf. On 02/11/25 at 11:15 am, Staff 3 (Wellness Director / LPN) reported the blood blister was identified by a caregiver on 02/01/25 and reported to the MT on duty. No additional documentation regarding the incident was available. There was no documented evidence an immediate investigation was completed for any of the injuries of unknown cause. Survey requested the above injuries of unknown cause be reported to the local SPD office. Confirmation of reporting for all injuries of unknown cause was received by 3:08 pm on 02/14/25. b. Resident 3 had a skin tear to his/her left elbow documented in an Observation note on 11/11/24. The Incident Investigation report from the event, dated 10/28/24, was reviewed and failed to have evidence the administrator reviewed the investigation. The need to ensure immediate investigations were completed for injuries of unknown cause and/or reported to the local SPD if abuse could not be ruled out and investigations of abuse or suspected abuse included documentation of the administrator’s review was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

1.Incidents have been investigated and reported to APS for each incident identified. APS reports were submitted during the survey for Resident 1 (11-9,11-15,11-26,12-18/ 2024, 1-9-25 and 1-31-25) Resident 2 (1/31/25), Resident 3 (12-2, 12-8, and 12-12-2024), and Resident 4 (11-19- 2024 and 1-22-2025 2. Incidents reviewed daily by the clinical team during morning stand-up(Administrator, RCC, RN). Investigations will be completed within 24 hours of incident. Once investigations are completed they will be emailed to Administrator to review and sign. Anything deemed reportable to APS will be reported within 24 hours per policy and Oregon Administrative rules. 3. Incident reporting and investigation reviewed daily and completed within 24 hours per policy. Monthly on-going quality assurance from company COO and VP of Health Services regarding incident reporting. 4. RN, Administrator, COO and VP of Health Services.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure initial evaluations addressed all required elements, and were updated and changed as appropriate within the first 30 days for 1 of 1 newly admitted resident (#2), and quarterly evaluations were the foundation used to develop residents' quarterly service plans, including documentation relevant to the residents' needs and current condition for 2 of 3 sampled residents (#s 1 and 3) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer's disease, anxiety, and depression. The resident's initial evaluation was reviewed, and it failed to address the following required elements: * Customary routines including sleeping, eating, and bathing; * List of medications and PRN use; * Presence of depression, thought disorders, and/or behavioral or mood problems; * History of treatment and effective non-drug interventions relating to mental health issues; * Memory, orientation, and confusion; * Vision and speech; * Pain including pharmaceutical and non-pharmaceutical interventions, and how a person expresses pain or discomfort; * Nutrition habits, fluid preferences, and weight if indicated; * List of treatments; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Elopement risk or history; * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature; * Pronouns; and * Gender identity. On 02/14/25 at 11:59 am, it was confirmed that there was no documented evidence the resident was re-evaluated with updates and changes as appropriate within 30 days of move in. The need to ensure the initial evaluation included all required elements and was updated and changes were made as appropriate was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia. Observations of the resident, staff interviews, and review of the record were conducted. Between 09/17/24 and 10/23/24, the resident experienced a resident to resident altercation, a fall that resulted in a hip fracture and hospitalization, and was admitted onto hospice. Resident 1's most recent evaluation, dated 10/31/24, was not reflective of, or had conflicting information related to the resident's health status and current needs in the following areas: * The admission onto hospice and what services they were going to provide; * Ability to ambulate (the “Fall” section noted independence with walking); * Behavior interventions for physical aggression towards other residents; and * Weight bearing status. There was no documented evidence Resident 1 was evaluated at least quarterly after 10/31/24. The need to ensure Resident 1's evaluation was reflective of his/her health status and current needs, and was updated at least quarterly was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer's disease. The resident’s clinical record was reviewed. The most recent quarterly evaluation for Resident 3 was completed on 10/15/24. On 02/12/25 at 2:40 pm, Staff 3 (Wellness Director / LPN) confirmed the subsequent quarterly evaluation, due on 01/13/25, was not completed. The need to ensure evaluations were completed quarterly was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided.

1.Residents surveyed (1,2,3) have all been reviewed and updated for accuracy. Resident 4 is deceased. All other resident service plans are under review and will be up to date and in compliance and reviewed for accuracy by alleged compliance date. All questions in the evaluation are answered completely and anyone doing evaluations has training requiring the elements in the evaluation. Gender identity and pronouns have been added to the evaluation and associated service plan to assure this is addressed with each evaluation. All residents have had gender identity and pronouns updated. 2. Prior to the beginning of the next month, the RCC/Administrator prints the next month's service plan due dates and schedules service conferences with the resident, resident representative, case manager, and community staff. Any one doing evaluations will assure that all components of the evaluation are answered thoroughly. Re-training on complete evaluation and service planning with VP of Health Services (RN) to be completed the week of March 10th. The complete evaluation located in the EHR mirrors the required components in the OAR if all questions and associated services are answered and identified. 3. Monthly audit of scheduled evaluations to assure timely compliance. Time frame of initial evaluation, 30 day evaluation and quarterly evaluations will be followed per policy and OAR. 4. RCC, RN, Administrator and VP of Health Services.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes and entries made to the service plan must be dated and initialed, service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and service plans were implemented for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia. The resident's current service plan available to staff, dated 01/19/25, and 11/10/24 through 02/10/25 Observation notes 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: * Ted hose; * Bathing; * Involvement of hospice, including tasks they assisted with and frequency of visits; * Repositioning; * Hospital bed with half side rails; * Assistance required with eating; * Frequency of safety checks; * Evacuation assistance; and * Number of staff required to assist with transfers, incontinence care, dressing. The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan available to staff, dated 10/31/24, revealed 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: * What services hospice provided and when they provided them; * Mobility and ability to walk short distances on his/her own; * All fall interventions staff should be utilizing; * Customary routines relating to Resident 1's sleeping patterns; * How the resident participated in dressing, toileting, and bathing; * The frequency of toenail care provided when facility staff assisted with showers and where his/her personal nail kit was located; * Who staff would contact if the shower chair was not in "safe working condition"; * Monitoring and/or cueing while eating; * Meal reminders; * What a "bad day" looked like and which behaviors the resident exhibited when s/he was having a "bad day"; * Missing toes on the resident's right foot; * Resident 1's daily routine; and * The resident's independence with the key to his/her apartment. Additionally, there were handwritten updates that lacked staff initials and dates. There was no documented evidence the facility had completed a quarterly service plan review for the resident, which would have been due on or around 01/29/25. The need to ensure resident service plans were completed quarterly, were reflective of current care needs and preferences, provided clear direction to staff, and handwritten updates were initialed and dated was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings. 3. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the service plan available to staff, dated 12/20/24, revealed 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: * Fall risk; * Mobility device used; * What to monitor for relating to receiving a scheduled blood thinner; * How Resident 2 assisted with dressing, grooming, oral care, and bathing; * Dressing in layers at times; * Brief versus regular underwear use; * Who staff would contact if the shower chair was not in "safe working condition"; * Hearing aids and assistance needed; and * Interventions for when Resident 2 was "helping" other residents. Additionally, there were handwritten updates that lacked staff initials and dates. The need to ensure resident service plans were reviewed within 30 days of move in, were reflective of current care needs and preferences, provided clear direction to staff, and handwritten updates were initialed and dated was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with the resident’s family and staff, and review of the service plan available to staff, dated 04/30/24, revealed the service plan was not reflective of the resident’s current care needs, did not provide clear direction to staff, and/or was not implemented in the following areas: * Ambulation status; * Wheelchair versus walker use; * Transfer assistance required; * Frequency of safety checks; * Emergency evacuation needs; * Fall mat; * Wheelchair seat cushion; * Clothing preferences while sleeping; * Mechanical soft and thickened liquids; * Use of a straw; and * Divided plate. There was no documented evidence the facility had completed a quarterly service plan review for the resident, which would have been due on or around 01/13/25. The need to ensure resident service plans were completed quarterly, were reflective of current care needs and preferences, provided clear direction to staff, and were implemented was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided.

1. Resident 4 deceased as of 2/17. Residents 1 (BG), 2 (RW), and 3 (PH) updated for all components listed on the survey report. All other service plans are under review for accuracy and will be completed by the listed compliance date. The Service Plan binder has been updated with current service plan, Activity evaluation and plan, and Life Story. The binder also includes any pertinent instructions from Home Health, hospice, behavioral support, and community nurse. 2. Service plans are printed quarterly at the same time the service conference occurs to assure timely updates. Service plans are printed any time a TSP, Signficant change of condition, or any other change is made to the service plan. An acknowledgement form for staff to sign will be kept with service plans. 3. Monthly review to assure that the latest service plan is included. 4. RCC, RN, Administrator.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 3 of 4 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 3 and 4’s most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. During an interview on 02/14/25 at 10:10 am, Staff 5 (RCC) confirmed the facility lacked documented evidence of a Service Planning Team for all residents. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

1.All service plans will be reviewed and updated for accuracy by the alleged compliance date. Re-implementation of use of the company Service conference form has occurred and RCC and Administrator have been trained on it's use by VP of Health Services the week of March 10th. Using this form allows for documentation of the occurrence of the Service conference and documents involved parties including, but not limited to the resident as able, family representative, caseworker, direct care staff, and other entities. 2. The company approved Service Plan form is be used to assure that the service plan is completed and that the conference is documented. A record book of service conferences is to be maintained. Caseworkers will be sent monthly notifications of service conferences for them to attend as able. 3. Monthly evaluation to assure that service conferences and the associated service plans are done timely and within the standard time frame. A review of attendees will be checked. A report will be run prior to the upcoming month to schedule service conferences prior to the expiration of the current service plan. 4. RCC, RN, Administrator and VP of Health Services.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated, referred to the RN for assessment and the service plan was updated as needed for 2 of 2 sampled residents (#s 1 and 3); and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. The resident's current service plan available to staff, dated 04/30/24, Observation notes, dated 11/10/24 through 02/14/25, Interim Service Plans (ISPs), and weight records, dated 09/10/24 through 02/10/25, were reviewed, and observations of the resident during ADL care were made. a. Resident 3’s weight records were reviewed and revealed the following: * 11/01/24 - 89.8 pounds; * 12/03/24 - 85.3 pounds; * 01/06/25 - 93.2 pounds; and * 02/06/25 - 88.6 pounds. Between 11/01/24 and 12/03/24, Resident 3 had a weight loss of 4.5 pounds or 5.01% of his/her total body weight in one month. Between 12/03/24 and 01/06/25, Resident 3 had a weight gain of 7.9 pounds or 9.26% of his/her body weight in one month. These weight fluctuations represented significant changes of condition, and the facility was required to evaluate, to refer to the facility RN, to document the change, and to update the service plan as needed. On 02/13/25 at 1:26 pm, Staff 3 (Wellness Director/LPN) stated the weight changes were “probably not” referred to the RN, and no additional documentation regarding the weight changes was provided. b. 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 progress noted at least weekly through resolution: * 11/11/24 - Skin tear to left elbow; * 11/29/24 - New medications; * 12/02/24 - Bruise on left arm; * 12/07/24 - Out of liquid thickening powder; * 12/08/24 - Bruise to left calf; * 12/12/24 - Discontinuation of routine Tylenol (for pain); and * Refused medications in 01/2025 and 02/2025. During an ADL observation on 02/11/25, a blood blister was visualized by this surveyor on the resident’s left calf. On 02/11/25 at 11:15 am, Staff 3 reported the blood blister was identified by a caregiver on 02/01/25 and reported to the MT on duty. However, the facility had no documentation of the blood blister in the resident’s chart, including resident-specific actions or interventions needed for the blister, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly. The need to ensure the facility evaluated residents who experienced significant changes of condition, referred the resident to the facility nurse, documented the change and updated the service plan as needed; and 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 discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided. 2. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia. The resident's current service plan available to staff dated 10/31/24, Observation notes, dated from 11/12/24 through 02/10/25, Interim Service Plans, dated from 09/18/24 through 02/08/25, and weight records, dated from 11/01/24 through 02/05/25 were reviewed. Observations of the resident were made, and staff were interviewed. The following changes of condition were noted: * 10/23/24: Return from hospital due to a fall with a hip fracture, surgical incision, and weight bearing as tolerated. There was no documented evidence the surgical incision or his/her weight bearing status was monitored through resolution. * 10/23/24: Hospice admission (which constituted a significant change of condition). There was no documented evidence the facility referred to the RN. * 11/26/24: Fall with a skin tear on left arm. Although the fall was monitored, there was no documented evidence of the facility monitoring the skin tear that resulted from the fall through resolution. * 12/01/24: Significant weight loss. There was no documented evidence the weight loss was referred to the RN. Refer to C 280, example 1b. * 01/06/25: Significant weight gain. There was no documented evidence the weight gain was referred to the RN. Refer to C 280, example 1b. * 01/29/25: Increase in the morning dosage of Seroquel (for agitation). There was no documented evidence of monitoring through resolution. * 01/31/25: Resident to resident altercation. There was no documented evidence of monitoring through resolution. * 02/08/25: The resident fell out of his/her wheelchair as another resident was pushing him/her and caused the wheelchair to "tip over." There was no documented evidence that actions or interventions were determined and communicated to staff on each shift. The need to ensure the facility evaluated residents who experienced significant changes of condition, referred the resident to the facility nurse, documented the change and updated the service plan as needed, and determined and documented what action or interventions were needed for short-term changes of condition, communicated the actions or interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings. 3. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease. The resident's current service plan available to staff dated 12/20/24, Observation notes, dated from 12/21/24 through 02/10/25, and Interim Service Plans, dated from 12/21/24 through 01/31/25. Observations of the resident were made, and staff were interviewed. The following changes of condition were noted: * 12/24/24: Fall; * 12/28/24: Staff documented the resident was experiencing "chest burn/pain in chest area"; * 01/15/25: Staff documented "resident felt not good"; and * 01/31/25: Resident to resident altercation. There was no documented evidence the facility determined and documented actions or interventions, communicated those actions or interventions to staff on all shifts, and/or monitored the changes of condition through resolution. The need to ensure the facility determined and documented actions or interventions needed, communicated those actions or interventions to staff on all shifts, and monitored the changes of condition at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings. 4. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia. The resident's current service plan available to staff, dated 01/19/25, and 11/10/24 through 02/10/25 Observation notes 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: * 11/19/24 – Bruise on ribs; * 12/12/24 – Change in diet texture to mechanical soft; * 01/13/25 – Change in diet texture to puree; * 01/15/25 – New medication; * 01/22/25 – Unwitnessed fall with injury; * 02/04/25 – Changes to medications; and * Missed medications throughout 01/2025 and 02/2025. The need to ensure the facility determined and documented actions or interventions 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 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

1.Residents identified have had service plans updated and sig. change of condition completed by RN and service plans were updated for the elements noted in the statement of deficiency. A weight report was run and any changes in weight requiring reporting and/or significant change of condition were assessed by an RN the week of March 10th. A review of all TSP's was completed and resolved or further service planned. 2. The community will follow the following processes to assure TSP's and Sig. change of conditions will be promptly completed. The community utilizes the following processes available in EHR (electronic health record.) a. Temporary Service Plans (TSP) in the EHR. Med Techs are to use only the approved TSP's and are to implement and notify RCC and RN using the Nurse reporting guidline form. RCC or RN to review and DC TSP's. b. EHR Alert Charting following the Alert Charting Guidelines c. TSP and Fall Interventions available on the Incident Report for any associated falls. Nursing responsibilities: a.Review Observation Notes Monday- Friday b.Review Incident Reports Monday -Friday- Coordinate with Administration for investigations c.Nurse to work with Med Techs and RCC to assure alert charting and TSP’s are utilized appropriately and that the information is accurate.. d.Review Alert Charting in EHR Monday-Friday e.Review Monthly Weight Change Summary in EHR f.Keep Log of all skin concerns and provide weekly skin/wound monitoring g.Coordinate Care with home health, hospice, wound clinic for wounds assessment monitoring by RN. h.Monthly review, or more frequently as ordered by PCP, of CBG’s i.RCC, Med Techs, and/or Administrator to communicate with RN’s for significant change of condition j.RN to complete Significant change of condition assessment as required per policy and OAR. k.VP of Health Services to provide additional Med Tech trainings the weeks of March 10th and March 17th, with change of shift meetings. All Day Trainings on the 21 and 24 of March. Trainings will be attended by RCC and Administrator. Med Tech responsibilities: a. Use only approved EHR TSP. b.Prompt notifications following Nurse notification guidelines document. c.Follow charting guidelines to assure prompt and accurate reporting of resident status d.Med Techs to use Med Tech to Med Tech communication log (24 hour report) each shift. Administrator Responsibility a.Morning Stand up done daily, At least one Nurse will attend in person or remotely when not on site. b. Administrator reviews all IR's and observation notes Monday through Friday. Staff trained to provide weekend notifications to ED per Call Guideline document. 3. Daily review of TSP's and IR, Weekly clinical meeting with VP of Health Services. This system requires daily monitoring and weekend Med Techs trained regarding notifications to Nurse and Administrator using the company notification form. 4. RCC, RN and Administrator with oversight of VP of Health Services and COO

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 2 sampled residents (#s 1 and 3) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia and atrial fibrillation. The resident’s weight records, dated 11/01/24 through 02/05/25, Outside Services Documentation, dated 11/03/24 through 02/07/25, and Observation notes, dated 11/12/24 through 02/10/25, were reviewed and staff were interviewed. a. The resident sustained a fall on 09/24/24 which resulted in a hip fracture with surgical repair and a hospital admission. The resident returned to the facility on 10/23/24 when s/he had been admitted onto hospice services and was identified as “weight bearing as tolerated”, which constituted a significant change of condition. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. b. The following weights were recorded by the facility: * 11/01/23: 139.4 pounds; * 12/01/24: 130.8 pounds; * 01/06/25: 143.8 pounds; and * 02/05/25: 143 pounds. Weights for 09/2024 and 10/2024 were requested on 02/11/25 at 11:37 am. On 02/11/25 at 12:19 pm, Staff 16 (MT) verified the facility had not obtained Resident 1’s weights during that specific time period. Resident 1 experienced an 8.6 pound weight loss, or 6.16% of his/her total body weight, in one month (from 11/01/24 through 12/01/24), and a 12.2 pound weight gain, or 8.53% of his/her total body weight, in one month (from 12/01/24 through 01/06/25). Both the weight loss and weight gain represented a significant change of condition. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer’s disease. Resident 3's weight records were reviewed and revealed the following: * 11/01/24 - 89.8 pounds; * 12/03/24 - 85.3 pounds; * 01/06/25 - 93.2 pounds; * 02/06/25 - 88.6 pounds; and * 02/12/25 - Resident refused re-weigh during survey. From 11/01/24 to 12/03/24, Resident 3 had a weight loss of 4.5 pounds or 5.01% of his/her body weight in one month. Additionally, from 12/03/24 to 01/06/25 the resident had a weight gain of 7.9 pounds or 9.26% of his/her body weight in one month. Both weight fluctuations indicated a significant change of condition and required an RN assessment. RN assessments for both significant changes of condition were requested on 02/11/25. On 02/14/25 at 9:41 am, Staff 2 (Executive Nurse) confirmed there was no documented evidence the facility RN completed an assessment of Resident 3’s significant weight loss or weight gain. The need to ensure all significant changes of condition were assessed by an RN was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings, and no additional documentation was provided.

1.Significant change of condition assessment completed as necessitated for identified residents 1 and 3. Weight report was run and Sig. changes of condition were completed on all residents with documented weight changes on residents experiencing weight changes per OAR. 2. New RN hired to perform on-site work and eliminate LPN position. VP of Health Service (RN) to train new RN and the new RN will be signed up to attend the OHCA Role of the Nurse class. Med Techs, RCC and Administrator retrained on the nurse notification system as identified in Tag C270. New RN to be taught systems to do monitoring for changes in additon to relying on reports from other staff. VP of Health Services (RN) sitting the building currently. 3. Daily for changes of condition requiring temporary service plan, alert charting, and/or significant change of condition. Weekly and Monthly schedules followed as above for monitoring. 4. RN, Administrator and VP of Health Services oversight.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#5) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task. During the acuity interview on 02/10/25, Resident 5 was identified to be administered insulin injections by non-licensed staff. Resident 5’s MAR, reviewed from 01/01/25 through 02/12/25, revealed the resident received Admelog (insulin to treat diabetes) once daily and Lantus (insulin to treat diabetes) once daily. The insulin had been given by Staff 13 (Lead MT) and Staff 16 (MT) on multiple occasions. Review of delegation records and the MAR, showed the following: a. There was no documented evidence that the reauthorization for Staff 13, dated 02/06/25, and Staff 16, dated 01/09/25, occurred prior to the end of the prior reauthorization period. b. There was no documentation by the RN verifying that all requirements from the initial delegation were met. c. There was no documented evidence of a nursing assessment and condition of the resident in their environment of care to determine that the condition remained stable and predictable, and delegation remained a safe care delivery option. d. There was no documented evidence that the RN had verified Staff 13 and Staff 16’s documentation and observed Staff 13 and Staff 16 perform the nursing procedure. e. There was no documentation of the length of authorization period. The requirements for delegation were reviewed with Staff 2 (Executive Nurse) on 02/13/25 and 02/14/25. She acknowledged the findings. The need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings.

1. The community is cancelling it's contract with outside agency for delegations and bringing in house to company hired RN's who are trained in Oregon delegation rules. All company RN's are enrolled in NurseLearn. Resident number 5 was assessed by VP of Health Services (RN) and review of all current delegations was completed. RN currently in process of re-doing all delegations to be in compliance and to be "in-house". 2. Assuring proper training of delegating RN's within company systems and training of OSBN Delegations per OAR's. 3. With new delegations and quarterly. 4. RN, RCC, and Administrator

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

Based on interview and record review, it was determined the facility failed to ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure staff were informed of new interventions, and the service plan was adjusted, if necessary, and reporting protocols were in place for 2 of 3 sampled residents (#s 1 and 3) who received outside services. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer's disease. The resident's service plan available to staff, dated 04/30/24, the 01/2025 MAR, current physician orders, outside provider notes, and Interim Service Plans were reviewed. The following recommendation from outside providers was identified: * 12/22/24 - “There was an issue and discrepancy with [his/her] Xanax order [for anxiety/agitation]. Hospice showed 2 tabs PRN [every four hours] but [the] facility order showed 1 tab [every four hours]. The meds were sent from the pharmacy with 2 tabs per bubble pack, which means only 1 was being used and the other wasted. This is a risk for miscount and diversion. Xanax with 1 tab per bubble pack is being delivered and the others with 2 tabs per pack will be wasted per protocol.” On 02/12/25 at 11:39 am, Staff 11 (Lead MT) and this surveyor reviewed Resident 3’s narcotics which included a bubble pack for Xanax with two tablets per bubble dated as delivered to the facility on 12/09/24. On 02/13/25 at 1:26 pm, Staff 3 (Wellness Director/LPN) verified she was unaware of this recommendation by the hospice RN. The need to ensure the facility management or the licensed nurse was notified of the services provided by the outside provider to ensure staff were informed of new interventions, the service plan was adjusted, if necessary, and reporting protocols were in place was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia. The resident's service plan available to staff, dated 10/31/24, Outside Services Documentation, dated from 11/03/24 through 02/07/25, and Interim Service Plans, dated from 09/18/24 through 02/08/25, were reviewed. The following recommendations from outside providers was identified: * 11/03/24: "day [three] or [four] of [no bowel movement], advised give suppository," call if "impaction", and call if the resident starts exhibiting "pain or [decrease] in mobility"; and * 01/09/25: "monitor [left second] finger wound." There was no documented evidence the recommendations were communicated to staff or that the facility followed the recommendations. The need to ensure the facility management or the licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, that the service plan was adjusted, if necessary, and reporting protocols were in place was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings.

1. Change to a wall box for all outside provider notes. Med Tech's retrained on transcription of outside provider notes. Resident 3 had new bubble pack ordered for 1 tab and bubble pack with 2 tabs destroyed. Resident 1 notes from hospice were no longer applicable and the concerns had resolved. 2.The RCC checks daily to assure documentation and any changes to care plan are followed timely. The nurse reviews weekly for coordination of care. For outside community providers an envelope with a provider communication form, face sheet, and current med list will be sent. Any concerns from the community will be noted for the outside provider to see. When the resident returns these are reviewed for any changes to medications or plan of care. 3. At least monthly review of systems to assure adequacy and efficiency in the system. 4. RCC, RN, and Administrator

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

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 2 of 3 sampled residents (#s 3 and 4) whose ADL care was observed, and for multiple unsampled residents who received meal service and assistance. Findings include, but are not limited to: 1a. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia. The resident was dependent on staff for all ADL care including incontinence care, grooming, and hygiene. At 10:15 am on 02/11/25, Staff 19 (CG) and Staff 27 (CG) were observed providing incontinence care for Resident 4 in his/her bed. Staff 19 and Staff 27 were observed donning gloves and then assisting the resident in rolling in order to remove his/her soiled incontinence pad and soiled brief. Staff 27 placed the soiled incontinence pad onto the floor without first placing it in a bag. Staff 19 and 27 proceeded to assist the resident in donning a clean brief and placing a clean incontinence pad on the bed without removing their soiled gloves or performing hand hygiene. After providing incontinence care, staff were observed discussing oral hygiene for the resident, and Staff 27 began to reach for an oral mouth swab while still wearing soiled gloves. This surveyor stopped the process and requested staff perform hand hygiene and don clean gloves prior to continuing to provide ADL assistance. b. Observations of meal service were conducted from 02/10/25 through 02/13/25 and the following was identified: * Caregiving staff were observed serving food and feeding residents without wearing a protective covering over potentially contaminated clothing; and * No hand hygiene for residents occurred, despite multiple unsampled residents observed to be eating with their hands. The need to maintain effective infection prevention and control protocols was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings. 2. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. At 10:00 am on 02/11/25, Staff 16 (MT) and Staff 18 (CG) were observed providing ADL assistance for Resident 3. During the observation, both staff donned gloves and assisted the resident in transferring to the toilet. Staff 16 removed the resident’s soiled brief and incontinence pad. Staff 16 proceeded to put lotion on the resident’s arms and legs. No glove change or hand hygiene was performed between tasks. Staff 18 provided perineal care and assisted the resident in donning a clean brief and pants. Staff 18 then assisted the resident to the sink and started to set-up the resident’s toothbrush. No glove change or hand hygiene was performed between tasks. This surveyor stopped the process and requested the staff perform hand hygiene and don clean gloves prior to continuing ADL assistance. The need to establish and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

1. Staff involved in the noted incident were counseled and retrained by RCC at the time of reporting (February 14th and February 15th.) regarding proper use of PPE, in particular gloves and effective hand hygiene. All staff have completed a 1 hour training in Relias. 2. All Day Staff Mandatory Trainings being held on March 21 and 24th. Proper use of PPE and Handwashing will be covered during this training. All staff required to take the mandatory Infection control training prior to being on the floor. 3. At least weekly spot checks in the cottages by RCC. 4. RCC, RN and Administrator.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system.

Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to: During the re-licensure survey, conducted 02/10/25 through 02/14/25, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C 160 – Reasonable Precautions; * C 282 – RN Delegation and Teaching; * C 302 – Tracking Control Substances; * C 303 - Medication and Treatment Orders; * C 305 - Resident Right to Refuse; * C 310 - Medication Administration; and * C 330 – Psychotropic Medications. The need to ensure a safe medication and treatment system was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

1.Complete MAR audit to be completed by nursing by alleged compliance date. When completed, new 90 day orders will be sent to providers. 2. 90 Day orders are done quarterly by the RN and sent to providers. All new orders, changes, or DC orders are managed by qualified staff. Manual imputation of orders are limited to nursing and only for urgent orders. Otherwise orders are entered by the pharmacy and approved in the EHR through the pharmacy link section by trained Med techs with 3 check process in place. 3. Quarterly MAR audit while preparing 90 physician orders. Daily review of "Dashboard" in ECP to identify MAR discrepancies for quality assurance. Monthly Med Room Audits are completed by RN. 4. RN and Administrator See Tag C160, C282, C302, C303, C305, C310, C330

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 3 of 3 sampled residents (#s 2, 3, and 4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia. The resident had a signed physician orders for scheduled morphine (for pain), 20mg/ml, to be administered four times daily, PRN morphine, 20 mg/ml, to be administered hourly as needed, and PRN oxycodone (for pain), 5 mg tablet, to be administered every six hours as needed. Morphine and oxycodone are narcotic pain medications and are controlled substances. Review of the resident's 01/01/25 through 02/10/25 MARs and Controlled Substance Disposition logs revealed the following: a. On the following dates, scheduled morphine was shown as administered on the MAR, but was not documented in the Controlled Substance Disposition log: * 01/21/25 at 8:00 am; * 01/22/25 at 8:00 am; * 01/29/25 at 8:00 am; * 02/05/25 at 12:00 am; * 02/05/25 at 6:00 am; * 02/06/25 at 12:00 am; and * 02/06/25 at 6:00 am. b. On 02/04/25 at 6:00 pm, morphine was documented as administered in the Controlled Substance Disposition log, but was not documented as administered on the MAR. c. On 02/09/25 at 6:00 am, the MAR was blank with no indication of whether morphine had been administered to the resident. d. On 02/11/25 at 12:30 pm, Staff 14 (MT) was unable to locate Resident 4’s PRN oxycodone medication. Upon further investigation, Staff 3 (Wellness Director/LPN) stated it appeared the resident had not used PRN oxycodone since 07/2023, and the medication was disposed of in 08/2024. She stated it appeared the medication had not been reordered from the pharmacy and was not made available for the resident to use if needed since 08/2024. She stated she had not been aware the medication was not in the medication cart. As of 02/11/25 at 12:30 pm, the resident’s bottle of liquid morphine appeared to have 19 ml remaining, confirmed by Staff 14 who was present. The Controlled Substance Disposition log showed that as of 02/11/25 at 12:00 pm, the bottle had 15.50 ml remaining. During an interview on 02/11/25 at 4:00 pm, the above information was reviewed with Staff 3, who acknowledged the facility was not aware of the above discrepancies prior to them being identified by the survey team. She stated there was no current process for reviewing or reconciling narcotic medications. The need to ensure a system was in place for accurately tracking controlled substance distribution was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease. The resident's Controlled Substance Disposition logs, MARs, dated 01/01/25 through 02/10/25, and physician’s orders were reviewed. Resident 2 was prescribed PRN hydrocodone/APAP 5-325 mgs for pain. The following inaccuracies were identified between the resident's MARs and the Controlled Substance Disposition log: The Controlled Substance Disposition log reflected the medication was administered on 01/07/25 and 01/09/25, but the 01/2025 MAR only had documentation that the PRN was administered on 01/09/25. The narcotic count reflected the information documented in the Controlled Substance Disposition log. The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings. 3. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. The resident's physician orders, the Controlled Substance Disposition logs and the MAR, dated 01/01/25 through 02/09/25 were reviewed. Resident 3 had a physician order dated 08/02/24 for alprazolam 0.25 mg – one tablet by mouth every four hours as needed for anxiety, agitation, or sleep. The following inaccuracy was identified between the resident's MAR, physician orders, and the Controlled Substance Disposition log: Resident 3’s MAR indicated s/he received a PRN dose of alprazolam on 01/03/25 at 10:36 pm by Staff 31 (MT). The Controlled Substance Disposition log documented the dose was administered by Staff 32 (MT) on 01/02/25 at 6:30 with am and pm not specified. No other doses were documented as administered in the MAR or the Controlled Substance Disposition log for 01/2025. The inaccuracy was reviewed with Staff 3 (Wellness Director / LPN) on 02/13/25 at 1:26 pm. She acknowledged the discrepancies. The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

1. Complete review of controlled substances within the Med room and carts was completed. Discontinued medications were destroyed per policy for controlled substances. Re-education done with Med Techs regarding proper documentation of controlled substances with controlled substance log, electronic health record, and appropriate shift to shift controlled substances count. Resident 4 is deceased and medication was destroyed. This concern is under investigation with RN. Staff have been re- trained on the concerns with resident's 2 and 3 with MAR and Controlled substance log not being consistent with both being signed each time a medication is given. 2. Weekly controlled substances audits resumed per policy and procedure. All Med Techs will receive a medication training review which will include management of controlled substances, on March 21st and 24th. 3. At least weeky with controlled substances audit and monthly with Medication room audit. 4. RN, RCC, and Administrator.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed; and failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. Resident 3's current physician's orders, the MAR, dated 01/01/25 through 02/09/25, and bowel monitoring records, dated 01/01/25 through 02/09/25 were reviewed. a. The MAR was blank for the following medications: * Alprazolam (for anxiety) – blank on one occasion; * Carbamide (for ear wax build up) – blank on one occasion; * Nystatin (for rash) – blank on one occasion; and * Refresh artificial tears (for dry eyes) – blank on one occasion. On 02/12/25 at 11:39 am, the surveyor and Staff 11 (Lead MT) reviewed the MAR and medication supply. Staff 11 was unable to verify if the above orders had been followed. b. The resident’s triple antibiotic cream (for infection prevention) was not administered as prescribed on 01/24/25, 01/28/25, and 02/08/25. The MT documented the resident’s skin was clear. c. The resident’s scheduled Senna (for constipation) was not administered as prescribed on 02/07/25 and 02/08/25 because the medication was documented as not in the cart. d. The resident had physician ordered parameters for PRN Senna and PRN polyethylene glycol powder (both for constipation). The resident’s Senna was not administered as prescribed on ten occasions, and his/her PRN polyethylene glycol powder for constipation was not administered as prescribed on five occasions. e. Observations of the resident during meals occurred on 02/10/25 and 02/11/25. On 02/10/25, the resident received a dinner meal of regular textured garlic bread, pasta salad, mixed vegetables and thin liquid water. On 02/11/25, the resident received a regular textured breakfast meal of cut waffle and cut sausage. The facility failed to provide the resident’s prescribed diet orders of mechanical soft textures and thickened liquids. f. On 01/02/25, according to the Controlled Disposition log the resident received two tablets of alprazolam; however, the resident’s physician orders instructed staff to administer one tablet. g. The facility failed to have signed physician orders in the resident’s record for the following two treatments the facility was responsible to administer: * Triple antibiotic ointment – topically apply to sore on right side of face two times daily; and * Carbamide 6.5% ear solution – use five drops in both ears at bedtime. The need to ensure all medications were carried out as prescribed and written signed physician orders were documented in the resident’s facility record was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia. The resident's current physician's orders, and MARs, dated 01/01/25 through 02/10/25, were reviewed. The following scheduled medications were not administered per physician's orders as staff documented that the medication was not available in the facility: * Pepcid (for acid reflux): Three occasions; * Senna (for bowel care): Once; * Miralax (for bowel care): Once; * Celexa (for depression): Once; and * Flomax (for enlarged prostate): Eight occasions. The need to ensure all physician’s orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings. 3. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease. The resident’s physician’s orders, MARs, dated 01/01/25 through 02/10/25, and Patient Discharge Instructions, dated 12/22/24, were reviewed. The following was identified: a. There was an order that was signed on 12/19/24 for the facility to report if the systolic blood pressure was greater than 180 or less than 100 or the diastolic blood pressure was greater than 90 or less than 40 unless otherwise specified. The facility had documented evidence that Resident 2’s blood pressure was only taken on 12/24/24. Multiple staff reported they were unaware of the signed physician’s order to obtain the resident’s blood pressure or the parameters of when to contact the physician. b. The following medications were not administered as staff documented that they weren't available at the facility: * Seroquel (for agitation/aggressive behaviors): Ten occasions; * Senna (for bowel care): Ten occasions; and * Valacyclovir (for shingles): 11 occasions. c. There was no documented evidence the facility had signed orders for eight out of nine medications that they were responsible to administer to the resident. The need to ensure written signed physician orders were documented in the resident’s facility record and that all medications and treatments were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings. 4. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia. The resident’s MAR dated 01/01/25 through 02/10/25 and all signed physician orders were reviewed, and interviews were conducted. The following was identified: a. The resident’s facility record did not have documentation of a signed order for Desitin cream (for skin redness). b. The resident had a signed order from hospice, dated 12/12/24, stating “Okay to do mechanical soft diet”, which was implemented by the facility. On 01/13/25, an Interim Service Plan instructed staff to provide the resident with a puree diet texture. The facility was not able to provide documentation of a signed order for this diet texture change. c. The resident had a signed order, dated 11/21/24, for Secura Protective Cream (for skin protection) to be applied as needed. The treatment was not located on the MAR/TAR. d. The resident had a signed order for docusate 50 mg / 5 ml solution to be given by mouth every 12 hours (for constipation). The medication was not administered as ordered on 31 out of 69 occasions with notations including the medication was “out of stock in cart”, “unable to find medication”, or the “resident was sleeping”. e. The following medications were not administered as ordered, with notations stating the resident was sleeping: * Citalopram 10 mg (for depression): 12 occasions; * Olanzapine 5 mg (for agitation/paranoia): six occasions; and * Acetaminophen 325 mg (for pain); 11 occasions. The need to ensure written, signed physician’s orders were present in the resident’s facility record for all medications and treatments the facility was responsible for administering, and all medication and treatment orders were carried out as prescribed, was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings. 5. Resident 5 moved into the facility in 01/2024 with diagnoses include dementia and type II diabetes. The resident’s MAR, dated 01/01/25 through 02/12/25, and all signed physician orders were reviewed, and interviews were conducted. The following was identified: a. The resident’s facility record did not have documentation of a signed order for the following medications and/or treatments: * Icthammol ointment (for nail inflammation); * Hydrocortisone 2.5% cream (for rash); * Nystatin powder (for rash); * Acetaminophen 500 mg (for pain) PRN every six hours; and * Admelog insulin pen (for type II diabetes). b. The order for nystatin powder stated it was to be applied “every 8 hours [for] 14 days.” The order was dated 01/09/25, and the facility began administering the treatment on 01/11/25. The facility was still administering the treatment every eight hours as of 02/12/25. c. The resident had a signed order dated 12/19/24 which instructed staff to “Check blood sugar before each meal and at bedtime.” Staff 2 (Executive Nurse) confirmed on 02/13/24 that this order was not being followed. d. The resident had a signed order dated 12/19/24 for Admelog insulin pen which was not being followed: * The order instructed staff to administer the medication with the largest meal of the day. There was no documentation of which meal of the day was the largest. The medication was scheduled to be administered at 7:30 am. * On 01/05/25, the medication was not administered. Notations stated the resident’s CBG was 73 mg/dl. The signed orders stated that “if blood sugar is less than 80 mg/dl, then eat 15 gm of fast-acting carbohydrate” and “recheck blood sugar in 15 minutes and repeat if blood sugar is not above 90.” There was no documented evidence the resident received 15 gm of fast-acting carbohydrate or that his/her blood sugar was rechecked. *On 02/11/25 at 7:19 am, Admelog Insulin was not administered as ordered, with notations stating “no pass reason: other” and no additional information documented. The need to ensure medication and treatment orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings.

1.Complete MAR audit to be completed by nursing. When completed new 90 day orders will be sent to providers. Systems placed within EHR to trigger provider notifications for CBG's, weights, and any physician ordered non-medication orders. Complete review of med room processes and box system reimplemented. Filing system reviewed for accuracy and timliness. Accurate purging system implemented to assure orders processed and filed timely. Copies of orginal orders obtained for residents identified. Training being done March 21 and 24th for all staff on Diet Texture modifications, Dementia training and Infection Control. Med Techs will have a separate Med Tech review training to address all elements listed in the statement of deficiency. This will be taught "in-house" by VP of Health Services. Med Techs have been taught and are now required to show the oncoming shift their Med pass to assure that all medications have been addressed and that there are no "holes" in the MAR. BP was added to Resident 1 MAR with notification parameters. Bowel Monitoring was added to #3. #5 orders clarified.CBG's on MAR per orders. Standing Orders will be updated to not have a time limit of 72 hours and will instead state "for complaints of constipation or signs and symptoms of constipation and as directed by community nurse". This will be done since routine bowel monitoring is not done unless as ordered. System in place to monitor daily for missed medication as "out of stock" so that medications are ordered timely. Retraining of staff on administration of medication for resident sleeping will occur on the 21st and 24th training dates. 2. 90 Day orders are done quarterly by the RN and sent to providers. All new orders, changes, or DC orders will be overseen by qualified staff. Manual imputation of orders will be limited to nursing and only for urgent orders. Otherwise orders will be entered by the pharmacy and approved in the EHR through the pharmacy link section by trained Med Techs. 3 check med review in place. 3. Daily monitoring of "out of stock" meds, "holes" and missed medications at daily standup using EHR "dashboard" At least quarterly MAR audit while preparing 90 physician orders. Spot checks by RN for modified diets. Daily review of "Dashboard" in EHR to identify MAR discrepancies for quality assurance. Weekly Controlled Substances audit and Monthly Med Room Audit completed by RN. 4. RCC, RN & Administrator and oversight by VP of Health Services.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order, for 3 of 3 sampled residents (#s 1, 2, and 3) with documented refusals. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease. The resident's MARs, dated from 01/01/25 through 02/10/25, physician’s orders, and Observation notes, dated from 12/21/24 through 02/10/25, were reviewed. The following refusals were noted: * Metamucil (for bowel care): Three occasions; * Eliquis (blood thinner): Four occasions; * Seroquel (for agitation/aggressive behaviors): Five occasions; * Valacyclovir (for shingles): Four occasions; * Latanoprost (for glaucoma): Three occasions; and * Senna (for bowel care): Four occasions. There was no documented evidence the facility notified the provider when the resident refused to consent to physician’s orders. The need to notify the provider when residents refused to consent to an order was reviewed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 09/2023 with diagnoses including dementia. The resident's MARs, dated from 01/01/25 through 02/10/25, physician’s orders, and Observation notes, dated from 11/12/24 through 02/10/25, were reviewed. The following refusal was noted: * 01/11/25: Miralax (for bowel care). There was no documented evidence the facility notified the provider when the resident refused to consent to physician’s orders. The need to notify the provider when residents refused to consent to an order was reviewed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer's disease. The resident's MAR, dated 01/01/25 through 02/09/25, was reviewed and revealed facility staff documented Resident 3 refused the following orders: * Alprazolam 0.25 mg (for anxiety) on one occasion; * Carbamide 6.5% (for ear wax) on 11 occasions; * Nystatin powder (for rash) on seven occasions; * Refresh eye drops (for dry eye) on 20 occasions; * Secura Protective 10% cream (for skin protection) on 11 occasions; * Senna (for constipation) on 11 occasions; and * Triple antibiotic ointment (for infection prevention) on nine occasions. On 02/12/25 at 10:43 am, Staff 3 (Wellness Director/LPN) confirmed there was no documented evidence the facility notified Resident 3's physician of the refusals. On 02/14/25, the need to notify the physician/practitioner when a resident refused consent to orders was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

1. System fix has been completed. Med Techs re-instructed on daily notifications unless otherwise noted by the PCP. Med Techs notifying daily. Faxes were sent to PCP's to clarify their preference for notifications and if other than daily, this will be added to EMAR to prompt for notification. Company form for refusals was re-implemented and Med Techs trained on it's use 3/10/25 by RCC and VP of Health Services (RN) 2. At least weekly review of "Dashboard" in EHR are completed by RN. For residents with frequent refusals- parameters for notification are requested from provider. For consistent refusals of certain medications, a request for provider review of appropriateness of continued order are sent. If refusals are deemed to be behavioral in nature, a consideration for Behavioral Support is made. 3. At least daily and weekly per policy 4. RCC and RN with Administrator oversight.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept and/or resident-specific parameters and instructions were included for PRN medications for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia. The resident’s MAR dated 01/01/25 through 02/10/25, and physician’s orders were reviewed. The following was identified: a. The resident had three PRN medications for pain which did not have parameters for order of administration: *Morphine Sulfate 20mg/ml (.25ml / 5 mg per dose) every hour; *Oxycodone 5 mg every six hours; and *Acetaminophen 325 mg every four hours. b. The resident had three PRN medications for shortness of breath which did not have parameters for order of administration: *Morphine Sulfate 20mg/ml (.25ml / 5 mg per dose) every hour; *Oxycodone 5 mg every six hours; and *Promethazine 25 mg every four hours. c. The resident had two PRN medications for nausea which did not have parameters for order of administration: *Lorazepam 0.5 mg every four hours; and *Promethazine 25 mg every four hours. d. The resident had three PRN medications for constipation which did not have clear parameters for order of administration: *Bisacodyl 10 mg suppository; *Milk of magnesia 400 mg/5ml; and *Lactulose 10 gm/15 ml solution. e. Staff documented two separate reasons for why a medication was not administered at the same time and date (refused by the resident and the medication was not available or the resident was sleeping) for the following medications: * Citalopram 10 mg (for depression): 10 occasions; * Docusate 100 mg (constipation): 13 occasions; * Acetaminophen 325 mg (for pain): eight occasions; and * Olanzapine 5 mg (for agitation/paranoia): three occasions. The need to ensure the MAR was accurate and that PRN medications included resident-specific parameters and instructions for administration was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings. 2. Resident 5 moved into the facility in 01/2024 with diagnoses include dementia and type II diabetes. The resident’s MAR dated 01/01/25 through 02/11/25 and physician’s orders were reviewed. The following was identified: a. On 02/09/25 and 02/11/25, Lantus subcutaneous injection (for type II diabetes) was signed as administered by Staff 12 (Lead MT). At 11:56 am on 02/13/25, Staff 2 (Executive Nurse) stated she spoke with Staff 12 via phone and that Staff 12 reported she did not administer the medication on the dates above. Staff 12 told Staff 2 that another MT had administered the medication because Staff 12 was not yet delegated, but Staff 12 had still signed the MAR as the one administering the medication. b. The resident received Admelog insulin pen injections (for type II diabetes) once daily. There was no documentation of the location of injection. The need to ensure the MAR was accurate and complete was reviewed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings. 3. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia. The resident’s MARs, dated from 01/01/25 through 02/10/25, and physician’s orders were reviewed. The following inaccuracies were identified: a. There were two separate reasons staff documented why a medication was not administered at the same time and on the same date (refused by the resident and the medication was not available to administer): * Pepcid (for acid reflux): Five occasions; * Senna (for bowel care): Once; * Flomax (for enlarged prostate): Three occasions; and * Seroquel (for agitation/restlessness): Once. b. There was no documentation if the following medications were administered as the MAR entries were blank on 01/22/25 at 8:00 am: * Flomax; * Celexa (for depression); * Seroquel; * Senna; and * Dilaudid (for pain). On 02/12/25 at approximately 11:15 am, Staff 14 (MT) verified the medications were administered per looking at the medication cards. The need to ensure MARs were accurate and included the date and time of administration was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings. 4. Resident 2 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease. The resident’s MARs, dated from 01/01/25 through 02/10/25, and physician’s orders were reviewed. The following inaccuracies were identified: There were two separate reasons staff documented why a medication was not administered at the same time and on the same date (refused by the resident and the medication was not available to administer): * Seroquel (for agitation/aggressive behaviors): Four occasions; * Senna (for bowel care): Nine occasions; and * Valacyclovir (for shingles): 11 occasions. The need to ensure MARs were accurate was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:59 am. They acknowledged the findings. 5. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. The resident’s MAR, dated 01/01/25 through 02/09/25, and physician orders were reviewed during the survey and revealed the following: a. Resident 3 had an order to receive ketoconazole shampoo as directed to wash hair on shower days (for fungal infection) dated 08/02/24. The order was transcribed onto the MAR to be administered as needed. On 02/12/25 at 11:55 am, Staff 11 (Lead MT) confirmed there was no documentation the treatment was ever administered, and she was unable to verify if the treatment had been administered as prescribed. b. The facility failed to maintain an accurate MAR because staff documented Resident 3 refused the following medications because s/he was sleeping: * Carbamide 6.5% (for ear wax) on one occasion; * Nystatin powder (for rash) on three occasions; * Refresh eye drops (for dry eye) on three occasions; * Secura Protective 10% cream (for skin protection) on three occasions; * Senna (for constipation) on three occasions; and * Triple antibiotic ointment (for infection prevention) on four occasions. On 02/14/25 at 12:45 pm, Staff 2 (Executive Nurse) stated the expectation was for MTs to attempt to wake the resident and sleeping did not constitute a refusal for a scheduled medication or treatment. c. The following orders lacked a documented reason for use in the MAR: * Ketoconazole; and * Thick-It. The need to ensure MARs were accurate and included the reason for use, date, and time administered was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings.

1.Complete MAR audit to be completed by VP of Health Services (RN) by alleged compliance date. When completed new 90 day orders will be sent to providers. Nursing specifically looking for diagnoses, parameters, and instructions for unlicensed staff. Staff instructed on process to assure all of medication pass done prior to leaving and not leaving any incomplete medications. Issues on resident's 1,2,3, and 5 have been resolved. Parameters written, New orders obtained. Resident 4 was deceased as of 2/17/2025. All Day Med Tech trainings to be held March 21st and 24th 2025 and taught by VP of Health Services. 2. Pharmacy links in EHR used with manual entering of medication only by licensed nurse and only under urgent need. Unlicensed staff will be given additional training on parameters and scope of practice during March Trainings. On-site competency (watching med passes) in the med room for med techs will be completed by VP of Health Services (RN) the weeks of March 10th and 17th, 2025. Daily review of dashboard for missed medications. 3. Evaluated daily as new changes occur, in addition during 90 day MAR audit as 90 day physician orders are prepared. 4. RCC, RN, in addition to oversight of Administrator. See 300, 302, 303

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 1 and 3) who were prescribed and administered PRN medications to treat behaviors. Findings include, but are not limited to: 1. Resident 1 was moved into the facility in 09/2024 with diagnoses including dementia. The resident had a physician's order for Seroquel, 50 mgs every six hours as needed for agitation and restlessness. Resident 1's MARs, dated from 01/01/25 through 02/10/25, and Observation notes, dated from 11/12/24 through 02/10/25, were reviewed. The resident was administered the psychotropic medication on 14 occasions with no documented evidence staff had first attempted non-drug interventions with ineffective results. On 02/12/25 at 11:07 am, Staff 3 (Wellness Director/LPN) verified by looking in the electronic MAR system that there were no non-drug interventions listed for staff use nor was there documentation of non-drug interventions attempted with ineffective results prior to the administration of the PRN psychotropic. The need to attempt non-drug interventions prior to administering PRN psychotropic medications was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings. 2. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. The resident's 12/14/24 through 02/09/25 MAR and prescriber orders were reviewed, and staff were interviewed. Resident 3 had a physician order for alprazolam 0.25 mg - take one tablet by mouth every four hours as needed for anxiety, agitation, or sleep. The MAR indicated the resident received the PRN medication on 12/14/24, 12/29/24, and 01/03/25. The resident's record lacked documented evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication. The need to ensure non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings.

1.The residents identified (1 and 3) have had MAR updated for resident specific non-pharmacological interventions prior to administration of medications. A new question was added to the EMAR to prompt for documentation that 4 non-pharmacological interventions were attempted prior to administration of psychtropic medication. Med Techs have been trained at a meeting on March 10th by VP of Health Services and this will also be reviewed at the trainings March 21 and 24th. 2. Nursing adds non-pharmacolocal resident specific interventions any time a new medication is ordered. Med Techs trained to notify nursing any time they see a PRN psychotropic. In addition with the 3rd check of all orders the RN will review. In additon, this will be reviewed quarterly with the service conference and referral to nursing if resident has a PRN psychotropic medication. 3. With all new orders and quarterly 4. RCC and RN with oversight of Administrator.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT; failed to document other less restrictive alternatives evaluated prior to the use of the device; and failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (#3) who had full length side rails. Findings include, but are not limited to: Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer’s disease. Resident 3 was observed to have a hospital bed with a single full side rail that ran the length of the left side of the bed, and the right side of the bed was positioned against the wall. The full side rail was visualized to be in the elevated position on 02/11/25 at 10:00 am with the resident calling for help with his/her left leg draped over the side rail. There was no documented evidence the following required elements were completed related to the full bed rail: * Assessment by facility RN, PT, or OT; * The facility documented other less restrictive alternatives evaluated prior to the use of the device; and * The facility had instructed caregivers on the correct use and precautions related to the use of the device. The full side rail was replaced with a half side rail on 02/12/25. On 02/13/25, Staff 2 (Executive Nurse) confirmed she had completed the resident's "Lenity Oregon Device Assessment” related to the half side rail that replaced the full bed rail. The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives were evaluated prior to the use of the device and caregivers were instructed on the correct use and precautions related to the device was discussed with Staff 1 (Administrator) and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings.

1. The policy is followed for restraint free community. Any assistive device with restraiing qualities will have an assessment by the RN. Resident 3 had RN assessment completed on 2/19/25 for the full bed rail and in addition has an IBL in place to have a full side rail with consents from her family. 2. Policy and Procedure for assistive devices with restraining quality reviewed with Providence Hospice and their associated supplier. All staff retrained on supportive devices with restraining qualities and notification to Administrator if a new device is seen within resident apartments without associated service planning. Further training to occur the 21st and 24th during all staff mandatory trainings. Med Techs, RCC and Administrator retrained on RN notification of any devices so that the RN may perform the assessments. 3. Administrator or designee does a weekly walkthrough to determine any new devices that may have come into the community unbeknownst to management staff. 4. Administrator, RN or designee will oversee the corrections are being followed weekly.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident and to meet the fire safety evacuation standards during the night shift. Findings include, but are not limited to the following: During the entrance conference on 02/10/25 at approximately 2:30 pm with Staff 1 (Administrator), Staff 3 (Wellness Director/LPN) and Staff 27 (CG), the following was identified: * The MCC consisted of three distinct cottages – Lily, Rose, and Daisy. Sixteen residents were living in Lily, 14 residents were living in Rose, and 13 residents were living in Daisy; * Two residents required two-person assist for transfers at all times – one resident resided in Lily and one resident resided in Daisy; * One resident, who resided in Rose, required occasional two-person assist for transfers; and * Eighteen residents were reported to require high levels of caregiving assistance due to requiring hospice services, cognitive decline, history of falls/fall risk, feeding assistance, history of behaviors, and history of resident-to-resident altercations. Observations of cares provided to residents and interviews with staff throughout the survey revealed five residents who required two-person transfer assistance. Daisy cottage had one resident who required two-person transfer assistance, Lily cottage had two residents, and Rose cottage had one resident who required two-person assistance at all times and one who required occasional two-person assistance. The facility's posted staffing plans, the staffing schedule from 01/25/25 through 01/31/25, and the corresponding timeslips were reviewed. The facility's posted staffing plan indicated three caregivers and one medication technician were scheduled to work the 10:00 pm to 6:00 am shift daily. This equated to one caregiver in each cottage and a MT to assist with caregiving duties as needed. On 02/12/25 at 2:57 pm, Staff 1 and Staff 2 (Executive Nurse) acknowledged the facility had not completed fire drills every other month with evacuation or relocation of residents, including the residents who required two-person transfer assistance. Additionally, when asked how the current overnight staffing plans accounted for the two-person transfers, Staff 2 acknowledged she would adjust the overnight staffing immediately. The facility lacked a sufficient number of overnight staff to meet the scheduled and unscheduled needs and fire evacuation standards of the multiple residents who required the assist of two care staff for transfers, had high levels of care needs, had behaviors (including resident-to-resident altercations) and resided in three distinct cottages. On 02/13/25 at 3:13 pm, the facility provided an updated schedule and staffing plan which included five caregivers and one MT for the 10:00 pm to 6:00 am shift. This updated schedule accounted for the scheduled and unscheduled needs of the residents and the fire safety evacuation standards. The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents and fire evacuation standards on the overnight shift was discussed with Staff 1 and Staff 2 on 02/14/25 at 12:12 pm. They acknowledged the findings.

1. The community has co-horted residents who are two person transfers and staffed accordingly. Rose cottage has ( 3) 2-person transfers and has higher acuity than Lily and Daisy. 1 of the 3 is always a two-person and 2 of the 3 are intermittently a 2-person. The current staffing is 5 on NOC. 1 in Lily, 1 in Daisy, 2 in Rose, and 1 Med Tech. Resident 4 is now deceased. There are sufficient staff to meet the scheduled and unscheduled needs of residents including evacuation on night shift (10PM-6AM). A fire drill was done on AM shift 3/14/2025 with an evaucation time of 6 minutes. A fire drill simulating night time with the residents in bed or in their rooms was accomplished with Rose cottage in 9 minutes with 2 care staff. Due to location, Lily and Daisy are behind 2 Fire Doors if the fire is in Rose. If those residents are in bed in their rooms they are behind 3 fire doors. In that situation, the Med Tech would go for evacuation allowing a decrease in time from 9 minutes. If the entire community needed evacuation then the med tech would assist all 3. Resident 1 who at survey was thought to be a intermittent 2 person, has been assessed as a 1 person by RN. This has been monitored and reports received from all 3 shifts. He has had continued improvement in his mobility. 2.The community continues to monitor two person transfer residents and staff for the ABST for scheduled, unscheduled, and evaucation needs. RN Assessment for significant changes of condition related to mobility. 3. At least monthly evaluation of ABST in addition to changes of condition and new or discharged residents. 4. RCC, RN, and Administrator with over sight of COO and VP of Health Services.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time that the staff were providing to each resident as outlined in each individual service plan for 3 of 4 sampled residents (#s 1, 3, and 4) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 09/2024 with diagnoses including dementia. The resident's service plan, Interim Service Plans, and ABST, were reviewed. Staff were interviewed and Resident 1 was observed. The resident's ABST was not reflective of care time needed in the following areas: * Escorts to and from meals and activities; * Transfers in and out of the bed and/or chair; and * Bowel and bladder management. The need to accurately capture care time on the resident's ABST was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25 at 11:09 am. They acknowledged the findings. 2. Resident 3 moved into the facility in 02/2022 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with the resident’s family and staff, the 10/15/24 service plan and Interim Service Plans, from 11/01/24 through 02/14/25, and Resident 3’s ABST data was reviewed. The resident's ABST evaluation was not reflective of care time needed in the following areas: * Safety checks, fall prevention; * Monitoring physical conditions or symptoms; * Providing treatments; * Supervising, cueing, or supporting while eating; * Transferring from bed; * Communication; and * Bowel and bladder management. The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:12 pm. They acknowledged the findings. 3. Resident 4 moved into the facility in 12/2017 with diagnoses including dementia. The resident's service plan, Interim Service Plans and ABST were reviewed. Staff were interviewed and Resident 4 was observed. The resident's ABST did not accurately capture care time in the following areas: * Medication administration; * Time spent repositioning; and * Frequency of safety checks. The need to ensure the ABST accurately captured care time was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

1. Residents 1 and 3 were updated on the ABST specifc to the items mentioned in the SOD. Resident 4 was deceased as of 2/17/2025. The remainder of the residents were reviewed and updated using caregiver reports on multiple shifts and while reviewing service plans in conjunction. Schedule and staffing has been updated to meet the needs in relation to ABST. The current RCC now has the duty of maintaining the ABST with oversight of RN and Administrator. Current RCC has extensive experience with the ABST in another community so no further training was completed. 2. The ABST is updated promptly as changes occur ensuring reflecting current needs. If a new RCC is hired the Administrator will assure that the RCC takes company training in relation to the ABST. The new RN will be trained on the ABST. 3. The ABST is reviewed at least weekly and with changes of condition, new admissions, and quarterly with service conferences by the RCC to ensure accuracy. The schedule is updated daily as needed when changes occur to reflect current ABST needs meeting state requirement. New admissions are done prior to move in. 4. RCC and Administrator with oversight of COO and VP of Health Services as company quality assurance activities.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in, no less than quarterly at the same time of service plan update, and/or with a significant change of condition for 3 of 4 sampled residents (#s 2, 3, and 4) and an unsampled resident, and failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. Findings include, but are not limited to: The facility was a licensed MCC with three distinct cottages. 1. The facility’s ABST was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/12/25 at 2:57 pm and on 02/14/25 at 9:13 am. The following was identified: a. Resident 2, who moved into the facility on 12/22/24, did not have an ABST evaluation completed until 02/02/25, or 42 days following the resident’s move to the facility. An unsampled resident, who moved into the facility on 02/03/25, did not have an ABST evaluation completed until after survey entered the facility on 02/10/25. b. Resident 3 experienced significant changes of condition related to weight changes on 12/03/24 and 01/06/25, and the resident required monitoring of physical conditions related to weight changes. There was no documented evidence the ABST was updated with the significant changes of condition. c. Resident 4’s ABST evaluation did not have evidence it was updated quarterly at the same time as the service plan update. 2. The facility’s posted staffing plan and staffing schedule from 01/25/25 to 01/31/25 were reviewed with Staff 1 and Staff 2 at 2:57 pm on 02/12/25. The following was identified: The posted staffing plan for the facility MCC was as follows: * Day shift: 6 CG, 2 MT; * Evening shift: 6 CG, 2 MT; and * Night shift: 3 CG, 1 MT. Review of the facility schedule and corresponding timecards from 01/25/25 to 01/31/25 revealed the facility failed to staff per the posted staffing plan on six shifts, or 28.6% of the total shifts reviewed. The need to ensure residents’ ABST evaluations were updated before move-in, with significant changes of condition, and no less than quarterly with the service plan, and the need to ensure consistent staffing to meet or exceed the posted staffing plan was discussed with Staff 1 and Staff 2 on 02/14/25 at 9:39 am. They acknowledged the findings.

1. Residents 1 and 3 have been updated to reflect their current needs. The ABST is updated prior to new residents moving in and once residents have moved out. The ABST is a reviewed and adjusted as needed when completing evaluations. Staffing and schedule updated daily as changes accur. 2. The ABST review added to the new resident movein check list ensuring completion prior to moving in. The ABST added as part of complete evaluation process as they are scheduled. Quarterly updates done in conjuction with service planning. The staffing plan will be updated quarterly and as needed based upon the changing ABST. RCC is maintaining schedule to assure adequate staffing. The community is hiring to 120% in order to account for call-offs or no-shows so that consistent staffing is in place. In addition, the community is staffing an extra staff member each shift to account for call-offs. Current days staffing is discussed at stand-up each morning to anticipate any staffing gaps that day. 3.The ABST is reviewed and updated daily as needed when changes occur and less than quartley with complete evaluations. Staffing and scheduling updated daily as needed when changes occur. 4.RCC and Administrator See 362

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired direct care staff (#s 25 and 30) 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 Manager) on 02/11/25. Staff 25 (CG), hired 01/01/25, and Staff 30 (CG), hired on 12/05/24, lacked documented evidence they had completed First Aid and abdominal thrust training within 30 days of hire. The need to ensure direct care staff completed the required First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 6 on 02/11/25 and with Staff 1 (Administrator) and Staff 2 (Executive Nurse) on 02/14/25. They acknowledged the findings.

1. Complete training audit under review to assure that all staff are trained per policy and OAR. All staff to be completed by the alleged compliance date. Mandatory trainings will be done on-site and in-person by VP of Health Services (RN) the week of March 21 and 24th. All competencies have been completed 3/14/2025. Staff 25 and Staff 30 have CPR(abd thrust included) and First Aid completed 3/20/2025 2.Designated staff trainers (experienced Med Tech, Caregiver and/or RCC, Dining supervisor) perform evaluated competency checks on their department staff to observe demonstrated performance skills. The Business Office Manager (BOM) monitors competency checks using tools such as the training tracker spreadsheet to ensure training is properly completed, and then record the documents in appropriate files. All on-line modules (Relias and Oregon Care Partners) are completed prior to beginning work on the floor or within the 30 day compliance date depending on if it is pre-service or 30 days. Company approved Orientation and competencies are done for each employee. Process: Hire, Onboarding with Orientation form and required pre-service trainings including CPR, First Aid,and Food Handerlers, shadowing on the floor, demonstrated competencies, finish 30 day trainings. BOM monitors staffing to assure compliance and trainings are completed. 3.The Business Office Manager or designee maintains the tracking spreadsheet to assure accuracy of training and within all required timeframes per policy and OAR. The BOM notifies managers if there are staff who are not in compliance. 4. BOM with Administrator oversight.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code and to provide fire and life safety instruction on alternate months. Findings include, but are not limited to: Six months of fire drill and fire and life safety training records were requested on 02/10/25. The following was identified: a. There was no documented evidence the facility had conducted a fire drill every other month between 08/2024 and 02/2025. b. One fire drill had been conducted during the reviewed time period. This fire drill, on 12/19/24, did not include activating the fire alarm system. Documentation of the fire drill failed to address the following: * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. c. During interviews completed 02/11/25 through 02/13/25, staff were unable to identify the designated point of safety in case of a fire. d. There was no documented evidence the facility was providing fire and life safety training to staff on alternating months from fire drills. The need to ensure fire drills were conducted in accordance with the Oregon Fire Code and fire and life safety instruction was provided to staff on alternate months was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) at 12:15 pm on 02/14/25. They acknowledged the findings.

1.Fire Drills are held every other month and Fire Safety Training at All Staff meeting on the alternate months. Alternating shifts implemented for fire drills. Fire Safety done 2/27/2025. Fire Drill (actual) held on 3/14/2025 on day shift. Updated forms in use. Designated safety point is the front parking lot. or the side parking lot depending on fire location. Orientation checklist has fire safety and fire locations performed by the Maintenance director for all new staff. 2. The system is corrected to follow the above plan for fire drills and twice yearly emergency drills. 3. At least monthly review of Fire and Life safety Drills. 4. Maintenance director is responisble to ensure fire and emergency drills are completed on alternative months. Administrator to assure oversight.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission; and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending per the Oregon Fire Code (OFC) unless the resident’s mental capability did not allow for following such instruction. Findings include, but are not limited to: Fire and life safety records were reviewed on 02/11/25. During an interview on 02/11/25 at 2:38 pm, Staff 1 (Administrator) reported that residents had not been receiving fire and life safety training on admission, nor had the facility been re-instructing residents at least annually. The need to instruct and re-instruct residents on fire and life safety training per the OFC requirements was discussed with Staff 1 and Staff 2 (Executive Nurse) at 12:15 pm on 02/14/25. They acknowledged the findings.

1. The Maintenance Director or designee has oversees the annual fire safety training with each individual Resident currently at the community. All current residents have had training presented and have either signed understanding or if understanding is not possible than this has been documented. The documented forms are copied and maintained in the resident binder and in the business office resident specific file. Company approved forms have been instituted for this compliance. 2. The Maintenance Director or designee meets with each Resident annually to go over the annual fire safety training. This will now be held annually in July through the entire company. If it has been less than annually those residents will be redone at that time. The Maintenance Director or designee has each Resident sign their attendance of this training and will have the information that was instructed attached to the signed attendance sheet as well as a copy offered to each Resident for their personal records. Residents who are not cognitvely able to understand have this noted. The community will use the company approved forms. This has been added to the new resident move in process and documented on the checklist for all new move-ins. 3. Trainings conducted upon move in and annually with each individual Resident. 4. Maintenance Director or designee, with Administrator oversight.

OAR 411-054-0093 (1-5) Emergency and Disaster Planning An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss. (1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC. (2) The emergency preparedness plan must: (a) Include analysis and response to potential emergency hazards including but not limited to: (A) Evacuation of a facility; (B) Fire, smoke, bomb threat, or explosion; (C) Prolonged power failure, water, or sewer loss; (D) Structural damage; (E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake; (F) Chemical spill or leak; and (G) Pandemic. (b) Address the medical needs of the residents including: (A) Access to medical records necessary to provide care and treatment; and (B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation. (c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff. (3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested. (4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills. (5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request.

Based on interview and record review, it was determined the facility failed to have an emergency preparedness plan that included analysis and response to emergency hazards in event of a prolonged power failure, and failed to conduct a drill of the emergency preparedness plan at least twice a year. Findings include, but are not limited to: In an interview on 02/11/25 at 11:20 am, Staff 7 (Facility Services Director) stated the facility frequently experienced “rolling blackouts”, including six times the previous summer. During interviews on 02/11/25 and 02/12/25, care staff expressed concern that the facility did not have an emergency plan in event of a power outage. They stated a power outage, lasting approximately ten hours, occurred at the facility on 02/04/25, and staff did not know how to complete tasks such as documenting medication administration. During an interview on 02/12/25 at 3:00 pm, Staff 1 (Administrator), Staff 2 (Executive Nurse) and Staff 7 confirmed the facility experienced a power outage on 02/04/25 and the facility did not implement a system for documenting medications administered while the power was out. They stated that the facility had not been conducting drills of the emergency preparedness plan at least twice per year. The survey team requested the facility’s emergency preparedness plan in the event of a power outage or other emergency. This was reviewed on 02/13/25 at 10:50 am and the following was identified: * Multiple areas of the plan were blank, including areas describing how the facility would gather provisions such as water, food or medical supplies for the resident’s needs in case of an emergency; and * Names and phone numbers of who should be contacted in case of an emergency belonged to staff who were no longer employed by the facility. The need to ensure the facility developed an emergency preparedness plan that included analysis and response to emergency hazards in event of an emergency such as a prolonged power failure, and to conduct a drill of the emergency preparedness plan at least twice a year, was reviewed with Staff 1 and Staff 2 on 02/14/25 at 12:15 pm. They acknowledged the findings.

1. The updated Emergency Preparedness plan was placed in a binder. Emergency Drill completed 3/14/2025 in conjunction with fire drill. A full evacuation was completed and table top for the emergency (earthquake) drill portion. Staff were trained on difference between an earthquake and fire. On going Emergency Drills will be done twice a year. A reminder notification from the company will go out twice a year for the community to complete and report back. Med Tech training will include response to how to document medications in a power outage occurs. They will be trained that 1. If cellular service is still active- phones will be used as "hot spots", 2. If cellular is down in addition to electricity,they contact the Executive Team to pull the most current medication list and MAR to be sent somewhere local that has service and can be printed. 3. For back up the med lists are printed weekly and kept in a binder. If the emergency causes loss of electricity and cellular service the back up med lists will be used assuring corrections using copies of most recent orders. 2. The Executive Director (Administrator) task list was implemented with this as one of the required elements to assure annual completion. 3. Annually 4. Administrator and COO

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure lever-type door handles were provided on all doors used by residents. Findings include, but are not limited to: The environment was toured on 02/11/25 at 1:45 pm. Multiple unsampled resident rooms, in the Daisy and Lily cottages, were observed to have a sliding barn door to access the bathroom located within the room. The doors did not have a lever-type handle. During a review of the environment on 02/12/25 at 4:15 pm, Staff 1 (Administrator) and Staff 7 (Facility Services Director) acknowledged that not all doors used by residents had a lever-type door handle. The need to ensure lever-type door handles were provided on all doors used by residents was reviewed with Staff 1 and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

1. All doors used by residents will be changed to have a lever style door handle by the compliance date, on any door that has a non-lever handle. 2. Once the doors and/or handles are replaced any future replacements will include a lever style door handle. 3. Upon installation of any new hardware. 4. Maintenance director and Administrator.

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting.

Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the right to freedom from restraints. Findings include, but are not limited to: Refer to C 200 and C 340.

Refer to C200 and C340

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

Based on observation and interview, the facility failed to ensure each individual resident had privacy in his/her unit. Findings include, but are not limited to: The environment was toured on 02/11/25 at 1:45 pm. Multiple unsampled resident rooms, shared between two residents, were observed to have a sliding barn door to access the bathroom located within the room. There was no way to lock the door to ensure privacy while using the bathroom. The environment was toured with Staff 1 (Administrator) and Staff 7 (Facility Services Director) on 02/12/25 at 4:15 pm. They acknowledged that the barn doors on shared resident room bathrooms did not have a way to lock to ensure privacy. The need to ensure each individual resident had privacy in his/her unit was reviewed with Staff 1 and Staff 2 (Executive Nurse) on 02/14/25 at 12:15 pm. They acknowledged the findings.

1. Barn doors to be brought into compliance by replacement or modification by the alleged compliance date. This is currently under review with a contractor on if there will be a replacement of the doors or if modifciations can be made to assure privacy. 2. All future installations assure that share a bathroom door shall allow for privacy with a locking mechansim. 3. With the installation of any new hardware. 4. Maintenance Director and Administrator.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Based on observation, interview, and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple sampled and unsampled residents. Findings include, but are not limited to: Multiple observations were made in Daisy, Rose, and Lily Cottages during the survey of staff using their key to open sampled and unsampled resident unit doors. During an interview during the survey, Staff 1 (Administrator) confirmed the residents did not have keys to their units. Review of Resident 1, 2, 3, and 4’s service plans did not indicate if the residents had a key to their unit or if they were evaluated to have one. Resident 1’s service plan, dated 10/31/24, reflected that the “resident is able to keep track of their own room key” and that staff “are to assist further if requested.” On 02/12/25 at 10:37 am, Staff 27 (CG) confirmed the resident did not have a key to their unit. The need to ensure the individual resident and only appropriate staff had a key to access their unit was discussed with Staff 1 and Staff 2 (Executive Nurse) during the survey. On 02/14/25, Staff 1 verified the keys were being made and that all residents would have a key to their unit as soon as the facility had the keys.

1. All residents have been issued their own room key and a signature sheet acknowledging receipt has been instituted. There is a new form acknowledging receipt and a new item has been added to the evaluation and service plan addressing this issue. Keys were placed in residents closets in a plastic sleeve for easy access should the resident desire to use it. 2. This is a part of the move-in process and the individual will be issued a key to their apartment with a documented form acknowleding receipt. Residents who are unable to understand or remember will have their key placed in their closet for easy access. 3. Upon move-in and upon request if the key should become lost. 4.Maintenance Director and Executive Director.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity.

Based on observation, interview, and record review, it was determined the facility failed to ensure initial evaluations addressed all required elements including the pronouns and gender identity for 1 of 1 sampled resident (#2) who’s evaluation was reviewed. Findings include, but are not limited to: Refer to C 252.

See C 252

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to: Refer to: C 150, C 156, C 160, C 200, C 231, C 295, C 360, C 362, C 363, C 372, C 420, C 422, C 435, and C 513.

Refer to C 150, C156, C160, C200, C231, C295, C360, C362, C363, C372, C420, C422, C435, C513

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 25, 28, and 30) completed pre-service orientation and dementia training prior to beginning their job responsibilities, 5 of 5 newly hired staff (#s 12, 25, 28, 30, and 33) had documented evidence of demonstrated competency in all required areas within 30 days of hire, 2 of 2 long term staff (#s 15 and 26) completed a total of 16 hours of annual in-service training, and 1 of 3 long term, non-direct care staff (#9) completed required annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed with Staff 6 (Business Office Manager) on 02/11/25 and 02/12/25. The following was identified: a. There was no documented evidence Staff 25 (CG), hired 01/01/25, Staff 28 (CG), hired 01/01/25, and Staff 30 (CG), hired 12/05/24, completed all required pre-service orientation topics and pre-service dementia training prior to beginning job duties in the following topics: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Environmental factors that are important to a resident’s well-being; * Family support and the role the family many have in the care of the resident; * How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan; and * Use of supportive devices with restraining qualities in memory care communities. b. Staff 12 (MT), hired 01/22/25, Staff 25, Staff 28, Staff 30, and Staff 33 (CG), hired 01/20/25, lacked documented evidence they had completed all of the required training and demonstrated competency in all job duties within 30 days of hire, or prior to working with residents independently, in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * Other duties as applicable. In an interview on 02/12/25, Staff 5 (RCC) acknowledged Staff 12 did not have documentation of demonstrated competency in medication pass prior to working independently as a MT. Staff 5 agreed to ensure Staff 12 demonstrated competence prior to independently passing medications. c. There was no documented evidence Staff 15 (MT), hired 01/09/23, and Staff 26 (CG), hired 01/19/20, completed 16 hours of annual in-service training, including at least six hours of dementia care topics. d. Staff 9 (Activity Aide), hired 01/23/23, lacked documented evidence of completion of annual infectious disease training. The need to ensure all staff completed pre-service orientation and dementia training, demonstrated competence in job duties within 30 days, had 16 hours of annual in-service training, and completed required infectious disease training annually, was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), Staff 5, and Staff 6 on 02/11/25, 02/12/25, and 02/14/25. They acknowledged the findings.

1.Complete training audit under review to assure that all staff are trained per policy and OAR. All staff to be completed by the alleged compliance date. Mandatory trainings will be done on-site and in-person by VP of Health Services (RN) the week of March 21 and 24th including a dementia specific training on Dementia. All competencies have been completed 3/14/2025. In specifc, Staff 25, 28,30, 15, 26, and 9 will have all missing training components completed by 3/24/2025. 2. Process: Hire, Onboarding with Orientation form and required pre-service trainings (Oregon Care Partners: Pre-Service Dementia, Infection control, Providing Inclusive Care, HCHB IBL) including CPR, First Aid,and Food Handlers, shadowing on the floor, demonstrated competencies, finish 30 day trainings. BOM monitors staffing to assure compliance and trainings are completed. Annual Training is completed with a variety of methods including training at All-Staff (documented appropriate with trainer, time, and topic), assigned Relias Courses, and company provided training with certificates documenting topic, hours, and trainer. 3.The Business Office Manager or designee maintains the tracking spreadsheet to assure accuracy of training and within all required timeframes per policy and OAR. The BOM notifies managers if there are staff who are not in compliance. 4. BOM with Administrator oversight. See also C372

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

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 252, C 260, C 262, C 270, C 280, C 282, C 290, C 300, C 302, C 303, C 305, C 310, C 330, and C340.

See C252, C260, C262, C270, C280, C282, C290, C300, C302, C303, C305, C310, C330, C340

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4's service plans were reviewed. The service plans were found to be lacking information and staff instructions related to an individualized nutrition and hydration plan. The need to develop an individualized nutrition and hydration plan for each resident and include it in the service plan was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25. They acknowledged the findings.

1. All resident service plans have been updated to reflect an individualized nutrition plan including likes and dislikes, any diet modifications, and a hydration plan. There is a new evaluation tool added to the EHR that synthesizes all information into an Individualized nutrition plan. Residents 1,2,3 completed by 3/24/2025 with all other residents completed by 4/15/2025 2. The Evaluation tool had an additional item added for all memory care residents entitled "Individualized Nutrition Plan". This will be part of the move-in and quarterly processes. RCC trained on the use of this tool. This supplemental plan will be placed with the service plan for staff to read and document their understanding. This tool will also be given to the kitchen quarterly and with any changes of condition. 3 At least quarterly and as needed for any changes of condition. 4. RCC, RN, and Administrator.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

Based on observation, interview and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, and 4’s records were reviewed and observations were made during the survey. The current activity evaluations did not address one or more of the following required components: * Past and current interests; * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations needed to participate; and * Identification of activities for behavioral interventions. The current activity plans were not individualized to each resident based on their activity evaluation and not included on the resident's activity service or care plan. In an interview with Staff 9 (Activity Aide) on 02/12/25 at 3:19 pm, she confirmed that the residents did not have an activity evaluation. The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Administrator), Staff 2 (Executive Nurse), and Staff 5 (RCC) on 02/14/25. They acknowledged the findings.

1. Activity Director re-educated on the use of the Memory Care Assessment Tool, Life Story, and the Individualized Activity Plan. All Residents have been updated to be reflective of this. 2. The Activity Director uses the standarized evaluation and plan initially and quarterly thereafter. All Activity staff trained on the use of this any any new staff will be trained during their on-boarding. 3. Initally, then 30 days, and quarterly thereafter. 4. Activity Director, RCC, and Administrator.

OAR 411-057-0170(9) Resident Rooms (9) RESIDENT ROOMS. (a) Residents may not be locked out of or inside of their rooms at any time. (b) Residents must be encouraged to decorate and furnish their rooms with personal items and furnishings based on the resident's needs, preferences, and appropriateness. (c) The memory care community must individually identify residents' rooms to assist residents in recognizing their room.

Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of their rooms. Findings include, but are not limited to: During the survey from 02/10/25 through 02/14/25, multiple sampled and unsampled residents were observed to be locked out of their room. During interviews on 02/10/25 through 02/12/25, care staff stated that “most” resident rooms were kept locked at all times. On 02/11/25 at 12:03 pm in Daisy cottage, an unsampled resident was observed attempting to enter his/her room and found it to be locked. The resident went to the dining room and asked a CG to “unlock my door so I can get my coat.” The CG replied, “not now, after lunch.” The resident appeared to become agitated and began yelling. During an interview at 12:35 pm, the CG stated the resident was not let back in to his/her room because the resident had “already been let back into [his/her] room three times” and the CG needed to finish serving lunch to the other residents. The need to ensure residents were not locked outside of their rooms was discussed with Staff 1 (Administrator) and Staff 2 (Executive Nurse) at 12:15 pm on 02/14/25. They acknowledged the findings.

1. All staff were provided training regarding the locking of resident rooms. Staff were trained on additional management of wandering residents. 2. All new staff are provided orientation and review of policy of not locking doors and given additional training on the management of wandering residents. 3. Reviewed at least monthly at staff meetings and spot checks done at least weekly by the RCC. 4. RCC, Administrator or designee

Based on interview and observation it was confirmed that the facility failed to keep all equipment in good repair.  Findings include, but is not limited to: In an interview on 8/2/2022, Witness #1 (W1) reported receiving a phone call from a family member of Resident #1 (R1) who stated the facility's A/C unit was not working in Cottage A, staff were shifting residents to other cottages during the day and returning them to their rooms to sleep at night. In an interview on 8/2/2022, Staff #1-2 (S1-2) reported there is a blower that is  "out"  located in Cottage A (Rose Cottage) that is affecting temperatures in the common area and the walkway that links the facility's 3 cottages together. S1 reported that Resident rooms in Cottage A are not affected by this, their rooms remain at 70 degrees.  S1 reported that during the days with temperatures reaching 110 degrees, they try to keep the residents in their air conditioned rooms, however with some of them it is not possible as they prefer to wander throughout the common areas.  In order to accommodate these residents, they move them to the other 2 cottages to provide some relief from heat during the day. During an unannounced visit on 8/2/2022, Compliance Specialist (CS) observed several standing fans located in Cottage A's common area and kitchen.   *CS used a thermal gun to test temperatures in the common area, kitchen area and adjoining hallway at the time of visit, temperatures were at 78 degrees at 11AM.   *CS tested temperatures in five resident rooms,  all were consistent at 70 degrees.  *CS observed thermostats for the remaining cottages and temp controlled hallways, all were consistent at 70 degrees. S1 acknowledged the findings. Plan of Correction: S1 reported that Comfort Flow was out to assess the issue and they are now waiting on bids for the parts/repairs.  S1 stated they already have approval from Corporate Office for whatever bid they receive, they are hoping to receive the bid by 8/3/2022 and will proceed with repairs as soon as parts arrive.

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 8/2/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

2. Resident 1 was admitted to the facility in August 2020 with diagnoses including dementia. Review of incident reports and progress notes from 7/15/21 to 7/31/21 showed the following: * An incident report dated 7/15/21 was created after Resident 1 sustained a skin tear to the left hand. The report indicated the resident was unable to recall how s/he had gotten the skin tear. There was no investigation completed related to this incident to rule out abuse and neglect and it was not reported to the local SPD office. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (Regional Director) and Staff 3 (RN) on 8/10/21. The staff acknowledged the findings. The facility was asked to report the incident from 7/15/21 to their local SPD office and a confirmation was provided prior to exit.

Based on interview and record review, it was determined the facility failed to ensure resident incidents were thoroughly investigated in a timely manner and/or reported to the local Seniors and People with Disability (SPD) office for 3 of 3 sampled residents (#1, 2 and 3) who were reviewed with injuries from falls or unknown cause. Findings include, but are not limited to: 1. Resident 2 moved into the facility in October of 2020 with a diagnosis dementia. Review of Resident 2's record revealed s/he sustained an injury on 6/15/21 after s/he hit his/her head on the floor as s/he fell out of a recliner sustaining a rug burn on their nose. Resident 2 appeared confused after the fall and an ambulance was called to take him/her to the ER. Interview with Staff 1 (Administrator) on 10/10/21, about the incident on 6/15/21, determined the facility failed to report the injury fall to the local SPD office. The surveyor asked Staff 1 to report the incident to the local SPD office. Confirmation of the self report to the local SPD office was received on 8/10/21. The need to ensure resident incidents were thoroughly investigated and reported to the local SPD office was discussed with Staff 1 and Staff 2 (Regional Director) on 8/10/21. They acknowledged the findings. 3. Resident 3 was admitted to facility 12/2020 with a diagnosis including dementia. Resident 3's current service plan noted the resident was at risk for falls. Review of Resident 3's record noted multiple unwitnessed falls between 2/23/21 and 8/3/21.  There was no documented evidence how the facility determined the fall was not the result of neglect or abuse. The need to thoroughly investigate all incidents to rule out suspected abuse and/or neglect was discussed with Staff 1 (Administrator), Staff 2 (Regional Director), Staff 3 (RN) and Staff 4 (RCC) on 8/10/21. They acknowledged the findings.

1. Action taken to correct this rule/violation is that Management RN/LPN/RCC and, or Administrator will conduct complete and full investigations of abuse, suspected abuse, or injuries of an unknown causes on all incidents discovered from the prior day. 2. How this system will be corrected so this violation will not happen again. We will review Incident Reports Monday through Friday during our clinical meeting. 3. This area needing correction will be reviewed daily Monday through Friday. 4. The Resident Care Coordinator will be responsible to ensure that Incident Reports are reviewed with Administrator, and/or RN each morning to determine if the incident needs to be reported to Adult and Protective Services. Administrator will conduct the final investigation, and report any incidents of abuse, suspected abuse, or injuries of unknown cause the proper authorities within 24 hours of each incident.

Based on observation, interview and record review, it was determined the facility failed to notify RN of a change in condition, document and communicate resident specific interventions, evaluate, and monitor weekly until resolution for 1 of 1 sampled resident (#2) who experienced a severe weight gain. Findings include, but are not limited to: Resident 2 was admitted to the facility in October of 2020 with a diagnosis of dementia. Resident 2's weight record, progress notes and interim service plans were reviewed on 8/9/21 and revealed the following: Residents 2's weight was noted to be 102.8 pounds on 2/24/21. Resident 2's weight on 5/26/21 was documented to be 120.8 pounds. This constituted a 16 pound, or 13.2%, severe weight gain in three months. Review of progress notes and interim service plans determined there was no documented evidence the facility evaluated and monitored the change of condition or implemented interventions related to the severe weight gain. Interview with Staff 1 (Administrator) and Staff 3 (RN) on 8/10/21 revealed there was no RN assessment or monitoring completed for Resident 2's weight gain or notification from staff that Resident 2 had a change of condition. Observation on 8/9/21 and 8/10/21 showed Resident 2 ate 100% during meals. Review of Resident 2's meal record showed s/he consistently ate 100% of all meals. The need to ensure staff notified the RN of a change of condition, documented and communicated resident specific interventions, evaluated, and monitored weekly until resolution was discussed with Staff 1 (Administrator) on 8/12/21. She acknowledged the findings.

1. The action taken is the clinical team will review residents whom are identified as high risk for a Change of Condition including temporary, and Significant on a weekly basis.  The RN/RCC will review weights weekly during the clinical meetings, and identify who needs to be more closely monitored. 2. How this system will be corrected is once a resident has been identified a temporary, or significant change of condition will be intiated by the RN, and the staff will be provided new care instructions via a revised Growth & Wellness Plan. 3. The area needing correction: these will be evaluated weekly, by the Administrator. 4. The Administrator and RN will be responsible to see that the corrections are completed/monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#2) who experienced significant changes of condition related to a weight change. Findings include, but are not limited to: Resident 2 was admitted to the facility in October of 2020 with a diagnosis of dementia. Residents 2's weight was noted to be 102.8 pounds on 2/24/21. Resident 2's weight on 5/26/21 was documented to be 120.8 pounds. This constituted a 16 pound, or 13.2%, severe weight gain in three months. There was no documented evidence the RN completed a Change of Condition assessment which included findings, resident status, and interventions made as a result of the 16 pound weight gain. The need to ensure an RN assessment was completed for residents who experience a significant changes of condition was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 8/10/21. They acknowledged the findings.

1. Action to correct this violation is to monitor each resident closely, and identify changes mentally or physically, in a timely manner, and to monitor the changes. 2. The system will be corrected during our daily clinical meeting.  The clinical team will identify residents who need to be monitored closer via our Electronic Medical Record System, and observation notes per the Medication Aides. 3. The RN, and RCC will monitor this system weekly to ensure the necessary monitoring of residents is complete. 4. The RN will be responsible for weekly notes and instructing the care staff, as needed, of any changes in regards to the residents.

Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. Findings include, but are not limited to: Fire and life safety training and records were reviewed with Staff 6 (Maintenance Director) on 8/10/21 at 10:10 am.  The following was identified: * No documented evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills; * No documented evidence fire drills were conducted every other month; * No documentation of escape route used; * No documentation of problems encountered and comments relating to residents who resisted or failed to participate in the drills; and *No documented evidence of alternate routes being used during fire drills. On 8/10/21, the above areas were reviewed with Staff 1 (Administrator) and Staff 2 (Regional Director). They acknowledged the findings.

1. Actions to correct this violation is to conduct and record Fire & Life Safety Drills, and provide instructions as per OAR 411-054-0090. 2. This system will be corrected as the Maintenance Director will conduct announced and unannounced Fire & Life Saftey Drills on a monthly basis during mandatory staff meetings.  The unannounced Fire Drills will be conducted every other month and all in-service trainings will be appropriately documented, including alternate routes used during fire drills. 3. This area needing correction will be monitored by the Administrator on a monthly basis. 4.The Maintenance Director will be responsible to see that these corrections are completed/monitored utilizing the TELS system.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows and furniture) and all equipment necessary for the health, safety and comfort of the resident was clean and in good repair. Findings include, but are not limited to: During a tour of the facility on 8/9/21, the following was observed: All dining room tables and chairs in Rose, Daisy and Lilly cottages were missing varnish on the table tops and legs. Multiple dining room chairs had stains on the fabric seats. On 8/10/21, the need to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents were clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director). They acknowledged the findings.

1. Action to correct this violation is to purchase new dining room chairs, and tables for Cottages Rose, Daisy, and Lilly. 2. This system will be corrected by closely monitoring the condition of furnishings within the cottages, and replace as needed in a timely manner. 3. This area will be monitored quartely at the beginning of each quarter, during the months of January, April, July, October. 4. The Administrator will be responsible for the corrections and monitoring.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows and furniture) and all equipment necessary for the health, safety and comfort of the resident was clean and in good repair. This is a repeat citation. Findings include, but are not limited to: During a tour of the facility on 11/29/21, the following was observed: All dining room tables and chairs in Rose, Daisy and Lilly cottages were missing varnish on the table tops and legs. Multiple dining room chairs had stains on the fabric seats. On 11/30/21, the need to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents were clean and in good repair was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. Actions taken to correct this violation is to ensure all tables will be sanded and revarnished.  All chairs will be cleaned and chairs will be sanded and revarnished if needed. 2.  An audit will be conducted of community furniture monthly by maintenance to ensure that all furniture is in working and good condition. 3.  Training will be done with staff to ensure they know how to report maintenance issues. 4.  The Administrator will ensure all audits and mainenance request are being followed up with and completed timely.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231, C420 and C513.

Refer to C231, C420 & C153

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 513 .

Refer to C 513.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff completed all required pre-service orientation prior to beginning job duties, and 2 of 2 long term staff completed the required number of hours of annual training. Findings include, but are not limited to: Staff training records were reviewed on 8/10/21 with Staff 2 (Regional Director). a. Training records for Staff 7 (CG) hired 6/4/21, Staff 9 (CG) hired 4/5/21 and Staff 15 (CG) hired 2/1/21, lacked documented evidence the following pre-service orientation elements were completed: * Resident rights and values of CBC care; * Abuse reporting requirements; * Standard precautions for infection control; * Fire safety and emergency procedures; and * Written job description. b. Training records for Staff 11 (MT) hired 10/2/17, and Staff 13 (CG) hired 7/9/18 lacked documentation of completion of 10 hours of training related to the provision of care in CBC and 6 hours of training related to dementia care annually. The need to ensure all required training was completed within the specified time frames was discussed with Staff 1 (Administrator) on 8/10/21. She acknowledged the findings.

1. Actions taken to correct this violation is to ensure all new hires have the appropriate new hire paperwork, skills checklists, and new hire trainings completed prior to working on the floor.  The community will record and monitor all monthly in-service staff trainings. 2. A thourough audit will be completed of all employee files, and items that are missing with be completed.  All trainings will be kept in their individual employee files instead of scattered in different areas. 3. This area will be monitored quartely at the beginning of each quarter, during the months of January, April, July, October. 4. The Administrator and Business Office Manager will be responsible doe the corrections and monitoring.

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 C270 and C280.

Refer to C270 and C280

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 513 and Z 142.

Refer to C 513

The findings of the re-licensure survey, conducted 8/9/21 through 8/10/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities. 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 08/10/21, conducted 11/29/21 through 11/30/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second revisit to the re-licensure survey of 08/10/21, conducted 02/03/22, are documented in this report. It was determined the facility was in substantial compliance with OARS 411 Division 54 for Residential Care and Assisted Living Facilities, OARS 411 Division 57 for Memory Care Communities and OARS 411 Division 004 for Home and Community Based Regulations.