Waverly Place Memory Care

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, record review and interview, it was determined the facility failed to maintain the kitchenette in good repair and in a sanitary manner. The facility failed to ensure hot foods were held and served at appropriate temperatures in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main facility kitchen, memory care kitchenette and lunch meal service on 09/25/25 from 11:15 am thru 1:30 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Reach in refrigerator in unit kitchenette * Oven in unit kitchenette * Flooring in unit kitchenette b. The following areas needed repair: * Red temperature control cart used for hot holding and transportation to unit was noted with a damaged door seal creating a ½ - 1 inch gap in the door where hot air was felt exiting the unit. Multiple puncture areas in and around the cart were observed. Hot air was felt exiting the unit around these puncture points. The gauge to display the internal hot holding temperature was not operational to inform of what temperature the food was being held at. c. Reach in refrigerator in the unit kitchenette was observed and did not contain a thermometer to ensure resident food was stored at appropriate cold food storage temperatures. Staff in unit acknowledged there was a log posted on the refrigerator. Surveyor reviewed the log and it was blank. Memory care unit staff acknowledged she was not checking or logging the refrigerator temperatures and did not know who was supposed to. Staff 2 (Culinary Services Director) acknowledged that the care staff was supposed to be checking and logging the refrigerator temperatures in the unit kitchenette. d. A tray of plated cake desserts were observed transported from the main kitchen to the unit uncovered and not protected from potential contamination. f. Memory care lunch service was observed and began in the main kitchen at 11:15 am. Plates were dished up in the main kitchen and placed in the Red hot box cart. The cart was taken to the memory care unit at 11:44 am. At approximately 11:50 am, staff began checking the temperatures for the food items for service on that day. Three of the four hot items were noted less than the 135 degrees required for hot holding temperatures and included (turkey and vegetable gravy at 120 degrees, Mashed potatoes at 123 degrees and peas at 114 degrees). Meal service temperature logs from 09/19/25 thru the lunch meal of that day were reviewed and documented 66/78 hot menu items that were found at temperatures less than 135 degrees. Thirty-two hot food items were documented at 110 degrees or less, and seven hot food items were documented as served at temperatures less than 100 degrees. Care staff was interviewed and stated that they were ok to served the food items as long as they were 80 degrees or more. When asked what temperatures were she looking for to be considered hot enough they stated between 80-120 degrees. Staff was not able to discuss what the appropriate hot holding temperature was. Staff 2 was interviewed and acknowledged the facility’s standard of hot holding was 140 degrees. Staff 2 acknowledged the items in the cart observed at that meal were not at appropriate hot holding temperatures. Surveyor reviewed the food service temperature logs for the last week and acknowledged service temperatures served at 110 or less are not palatable and not appropriate. At 12:30 pm, Staff 1 (Campus Executive Director) was informed of the observed hot holding temperatures and acknowledged the concern identified. Staff 1 also acknowledged food service temperatures at 110 degrees and/or less would not be palatable. Staff 1 was asked to provide resident council minutes for the last three months to review. Staff 1 indicated that the facility was not conducting resident council for the memory care unit. Staff 1 acknowledged the requirement for residents to have input into menus and food service program. Staff 1 and Staff 2 acknowledged the other identified areas outlined above.

A deep cleaning of the kitchenette, refrigerator and floor has been completed in Memory Care. A check list has been created and implemented for cleaning of the kitchenette. This will be overseen by the Memory Care Director daily and Culinary Services Director weekly. A new seal has been ordered for the red temp controled cart. We will also be repairing the sides of the cart to seal up any puncture areas in the cart. This is being completed by the Regional Director of Operations. A new thermometer has been placed in the fridge, temp logs are being completed daily by caregivers. This is being overseen by the Memory Care Director Daily and Culinary Services Director weekly. A temp training will be completed with MC staff on holding temps and safe temps for food. This will be completed by the MC Director at all staff in October 15, 2025 Activities department will hold a monthly Resident Council meeting with the memory care residents. This meeting will include getting their input on menus and the food service. This will be completed by the MC Activities Director and overseen by the MC Director.

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 observations and interviews, 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 C240.

See C240

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

Based on interview and record review, conducted during a site visit on 06/02/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to: A review of the facility's ABST report, with the last update dates indicated that an unsampled resident had not been quarterly evaluated since 01/20/25. An interview with Staff 1 (Executive Director) was conducted, and indicated that s/he had not known residents needed to be reviewed quarterly in the ABST. It was determined the facility's failure to fully implement and update an ABST was substantiated. The findings of the investigation were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

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 effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the re-licensure survey conducted 02/25/25 through 03/03/25, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations. Refer to deficiencies in report.

ED will monitor and sign off all new hires/backgrounds,and annual training. Meeting was held on 3/21 letting everyone know that all annual training is required, and if it is not done they will be pulled from the schedule until they are in compliance. ED will meet with staff weekly until all employees are current on training. ED will monitor and do write ups for thoes staff members not in compliance. ED will meet weekly with BOM and department managers to pull staff for required training to insure we are staying compliant with all annual training. BOM and ED will monitor to insure all employee are in compliance.

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.

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 ensure incidents, accidents and injuries of unknown cause were promptly investigated to rule out abuse and neglect and reported to the local SPD office when required, for 4 of 5 sampled residents (#s 1, 2, 3 and 5). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, review of the resident's 12/20/24 service plan, 11/07/24 through 02/25/25 interim service plans, progress notes, physician communications, and incident investigations were completed. The resident was intermittently able to direct his/her own care but frequently refused care and displayed agitation and anxiety. The resident became more confused later in the day and was more difficult to redirect. The resident could walk and transfer on his/her own but required some assistance with other ADL care. Review of the resident's records showed the following: * While investigating a progress note dated 02/02/25, related to another sampled resident, it was determined a resident–to-resident altercation had occurred. Resident 2 entered Resident 1’s apartment, was found shaking the resident and yelling for him/her to wake up. Resident 2 believed the other resident was his/her daughter. Staff separated the residents and reported to the medication technician. The MT at the time did not initiate an investigation, report to her supervisors that an altercation had occurred and documented minimal information on the incident. * A progress note dated 02/03/25, indicated the resident was agitated, yelling and aggressive towards staff and residents. The resident was observed to have ahold of another resident’s arm and would not let the other resident go. The altercation was not reported to administration, was not investigated and was not previously reported to the local SPD. In interviews between 02/26/25 and 02/28/25, Staff 1 (ED) and Staff 6 (Memory Care Coordinator) indicated both incidents were not investigated properly or reported to them. Staff 1 stated both incidents should have been reported as resident to resident altercations. A confirmation that the incidents were reported to the local SPD office was provided to the survey team prior to exit. The need to ensure incidents were investigated promptly to rule out abuse and neglect and reported to the local SPD office when required, was discussed with Staff 1 and Staff 6 on 02/28/25. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in 01/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the resident's 12/24/24 service plan, 11/01/24 through 02/25/25 interim service plans, progress notes, physician communications, and incident investigations were completed. The resident was intermittently able to direct his/her own care but frequently refused care. The resident would become intermittently anxious and circle the common areas and halls. The resident could be redirected most of the time when fixated on something. The resident could walk and transfer on his/her own but required some assistance with other ADL care when s/he would allow. Review of the resident's records showed the following: * A progress note dated 12/07/24, indicated the resident had a non-injury fall. The resident could not say why/how s/he fell. The fall was not investigated to determine cause and to rule out abuse and neglect. * A progress note dated, 12/27/24, indicated the resident was found to have a long scratch to the left leg and a scratch to his/her genitals. The injuries of unknown cause were not investigated, were not reported to administration and were not previously reported to the local SPD office. * A progress note dated 02/06/25, indicated the resident was lowered to the floor. No injuries were noted. The fall was not investigated to determine cause and rule out abuse and neglect. In interviews between 02/26/25 and 02/28/25, Staff 1 (ED) and Staff 6 (Memory Care Coordinator) indicated the incidents should have been investigated and the injuries of unknown cause reported to the local SPD. A confirmation that the injuries of unknown cause were reported to the local SPD office was provided to the survey team prior to exit. The need to ensure incidents were investigated promptly to rule out abuse and neglect and reported to the local SPD office when required, was discussed with Staff 1 and Staff 6 on 02/28/25. The staff acknowledged the findings. 3. Resident 5 was admitted to the facility in 08/2023 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the resident's 12/05/24 service plan, 11/01/24 through 02/27/25 interim service plans, progress notes, physician communications, and incident investigations were completed. The resident was intermittently able to direct his/her own care. The resident required extensive assistance with all care and two staff assistance for transfers. Review of the resident's records showed the following: * An incident report dated 11/11/24, indicated the resident was found with a bruise to the top of the right arm. The resident could not say how the injury occurred, and it was unclear the cause of the bruise. The injury was not reported to the local SPD office at the time it occurred. * A progress note dated, 01/06/25, indicated the resident’s arm was pinched in the wheelchair during a transfer. The area was reddened. No other information about what occurred was documented. The incident was not investigated, was not reported to administration and was not previously reported to the local SPD office. * A progress note dated 01/26/25, indicated the resident had a skin tear to the side of the right breast. The injury was not investigated to determine cause and rule out abuse and neglect. In interviews between 02/26/25 and 02/28/25, Staff 1 (ED) and Staff 6 (Memory Care Coordinator) indicated the incidents should have been investigated and the injuries of unknown cause reported to the local SPD. A confirmation that the injuries of unknown cause were reported to the local SPD office was provided to the survey team prior to exit. The need to ensure incidents were investigated promptly to rule out abuse and neglect and reported to the local SPD office when required, was discussed with Staff 1 and Staff 6 on 02/28/25. The staff acknowledged the findings. 4. Resident 1 moved into the community in 02/2024 with diagnoses including dementia and type 1 diabetes. The resident’s 11/27/24 through 02/20/25 progress notes and incident reports were reviewed. The following was identified: A 02/02/25 progress note documented, “Resident stated that someone came into [his/her] room and started hitting [him/her] and shaking [sic]. [S/he] did not know who it was but told staff.” There was no documented evidence the above incident was immediately reported to the local SPD office. In an interview at 4:30 pm on 02/26/25, Staff 1 (ED) and Staff 6 (Memory Care Coordinator) confirmed the above incident lacked an investigation and had not been reported to APS. The survey team requested the above incident be reported to the local SPD office, and confirmation was received on 02/27/25 at 9:45 am The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office was discussed with Staff 1 and Staff 6 on 02/26/25. They acknowledged the findings.

ED will meet with RN,RCC to review all clinical concerns daily and go over all needed COC,weights or upcoming re-assessments,all needed monitoring,medication,skins,quartley assessments,alert charting,and incident reports addressed and completed dail. ED will report all APS unknown cause of injury,unwhitnessed falls,any bruises,bums,scrapes, observed and conduct investigations with the MCC. ED and RN will followup daily,weekly,quatrley to review all areas of clinical to insure we are meeting all CBC needs. ED will edcuate team on required reporting,documenting,followup. ED with provide coaching counseling and write ups not limited to termination for refusal to follow policy. ED will assign all staff to complete Oregon Care Partners Elder Abuse prevention, investigation and reporting abuse. ED will review daily,weekly,monthly and quartley, to insure all areas are completed timely and in compliance with C231 ED and RN will work together to follow up on all areas of concern. ED will lead the compliance piece and monitor all areas are being completed timely.

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

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs;

Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that was based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: During the survey, 02/25/25 through 03/03/25, observations of the memory care unit showed minimal group activities. The television was on throughout the day. A small group of residents participated in the morning trivia activity in the memory care unit. Additional residents were observed sleeping in their chairs, on the sofas, in their rooms or wandering the common area, dining room and halls, throughout the rest of the day. The activity assistant took 3-5 residents out regularly to activities in the assisted living facility and ran a few group activities in the memory care unit. Care staff was not observed to initiate any large or small group activities or to sit down with residents and offer things to do. Staff 13 and Staff 17 (CGs) indicated they did not typically run any specific activities with the residents. The staff further indicated when Staff 12 (Activity Assistant) returned from the assisted living side she would most likely run an activity for the residents in the memory care. Staff 17 stated there was a cupboard with some activity items in it. Staff 17 indicated she would normally just wait for Staff 12 to return. The need to ensure a daily activity program was provided for residents to address their mental, physical and psychosocial needs was reviewed with Staff 1 (ED), Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings.

Activity schedule will be motified for residents engagement. Training for care staff to engage residents in activites all day alongside of the activity director. When the activity director take some residents to AL.The Activity Director will have a engagement setup and have care staff run that while they take others to AL. This will insure all residents have an opportunity to get engagement. ED will train staff to limit T.V. on during the day. Instead train staff to engage with residents more. Daily,Weekly,Monthly,Quartly. From having conversations,holding meeting,auditing how the week went,how the month went,and address during quartley review of residents. ED will work with MCC and ED will train staff on expectations. ED will work with MCC to make sure this process is effictive and residents engagement increases,and TV decreases.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs;

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 interview and record review, it was determined the facility failed to conduct an initial resident evaluation prior to move-in for 1 of 1 sampled resident (#4) who had recently moved into the community. Findings include, but are not limited to: Resident 4 moved into the community in 01/2025 with diagnoses including dementia and anxiety. There was no documentation a resident evaluation had been completed before the resident moved into the community. In an interview on 02/26/25 at 10:15 am, Staff 6 (Memory Care Coordinator) reported she did not know an initial evaluation needed to be completed when a resident moved from the assisted living community to the memory care community. The need to ensure initial evaluations were completed prior to move-in was discussed with Staff 1 (ED) and Staff 2 on 02/27/25. They acknowledged the findings.

ED will hold a training with the RCC,MCC to go voer every compotant and create a cheat seet to remember to capture all areas needed to be compliant with C-252 ED will read through all completed assessments to insure all areas are captured prior to residnet care conference. Each time a new assesment/care plan is needed the ED will review prior to the residents care conference.ED will hold weekly meeting with the MCC to schedule and plan all evlas that are needed. MCC will complete 1st draft of assessments,careplans, and the ED will review for final to be shown to thoes at residents care conference.

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

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

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff and were consistently implemented by staff for 3 of 5 sampled residents (#s 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, review of the resident's 12/20/24 service plan, 11/07/24 through 02/25/25 interim service plans and progress notes were completed. Staff indicated the resident was able to direct some care. The resident frequently refused care and displayed agitation and anxiety. The resident became more confused later in the day and was more difficult to redirect. The resident could walk and transfer on his/her own but required some assistance with other ADL care. The resident had a decline over the last several weeks and was spending more time in bed, refusing meals and required more assistance. The resident’s service plan was not reflective, not consistently implemented and/or lacked resident specific direction for staff in the following areas: * Incontinence and toileting assistance; * Behaviors, anxiety and agitation; * Non-drug interventions for pain; * Mealtime and 1:1 assistance; and * Grooming, dressing and hygiene assistance. The need to ensure resident service plans were reflective of current care needs, were consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 6 (Memory Care Coordinator) on 02/27/25. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in 01/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the resident's 12/24/24 service plan, 11/01/24 through 02/25/25 interim service plans and progress notes were completed. Staff indicated the resident was able to direct some of his/her own care but frequently declined assistance. Staff stated the resident would become anxious and circle the common areas and halls but could be redirected most of the time when fixated on something. The resident could walk and transfer on his/her own but required some assistance with other ADL care when s/he would allow. The resident’s service plan was not reflective, not consistently implemented and/or lacked resident specific direction for staff in the following areas: * Incontinence care and toileting assistance; * Behaviors, anxiety and hallucinations; * Skin breakdown and repositioning; * Nighttime routine and toileting; * Wheelchair vs. walker use; * Non-drug interventions for pain; and * Grooming, dressing and hygiene assistance. The need to ensure resident service plans were reflective of current care needs, were consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 6 (Memory Care Coordinator) on 02/27/25. The staff acknowledged the findings. 3. Resident 5 was admitted to the facility in 08/2023 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the resident's 12/05/24 service plan, 11/01/24 through 02/27/25 interim service plans and progress notes were completed. Staff indicated the resident was intermittently able to direct his/her own care. The resident required extensive assistance with all care and two staff assistance for transfers. The resident’s service plan was not reflective, not consistently implemented and/or lacked resident specific direction for staff in the following areas: * 1 vs 2 person transfers and gait belt use; * Incontinence care and toileting assistance; * Skin breakdown, repositioning and leg elevation; * Wedge cushion; * Nighttime assistance and toileting; * Non-drug interventions for pain; * Fall and safety interventions; and * Grooming, dressing and hygiene assistance. The need to ensure resident service plans were reflective of current care needs, were consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 6 (Memory Care Coordinator) on 02/27/25. The staff acknowledged the findings.

ED will review all completed service plans prior to implmenting them and providing in the care conference. ED will follow up with the RN to insure all ISP are clear with direction as a residents needs are changing frequently. ED will follow up with RN to insure all COC are captured and documented with proper ISP's in place with clear direction for staff to care for the residnets and their changing needs. ED will work with MCC and RN to insure residents needs are being captured and documented timely, and the ISP's are being followed. ED,RN and MCC will over see implementation of all interventions put in place. Daily during clinical meeting,weekly look back meeting to capture progress or correct implmentation as well as ,monthly,quatley meetings, when completing quartly resident reviews reviewing all areas of concern prior to care conferences. This will assist in not missing any needs a resident has. ED and RN will work together along with MCC to monitor and make sure items are all completed.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services for 2 of sampled residents (#s 6 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 01/2021 with diagnoses including dementia and a recent left hip fracture. Observations of the resident, interviews with staff, review of the resident's 06/24/25 service plan, 06/02/24 through 06/30/25 interim service plans, and progress notes were completed. Staff indicated the resident was bedbound, with two-person assistance with bed mobility, hygiene care, and dressing. The resident had returned from a hospitalization after a fall with hip fracture and was now bedbound, more confused, and required assistance for food and fluid intake. The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas: * Bed bound vs two-person transfer assist to wheelchair; * Diet texture of puree vs mechanical soft chopped; * Two one-half side rails on the bed, to include direction for safety and monitoring; * Oral care instructions; * Behaviors with direction for staff; and * Protein shakes three times daily. The need to ensure resident service plans were reflective of current care needs, and provided clear direction to staff was discussed with Staff 26 (Health Services Director/RN), Staff 27 (Assisted Living RN), Witness 3 (RN Consultant), and Staff 4 (Assisted Living RCC) on 07/01/25. The staff acknowledged the findings. 2. Resident 7 was admitted to the facility in 06/2025 with diagnoses including vascular dementia. The resident’s service plan, most recently updated on 06/09/25, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident’s current care needs and/or did not provide clear directions to staff regarding the delivery of services in the following areas: * Use of side rails and instructions to caregivers on the correct use and precautions related to use of side rails; * Use of top dentures; and * Unit key information. On 06/30/25 at 10:31 am, Resident 7’s bed was observed to have a half side rail on each side in the up position. The rail on the right side was loose. Staff 30 (CG) stated she did not know what to do about the rail being loose. The facility was informed of the loose side rail on 06/30/25. The need for the service plan to be reflective of the resident’s status and care needs, as well as provide clear direction to staff regarding the delivery of services, was discussed with Staff 4 (Assisted Living RCC), Staff 26 (Health Services Director/RN), Staff 27 (Assisted Living RN), and Witness 3 (RN Consultant) on 07/01/25 at 2:00 pm. They acknowledged the findings.

1. The residents identified in the survey have been reviewed and service plans have been updated to reflect the current needs. 2. Service plans will be updated for residents on admission, at 30 days, quarterly and with significant changes of condition. 3. RCC and RN will review service plans in clinical meeting to ensure service reflect individualized care, this will occur daily Monday through Friday and as needed. 4. Administrator will review service plans before conferences held with family as well as during clinical meeting. This will be conpleted on admissions, 30 day review, quarterly and with changes of condition.

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

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

C270-G Based on observation, interview ,and record review, it was determined the facility failed to ensure short term changes of condition had documented progress monitored at least weekly through resolution, evaluated effectiveness of current interventions, and determined additional interventions as needed for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5). Resident 2 experienced increased behaviors and ongoing pain that was not well controlled and affected his/her daily activities. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and review of the resident's service plan dated 12/20/24 and progress notes dated 11/07/24 to 02/25/25 were completed. a. Staff indicated the resident had a decline in cognition, increased confusion, required more assistance for ADLs, had been refusing to get out of bed and refusing most meals. The resident also had an increase in pain and felt ill most of the time staff asked how s/he was doing. The resident was difficult to redirect when exit seeking/family seeking and would sometimes confuse other residents for his/her children. Multiple observations of the resident between 02/25/25 and 02/28/25 showed the resident in bed. The resident did not leave his/her apartment. Staff provided all meals to the apartment. The resident inconsistently responded to a knock or greeting, and was soundly asleep on all but one observation. The resident was observed on one occasion with eyes open, lying in bed. The resident immediately became distressed upon greeting, calling for his/her children, stating in pain, “please help.” Review of the resident’s progress notes showed the following: * Progress notes dated 11/07/24 through 01/10/25 showed sporadic complaints of pain. The resident had chronic pain to the low back which PRN medications typically relieved. The resident was showing an increase in self-isolation and sleeping throughout the day in early January 2025. * On 01/16/25, the resident had blood in his/her urine and stool. The resident was seen by his/her physician and evaluated in the emergency room. The resident was diagnosed with inflammation of the colon and a bladder infection. Multiple antibiotics were ordered on 01/30/25. * On 02/01/25, the resident began to show an increase in behaviors including striking out at staff, throwing and/or shoving equipment into walls and trying to hit other residents. The resident’s behaviors remained escalated for several days with aggressive behavior towards staff and other residents. Paranoia was noted related to medication administration. The resident would refuse medications and question staff why s/he would take anything from them, “you guys are trying to kill me…” * Progress notes between 02/03/25 and 02/12/25 showed the resident’s behaviors again escalated with multiple attempts to strike staff and other residents. The resident refused medications and continued to lash out. The resident made statements of “I’m in pain and you are not trying to help me…” “I’m not hungry, I just want to sleep.” The resident continued to state s/he was in pain, with notes continuing to document meal, medication and care refusals. The resident had some nausea and vomiting while holding his/her back and stating s/he was in pain. Complaints of pain with bowel movements were also made by the resident. * On 02/17/25, the resident stated s/he did not feel well and experienced multiple bouts of diarrhea. The resident was very agitated, calling for family, and complaining of pain. Notes on 02/20/25 indicated the resident had not attended any meals outside of his/her apartment for three days, had multiple complaints of pain that “no medication has been able to manage.” * On 02/21/25, the resident refused care, refused meals and would not get up out of bed. The resident was offered fluids whenever awake, but s/he would only take a few sips and then lay back down. The resident was sent to the emergency room for evaluation a few hours later. The resident’s family indicated the resident called out repeatedly “help me, help me, I am in pain,” the resident called out that know one cared, repeatedly during the six hours in the ER as well. The resident was diagnosed with a urinary tract infection and a new order for antibiotics was received. * On 02/22/25, the resident was very agitated throughout the night complaining of pain. The resident was given PRN pain medications but continued to be very restless and agitated stating “no one cares,” “please god help me,” and “nothing you give me works.” The resident continued to have complaints of pain and nausea on 02/23/25. * On 02/24/25, the resident complained of increased pain all day, stayed in bed all day and refused dinner but did drink his/her shake. The resident was noted to have frequent urination, urgency with toileting. * On 02/28/25, the resident was referred to palliative care due to his/her consistent complaints of pain, refusal to eat, low fluid intake and confusion. The resident’s physician and family were contacted regarding a transport to the emergency room for evaluation. No additional notes reflected an ER trip. * On 03/01/25, the resident had many complaints of pain in his/her back. The resident refused all food, stayed in bed all day and cried “out the entire day over and over,” stating “I am hurting, I am in pain, why doesn’t anyone care.” The resident continued to have complaints of pain on 03/02/25. * On 03/03/25, the resident was sent to the emergency room, at the direction of the physician, for evaluation due to altered mental status and not drinking or eating. The resident’s 12/06/24 signed physician orders showed the following pain medications: * Acetaminophen 500 mg tablet, take one tablet twice daily PRN for pain or fever. Start with acetaminophen “and or” Ibuprofen before giving narcotic pain medication. * Diclofenac sodium 1% gel, apply 4 gm topically to affected area four times daily PRN for back pain. * Oxycodone-Acetaminophen 5-325, take a half a tablet every eight hours, PRN for pain not relieved by “Tylenol, Diclofenac, or Lidocaine patch.” * Scheduled Lidocaine patch on for 12 hours then off 12 hours for back pain. * Scheduled acetaminophen, 500 mg tablet, take two tablets twice a day for pain. The resident’s 02/01/25 to 02/25/25 2025 MAR showed the following: * Acetaminophen was administered 21 times for pain levels of 5 out of 10 pain and higher. * The pain level noted on the MAR was 8 of 10 or higher on 12 of the 21 occasions. * Diclofenac gel was applied 13 times; no pain level was noted and five of the 13 occasions no acetaminophen had been administered prior. * Oxycodone was administered on 15 occasions, plus two additional occasions that were not recorded on the MAR but were documented on the narcotic disposition log. No pain levels were noted for any of the administrations. * Six of the 15 occasions oxycodone was administered, exception notes on the MAR indicated the medication was not effective. No other information was documented about controlling the resident’s pain. In interviews with staff between 02/25/25 and 02/28/25 the following was determined: Staff 10, 11 and 15 (MTs) indicated the resident had declined over the last several weeks. The resident had more complaints of pain, was eating less due to the pain, had nausea and stayed in bed far more than s/he used to. The staff indicated the resident had scheduled and PRN medications for his/her pain, but they were not always effective. Staff 11 stated they had to give the resident his/her PRN Tylenol, Diclofenac gel and scheduled Lidocaine patch and determine they were ineffective, before the resident could get his/her PRN Oxycodone. Staff 17, 20 and 22 (CGs) indicated the resident was able to eat on own, could also transfer and walk on his/her own but needed more assistance over the last few weeks. The staff indicated the resident had been isolating in his/her apartment and refused to get out of bed. Staff 20 stated the resident had only come out of his/her room a few times since the beginning of the month. Staff 22 further indicated the resident’s meal intake recently was very poor; the resident had a lot of pain and was frequently nauseous as well. The staff stated the resident would refuse care, meals and to get up because of the pain. Staff 21 (CG) indicated the resident had not come out of his/her room much at all over the last few weeks. The resident was not eating well, had a lot of complaints of pain and not feeling well. The staff stated the resident was able to complete some ADLs on his/her own, but it was safer to have at least the standby assistance if not a one person assist. Staff 21 stated when the resident had pain s/he refused almost everything offered. The resident’s increased behaviors, increased pain and overall decline in condition was not monitored with interventions implemented, determined effectiveness of those interventions, resident specific instructions provided to staff to maintain resident comfort and safety. Staff were given unclear parameters on when to medicate the resident with what medications, for what pain level and what to do when the medication did not relieve the resident’s pain. Additionally, a lack of onsite RN oversight affected how quickly the resident received services and interventions to address the behaviors, infection and pain, putting the resident at unnecessary risk for harm. b. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Skin rashes to multiple areas; * Emergency room visits; * Feeling ill, nausea, vomiting and diarrhea; * Medication changes; * Resident to resident altercations; * Non-injury falls; and * Blood on bottom, in urine and stool. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, interventions implemented and reevaluated for effectiveness and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in 01/2024 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan dated 12/24/24 and progress notes dated 11/01/24 to 02/25/25 were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Behaviors, increased confusion and disrobing; * Bruises, scratches and abrasions; * Skin injury; * Emergency room visit; * Feeling ill, constipation, increased pain; * Increased hand tremors; * Medication changes; and * Falls and head injury. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, interventions implemented and reevaluated for effectiveness and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings. 3. Resident 5 was admitted to the facility in 08/2023 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan dated 12/05/24 and progress notes dated 11/01/24 to 02/27/25 were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Bruises to the right upper arm and left wrist; * Skin tear to the right breast and the lower buttocks; * Choking episodes; * Non-injury fall; * Rash and skin irritation; and * Right forearm pinched in the wheelchair. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, interventions implemented and reevaluated for effectiveness and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings. 4. Resident 1 moved into the community in 02/2024 with diagnoses including dementia and type 1 diabetes. The resident’s progress notes dated 11/27/24 through 02/20/25 were reviewed, and interviews with staff were conducted. There was no documented evidence the following changes of condition were monitored to resolution. * 12/27/24 – change in Aspart and Lantus insulins; and * 01/10/25 – skin breakdown on top of buttocks. The need to ensure short-term changes of condition were monitored weekly with progress noted to resolution was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator), and Staff 26 (Regional Director of Operations) on 03/03/25. They acknowledged the findings, and no additional information was provided. 5. Resident 4 moved into the community in 02/2025 with diagnoses including dementia and anxiety. The resident experienced a 12.8 pound weight gain from 01/23/25 to 02/11/25, which constituted a severe 9.7% weight gain in 19 days, requiring an RN assessment. In an interview on 02/2/25, Staff 6 (Memory Care Coordinator) reported she was not aware of the weight gain, so it had not been referred to the facility RN for a significant change of condition assessment. The need to ensure significant changes of condition were evaluated and referred to the facility RN for a timely assessment was discussed with Staff 1 (ED) and Staff 6 on 02/25/25. They acknowledged the findings. Refer to C280, example 4.

Holding daily clinical meeting with the RN and MCC to go over any changes with each residents, review all concerns.This will help in capturing all COC. ED will follow up with RN to make sure the COC is completed within required timeframe. ED will review the IPS from RN on the COC to make sure there is a clear description for care staff to know how to take care of the resident. ED will follow up with RN to make sure the RN is monitoring the COC and documenting or changing ISPs to fit residnets needs. Daily during clinical,weekly COC RN specific meeting to look back at all interventions put in place,to see what is working and what needs changed. ED will review with RN to make sure we are addresses and monitoring all COC timely and making sure all implemtations arre being followed.

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

OAR 411-054-0045 (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 observation, interview, and record review, it was determined the facility failed to ensure residents who experienced significant changes of condition were assessed by an RN and/or the assessments were completed in a timely manner and included findings, resident status, and interventions made as a result of the assessment, for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced significant changes in condition. Resident 2 experienced a significant increase in pain and an overall decline in condition which caused decreased appetite and self isolation with minimal intervention. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s disease. Multiple observations of the resident between 02/25/25 and 02/28/25 showed the resident in bed. The resident did not leave his/her apartment. Staff provided all meals to the apartment. The resident inconsistently responded to a knock and greeting, was soundly asleep on all but one observation. The resident was observed on one occasion with his/her eyes open, lying in bed. The resident immediately became distressed upon greeting, calling for his/her children, stating in pain, “please help.” Staff indicated the resident refused most of his/her meals or would only eat a few bites. The staff further indicated the resident had experienced increased confusion, behaviors and pain over the last few weeks and had not been getting out of bed. Progress notes dated 01/16/25 through 03/03/25 indicated the resident had increased pain, behaviors and confusion. The resident had a decrease in his/her intake for meals as well. The resident had multiple trips to the emergency room for evaluation related to blood in urine, blood in bowel movement and increased pain. The resident was treated for a bladder infection, urinary tract infection and inflammation of the colon. The resident’s physician ordered additional imaging and made changes to courses of multiple antibiotics. A late entry note dated 02/25/25 was in the progress notes and was labeled significant change of condition, altered mental status and decline in cognition. The note did not reference a specific date of the decline the late entry referred to. The progress note indicated the resident had experienced a “marked decline in cognition in the last 90 days.” The resident received treatment for bladder infections recently; the cognition change did not seem to be related to the infections but may be related to a new antidepressant medication. In interviews with staff between 02/25/25 and 02/28/25 the following was determined: Staff 10, 11 and 15 (MTs) indicated the resident had declined over the last several weeks. The resident had more complaints of pain, eating less due to the pain, nausea and staying in bed far more than s/he used to. The staff indicated the resident has scheduled and PRN medications for his/her pain, but they were not always effective. Staff 11 stated they had to give the resident his/her PRN Tylenol, Diclofenac gel and scheduled Lidocaine patch and determine they were ineffective before the resident can get his/her PRN Oxycodone. Staff 17, 20 and 22 (CGs) indicated the resident was able to eat on own, could also transfer and walk on his/her own but had needed more assistance over the last few weeks. The staff indicated the resident had been isolating in his/her apartment and refused to get out of bed. Staff 20 stated the resident had only come out of his/her room a few times since the beginning of the month. Staff 22 further indicated the resident’s meal intake recently was very poor, the resident had a lot of pain and was frequently nauseous as well. Staff 21 (CG) indicated the resident had not come out of his/her room much at all over the last few weeks. The resident was not eating well, has a lot of complaints of pain and not feeling well. The staff stated the resident was able to complete some ADLs on his/her own, but it was safer to have at least the standby assistance if not a one person assist. Witness 1 (RN Consultant) indicated he had only recently joined the facility. He estimated he had been working on resident issues for about a week. Witness 1 would also be training the permanent RN once hired. He was scheduled to be onsite once a week. Staff 1 (ED) and Staff 6 (Memory Care Coordinator) indicated the significant changes of condition were behind in completion but Witness 1 was working on them currently. Staff 6 further indicated she and Witness 1 had not reviewed and updated service plans yet. Staff 1 indicated Witness 1 was new to the facility while they hired a new permanent RN. The facility had been without their full time RN for about a month. The resident was not interviewable due to cognition and anxiety. The facility failed to ensure an RN assessment was completed timely for the resident’s decline in cognition and altered mental status which included increased pain and confusion. The late entry assessment, completed on 02/25/25, did not have a date referenced as to when the change of condition occurred, failed to reflect resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1, Staff 6 and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in 01/2024 with diagnoses including dementia. a. Weight records, dated 08/02/24 through 10/09/24, progress notes and physician communications dated 11/01/24 through 02/25/25, indicated the resident experienced the following: * The resident’s weight on 08/02/24 was 155.6 pounds. The resident’s next recorded weight was 141.2 pounds on 09/26/24. The resident experienced a severe weight loss of 14.4 pounds or 9.25% in less than two months. * The resident’s weight on 09/26/24 was 141.2 pounds. The resident’s next recorded weight was 151.6 pounds on 10/09/24 The resident experienced a severe weight gain of 10.4 pounds or 6.86% in less than two weeks. The resident’s weight fluctuated up and down between 141 pounds and 146 pounds between December 2024 and 02/25/25. The resident’s most recent weight on 02/23/25 was 143 pounds. Multiple observations of the resident between 02/25/25 and 02/28/25 showed the resident could direct some of his/her own care and ADLs. The resident required one staff assistance for a portion of his/her ADLs. The resident attempted to be independent with food and fluid intake. The resident had severe tremors and shaking of his/her arms which interfered with mealtime. Staff provided assistance and specialized utensils as the resident would allow. The resident ate between 50% and 75% of the meals observed. Fluid intake was closer to 100%. The resident utilized lidded cups with extended straws. Additionally, the resident was provided health shakes with each meal and fluids were encouraged throughout the shift. In interviews completed between 02/25/25 and 02/28/25, it was determined: Staff 11 (MT) and Staff 20 (CG) indicated the resident fed himself/herself most of the time. The resident preferred to be independent and would refuse offers unless shaking was significant. The staff indicated staff would help the resident feed himself/herself using hand over hand when s/he would allow. The resident was able to drink more efficiently even when shaking was severe due to type of cup used. Staff 22 (CG) stated the resident had weighted utensils to help with meal independence while shaking. The resident did not like to use the utensils so would frequently refuse. The staff indicated the resident did pretty well with most meals and staff were also available to help feed the resident if s/he was willing to accept the help. Witness 1 (RN Consultant) indicated he had only recently joined the facility. He estimated he had been working on resident issues for about a week. Witness 1 would also be training the permanent RN once hired. He was scheduled to be onsite once a week. Staff 1 (ED) and Staff 6 (Memory Care Coordinator) indicated the significant changes of condition were behind in completion but Witness 1 was working on them currently. Staff 6 further indicated she and Witness 1 had not reviewed and updated service plans yet. Staff 1 indicated Witness 1 was new to the facility while they hired a new permanent RN. The facility had been without their full time RN for about a month. Staff 1 and Staff 6 were not aware of the resident’s significant weight changes. The resident indicated s/he received plenty to eat and drink and could get help when s/he needed it. When asked about the special utensils the resident indicated s/he did not need them. The facility failed to ensure an RN assessment was completed for the significant weight loss and significant weight gain from August 2024 to October 2024 which documented findings, resident status, and interventions made as a result of the assessment. b. The resident was identified during the acuity interview on 02/25/25 to have a stage 2 pressure ulcer on his/her buttocks. Progress notes dated 11/04/24 through 02/25/25 showed the following: * On 11/04/24, a small open area to the resident’s bottom was noted. * On 11/19/24, referral to wound clinic was received. * On 12/05/24, an RN note indicated the wound was small 0.5 inch, open but not deep and no drainage was noted. * On 01/10/25, home health noted the area was resolved. * On 02/15/25, home health wound care was restarted. The progress notes do not specify when the area on the resident’s buttocks reopened. Staff 1 and Staff 6 were unable to locate any significant changes of condition completed by the previous RN regarding the resident’s skin breakdown. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1, Staff 6 and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings. 3. Resident 1 moved into the community in 02/2024 with diagnoses including dementia and type 1 diabetes. The resident's monthly weights dated 09/18/24 through 02/17/25 were reviewed, observations were made, and interviews with staff were conducted during the survey. The resident's weights were recorded as follows: * 09/18/24 – 120.6 pounds; * 10/09/24 – 117.2 pounds; * 11/11/24 – 128.0 pounds; * 12/08/24 – 126.0 pounds; * 12/09/24 – 126.0 pounds; * 01/03/25 – 125.6 pounds; * 01/06/25 – 125.6 pounds; * 02/03/25 – 125.6 pounds; * 02/17/25 – 124.9 pounds. From 10/09/24 to 11/11/24 the resident gained 10.8 pounds or 9.2% of his/her body weight which constituted severe weight gain which required an RN assessment. Observations and interviews during the survey identified the resident was independent with meals. S/he ate 75-100% of breakfast and lunch from 02/25/25 through 02/28/25. During an interview on 03/03/25, Staff 6 (Memory Care Coordinator) reported at that time the weight gain was the nurse’s responsibility to monitor weights, however that nurse no longer worked at the facility. Staff 6 was unable to find any documentation of an RN assessment for the significant change of condition. On 03/03/25 the need to ensure the facility RN completed an assessment for all residents who experienced significant changes of condition was discussed with Staff 1 (ED), Staff 6, and Staff 24 (Regional Director of Operations). They acknowledged the findings. 4. Resident 4 moved into the community in 01/2024 with diagnoses including dementia and anxiety. Review of the resident’s weights since moving into the community identified the resident had experienced a 12.8 pound weight gain from 01/23/25 to 02/11/25, which constituted a severe 9.7% weight gain in 19 days. Observations and interviews during the survey identified the resident was independent coming to the dining room and with self-feeding, requiring no meal assistance. S/he ate 75-100% of breakfast and lunch from 02/25/25 through 02/28/25. The resident’s weight was obtained during the survey and s/he weighed 146.0 pounds on 02/25/25. During an interview on 02/25/25, Staff 6 (Memory Care Coordinator) reported the resident had been doing well since moving from assisted living to memory care. She was not aware of the severe weight gain and stated the facility RN had not been notified of the significant change of condition. On 03/03/25 the need to ensure the facility RN completed an assessment for all residents who experienced significant changes of condition was discussed with Staff 1 (ED), Staff 6, and Staff 24 (Regional Director of Operations). They acknowledged the findings.

Hired a FT RN, and signed up the new RN for the Leading Age Oregon (RN in CBC) in April 2025. ED will shadow the class to assist with duty oversight. ED will follow up with the RN to make sure the COC is done timely and continued monitoring and documenting is done. ED will follow behind RN and oversee compliance. ED will go over Daily in clinical meeting, as well as weekly in COC meeting to insure we are capturing all areas of compliance. Daily, Weekly,Monthly,Quartley ED will over see and follow up with RN to make sure all COC are being captured timely. ED will work with RN and MCC to make sure all implementations are being followed.

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.

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 observation, interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers, review recommendations, and update the resident's service plan with new interventions as needed, for 1 of 4 sampled residents (#3) who received home health services. Findings include, but are not limited to: Resident 3 was admitted to the facility in 01/2024 with diagnoses including dementia. During the acuity interview on 02/25/25, Resident 3 was identified as receiving outside provider services related to wound clinic treatments and home health nursing for wound care. Observations of the resident, interviews with staff, review of the service plan dated 12/24/24, progress notes and outside provider notes dated 11/01/24 through 02/25/25 were completed. The resident had a stage 2 pressure ulcer to his/her bottom. The area was first noted on 11/04/24, resolved on 01/10/25 and was noted to reopen on 02/15/25. a. Multiple wound care visit notes between 12/20/24 and 01/10/25 were not available in the resident’s record. b. Home health nursing notes showed the following recommendations: * On 12/20/24, it was noted wound care visits would continue twice a week. Wound care of Cleanse with wound wash, pat dry, apply wound gel to wound bed, cover with a 3x3 border foam, change twice a week. Barrier ointment to buttocks and groin twice a day. * On 02/15/25, showed wound care twice per week to be done by agency, please encourage good dietary intake with increased protein to facilitate wound healing. Staff to maintain perineal cleanliness and dryness with every two hour toileting, if the resident was sitting or lying for extended times please rotate/change position every two hours as well. * On 02/18/25, indicated continue with wound care as ordered, nutritional supplements and frequent offloading as able. * On 02/21/25, indicated staff to change dressing to coccyx if it became soiled or dislodged. * On 02/24/25, indicated “Please keep covered as long as possible for protection.” There was no indication the recommendations were communicated with staff and implemented. In interviews between 02/25/25 and 02/28/25, the following was determined: Staff 10 and 15 (MTs) indicated they were unaware of any orders for treatment of the pressure ulcer on the resident’s bottom. The staff described that the area was closer to the inner portion of the resident’s buttocks crease. Staff 11 stated if she had verbally been told a few options for bandages. Staff 11 indicated there were no active orders for dressing changes that she was aware of. Staff 6 (Memory Care Coordinator) indicated she was unable to locate any orders for dressing changes or treatments other than the resident’s Desitin cream. Staff 6 had no additional information regarding the absence of wound information on the resident’s MAR/TAR. The need to ensure on-going coordination of care recommendations were implemented was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings.

During clinical ED,RN,MCC will review prior days 3rd party provider notes. All Third party notes to be reviewed by the RN, ED and MCC,to make sure the ISP is complete with clear directions for staff to care approicatly for residents needs. If the directions are not clear RN,ED,MCC will follow up with provider to get clear expectations,and RN,ED,MCC will foolow up with care staff to make sure the ISP's are being implemeted and working. Daily during clinical,Weekly during look back and followup meeting. Monthly during audit progress meeting ED will follow up with the RN and MCC to insure RN is monitoring as needed.ED will follow up with RN and MCC to make sure all areas have been implementedand documented according to C-290

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 411-054-0055 (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 system and failed to ensure adequate professional oversight. Findings include, but are not limited to: 1. During the relicensure survey, conducted 02/25/25 through 03/03/25, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas: C 302: Systems: Tracking Controlled Substances; C 303: Systems: Medication and Treatment Orders; C 310: Systems: Medication Administration; and C 330: Systems: Psychotropic Medications. Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings. 2. General observations of the medication room on 02/25/25 and 02/26/25 showed: * Two expired bottles of bowel medications were located in a drawer. * Loose medication cards were observed on top of the refrigerator to be returned to the pharmacy. The packs were tossed near the back of the refrigerator and contained no special labeling to indicate they were a return. * Two bottles, one bowel medication and one stomach medication were also noted to be on top of the refrigerator for return, no special labeling or storage was noted. * Six medications cards were stacked in the paper tray on the counter by the printer. Two of the cards were empty and four of the cards had medication in them: acetaminophen and quetiapine (psychotropic medication). Staff 10 (MT), who was in the room, stated the cards had been there since the beginning of her shift and that she wasn’t sure why they were there. She acknowledged the cards with medications should be in the medication cart. 3. 01/21/25 progress note for Resident 4 documented, “When going to give resident there [sic] normal medication this morning it was missing from the cart. Bottle was discovered on paper holding shelf by printer. Needing an update on the resident’s medication if not taking Levothyroxine.” On 02/27/25 the surveyor requested that this be investigated. In an interview on 3/03/25 Staff 6 (Memory Care Coordinator) reported she had spoken with the MT who had written the note and that it was a bottle of levothyroxine that was found on the paper holding shelf. 4. On 02/26/25 during the routine investigation of staff training, it was identified that a MT administering medications and treatments independently did not have documented evidence of demonstrated competencies of medication tasks being performed. The sample was expanded to include all MTs administering medications in the facility and it was identified that four of 13 MTs did not have evidence of demonstrated competencies of medication tasks being performed. An immediate plan of correction of requested and received from Staff 1 (ED) on 02/26/25 at 3:39 pm. 5. A controlled substance review for two sampled residents showed multiple active medication cards for the same medication. Scheduled pain and psychotropic medications were being administered from scheduled cards and PRN medication cards. Labels on the scheduled cards reflected only the scheduled order and PRN medication cards reflected only the PRN order. Staff were unclear where they had recorded different administrations, from the scheduled and PRN medication cards as they were used interchangeably regardless of the order label on the card. When tracking the use of the controlled substances, the documentation located on the MAR and disposition log, staff had difficulty finding the location adminstrations were recorded. Documentation of the administration of the controlled medications was inconsistent on the disposition log. The PRNs were not identified as PRNs on the log. A portion of the staff were documenting administration times in regular time without any indication if the dose was given in the AM or the PM. A controlled substance audit was completed on 03/03/25 by Staff 1 (ED) and Staff 24 (Regional Director of Operations). The staff completed a full audit of the count for all controlled medications to ensure the counts were accurate based on the inconsistent documentation by staff. Staff 1 and Staff 24 found the counts to be accurate. They were unable to determine exactly why staff were not following facility policy related to the tracking and documentation of controlled medications. 6. Review of sampled resident treatment records showed staff were not documenting treatments to resident skin breakdown and not monitoring resident’s skin and recording treatments on the MAR/TAR related to two sampled residents. The need to ensure a safe medication and treatment system was discussed with Staff 1, Staff 6, and Staff 24 on 03/03/25. The survey team requested a plan to correct the medication system concerns. Staff 1 and Staff 24’s response to the plan of correction request included completion of a controlled medication audit. Medication Technician training had already been scheduled to occur on 03/05/25. Staff 1 reached out to their contract pharmacy to have a pharmacist come in ahead of schedule and complete a medication review. Staff 24 had additional online trainings assigned to all medication technicians and implemented ongoing competency checks to be done currently and redone each quarter. Staff 1 also indicated audits would be completed daily and weekly around different aspects of the medication system to determine staff compliance. Refer to C270 and Z155.

In Person pharmacy audit being completed 3/25 1. Daily MAR/TAR Review: The Executive Director (ED), Health & Wellness Director (RN), and Resident Care Coordinator (RCC) will conduct a daily review of MAR/TAR records every morning. ( Yes all 3 will be present) Findings will be discussed in the daily clinical meeting and reviewed during stand-up.

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.

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 2 of 2 sampled residents (#s 2 and 4) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s disease. Observations of the resident, interviews with staff, and record review were completed. The resident's signed physician orders dated 12/06/24 included the following order: * Oxycodone-Acetaminophen 5-325 mg, take a half tablet by mouth every eight hours PRN for pain not relieved by Tylenol, Diclofenac or Lidocaine patch. The resident's Controlled Substance Disposition logs and MARS, reviewed from 02/01/25 through 02/25/25 showed the following: * On 02/03/25 PRN Oxycodone-Apap was signed out on the disposition log, no time noted and not recorded on the MAR; * On 02/12/25 PRN Oxycodone-Apap was signed out on the disposition log at 9:23 pm, but was not recorded on the MAR. Comparison of the medication bubble packs to the disposition logs, showed the amount of medication left was reflected accurately on the log. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings. 2. Resident 4 was admitted to the facility in 01/2025 with diagnoses including dementia. Observations of the resident, interviews with staff, and record review were completed. The resident's signed physician orders dated 12/27/24 included the following orders: a. An order for Lorazepam 0.5 mg, take one tablet by mouth every two hours PRN for anxiety or agitation. May dissolve in liquid, may dissolve in morphine and administer together. The resident's Controlled Substance Disposition logs and MARS, reviewed from 01/01/25 through 02/25/25 showed the following: * On 01/16/25 PRN Lorazepam was signed out at 11:48 pm on the MAR but not reflected on the log. * On 01/25/25 PRN Lorazepam was signed out at midnight on the MAR but not on the log. * On 01/26/25 PRN Lorazepam was signed out at 1:31 am on the MAR but not on the log. * On 01/30/25 PRN Lorazepam was signed out at 9:02 pm on the MAR but not on the log. * On 02/05/25 PRN Lorazepam was signed out, no time noted on the log, and was not signed out on the MAR. * On 02/11/25 PRN Lorazepam was signed out at 9:06 pm on the MAR but not on the log. b. An order for Oxycodone-Acetaminophen 5 mg tablet, take a half tablet by mouth every six hours PRN for pain. The resident's Controlled Substance Disposition logs and MARS, reviewed from 02/01/25 through 02/25/25 showed the following: * On 02/03/25 PRN Oxycodone-Apap was signed out on the disposition log, no time noted and not recorded on the MAR; and * On 02/12/25 PRN Oxycodone-Apap was signed out on the disposition log at 9:23 pm, but was not recorded on the MAR. c. An order for Tramadol 50 mg tablet, take one tablet by mouth every six hours PRN for pain. The resident's Controlled Substance Disposition logs and MARS, reviewed from 01/01/25 through 02/25/25 showed the following: * On 01/19/25 a PRN dose of Tramadol was signed out on the log at 8:59 pm but not recorded on the MAR. * On 01/22/25 a PRN dose of Tramadol was signed out on the log at 8:47 pm but not recorded on the MAR. Comparison of the medication bubble packs to the disposition logs, showed the amount of medication left was reflected accurately on the log. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings.

Medication Pass & Shift Change Observations: One medication pass will be observed daily on a random shift to ensure compliance with safe medication administration practices. Staff will attend shift changes to verify proper medication count, controlled substance log accuracy, and storage compliance. The ED, RN, and RCC will review each order to ensure staff training and proficiency in medication administration. ED asigned additional Med training. This will be addressed daily by RN,ED,MCC oversight. ED,RN,MCC

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.

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.

C303-E Hdr ex1 Laurie Based on observation, interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the residents’ facility records for all medications and treatments the facility was responsible to administer for 2 of 5 sampled residents (#s 1 and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the community in 02/2024 with diagnoses including dementia and type 1 diabetes. Resident 1’s MAR dated 02/01/25 through 02/25/25, and corresponding prescriber orders were reviewed. The following was identified. The resident had a physician’s order for the facility to apply Baza Protect 12% cream after toileting (for redness/rash). In an interview on 03/03/25 at 9:04 am Staff 18 (CG/MT) reported Resident 1 needed toileting up to five times per shift, including before and after breakfast and before and after lunch. The February MAR documented the treatment administered every day at 8:00 am, 12:00 pm, and 8:00 pm. The need to ensure medications and treatments were carried out as prescribed was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator), and Staff 24 (Regional Director of Operations) on 03/03/25. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 08/2023 with diagnoses including dementia. The resident's 01/01/25 through 02/27/25 physician communications, 12/16/24 signed physician orders and the 11/01/24 through 02/27/25 MAR/TAR and progress notes were reviewed. The resident was identified to have skin breakdown to the back of his/her left thigh during the acuity interview on 02/25/25 and during observations of ADL care. a. The 11/01/24 through 02/27/25 MAR/TARs and 12/16/24 physician orders showed the following: * Desitin cream, apply to affected area PRN every shift, “apply to diaper area and right groin for skin irritation.” No PRN Desitin cream was documented as applied during November 2024, December 2024 and January 2025. The PRN Desitin was administered four times in February 2025. b. There was no documentation on the MAR/TARs of any active skin breakdown for the resident. Additionally, there was no documentation related to any physician ordered dressings or treatments, besides the scheduled ointment and the PRN cream. c. Progress notes dated 11/01/24 through 02/27/25 showed the following: *On 11/08/24, a note indicated the resident had a popped blister to the right lower leg. A dressing change was completed of an “island dressing,” slight bleeding was noted but no other drainage. *On 11/10/24, a note indicated bandage was changed on the resident’s right leg. *On 02/20/25, a note indicated “skin irritation/breakdown,” “dry with flaky skin around the open area. Cream was applied and resident was placed on his/her left side to help “the pressure sore heal.” *On 02/21/25 to 02/23/25 notes indicated cream was applied to left buttocks skin breakdown, skin irritation. The area was noted as lower left buttocks and as an area below the left buttocks, cream was applied by staff. In an interview on 03/03/25, Staff 6 (Memory Care Coordinator) indicated there were no other physician orders for the resident’s skin besides the A & D ointment and the Desitin cream. Those would be the only creams being applied to the skin breakdown on the back of the resident’s thigh. Staff 6 stated the area was not a pressure ulcer, she was unsure it the resident’s physician was notified of the skin issue. The need to ensure medications and treatments were administered as ordered by the physician and orders were in place prior to providing treatments and dressing changes was discussed with Staff 1 (ED), Staff 6 and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings.

Triple-Check System Implementation: Physician Orders: RN,MCC will Ensure all orders are accurate and up to date. New Medications & Changes: RN,MCC Review all new medications, dosage adjustments, and discontinued orders. Prescription Clarity: RN, MCC Verify that all prescriptions contain clear instructions for proper usage, dosage, and administration. ED,RN,MCC will review during daily clinical. ED,RN,MCC will review daily during clinical meeting. ED will follow up with the RN to review triple check follow up and completation. ED is responsible for over sight, ED will review with the RN, MCC for follow up in a timely manner.

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

Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized prescriber orders were carried out as prescribed for 2 of 2 sampled residents (#s 6 and 7) whose MARs and physician orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 06/2025 with diagnoses including vascular dementia. The resident’s 06/09/25 through 06/30/25 MAR was reviewed, as well as physician orders. There was no documented evidence the facility had signed physician orders for the medications on the MAR. On 07/01/25, Staff 26 (Health Services Director/RN) provided a copy of physician orders signed 07/01/25. The need to have signed physician or other legally recognized prescriber orders in resident charts was discussed with Staff 4 (Assisted Living RCC), Staff 26, Staff 27 (Assisted Living RN), and Witness 3 (RN Consultant) on 07/01/25 at 2:00 pm. They acknowledged the findings. 2. Resident 6 moved into the community in 01/2021 with diagnoses including dementia and had a recent diagnosis of left hip fracture. Resident 6's MAR, dated 06/01/25 through 06/30/25, and corresponding prescriber orders were reviewed. The resident had a hospitalization from 06/06/25 through 06/23/25 for a left hip fracture with surgical repair. Prescriber orders from hospice, dated 06/23/25, included discontinuation of the following orders: * Ibuprofen - 400 mg three times daily for pain; * Multivitamin - one daily for supplement; * Doxepin HCL - 10 mg every day at bedtime for depression; * Senna-Docusate - 8.6-50mg daily at bedtime for bowel care; and * Thioridazine HCL - 50 mg at bedtime for mood. The MAR documentation revealed that staff continued to administer the medications after they were discontinued, from 06/24/25 through 06/30/25. The need to ensure the facility administered medications as ordered by the prescriber was discussed with Staff 26 (Health Services Director/RN) on 06/30/25. She acknowledged the findings and discontinued the medications.

1. The residents identified in the survey have been reviewed and corrections made to reflect their current orders. 2. Community has a 3 person check system for medication orders. MT 1st check, MCC 2nd check and RN final check. This process is reviewed on a daily basis. MCC and RN will review medications orders during the clinical meeting to ensure follow through has been completed, this review is completed on a daily basis Monday through Friday and as needed. 3. Physicians orders will be reviewed daily using the 3 check system. This will occur when new orders or the quarterly physician orders when they are received. 4. Administrator will review during clinical meeting on a daily basis and as needed.

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

OAR 411-054-0055 (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 maintained for each resident whose MARs were reviewed for 4 of 5 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Alzheimer’s disease and chronic pain. Review of the resident's 02/01/25 through 02/25/25 progress notes, MAR and physician communications, and the 12/06/24 signed physician orders showed the following: * Milk of Magnesia, give 30 ml PRN “until bowel movement.” The MAR lacked resident specific parameters on when to start the medication. * Tylenol, Diclofenac Sodium gel and Oxycodone-APAP were all ordered PRN for pain. The medications had unclear parameters and lacked direction for staff on when to give which medications, how long to wait before administering the next medication, and how the PRNs should be used in relation to the resident’s scheduled medications. The need to ensure medication/treatment administration records were complete and included resident specific parameters for PRN use was discussed with Staff 1 (ED) and Staff 6 (Memory Care Coordinator) on 02/27/25. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in 01/2024 with diagnoses including dementia. Review of the resident's 11/01/24 through 02/25/25 progress notes, MAR/TAR and physician communications, and the 12/04/24 signed physician orders showed the following: * Milk of Magnesia, give 30 ml PRN for constipation. There were no resident specific parameters on when to start the medication. * A stage 2 pressure ulcer was discovered on 11/04/24 and documented in a progress note. The wound remained active until 01/10/25 when a note indicated the wound had resolved. The resident’s wound reopened on 02/15/25. A physician’s order dated 12/05/24 indicated to apply zinc oxide to coccyx wound up to four times daily PRN for soiling. The December 2024 MAR/TAR reflected Desitin cream (Zinc Oxide) apply four times daily prn to affected area, “for peri area and groin area breakdown.” The resident’s MAR/TARs dated 11/01/24 through 11/30/24 and 01/01/25 through 02/25/25 contained no information on the resident’s skin breakdown or treatments provided by staff. The 12/01/24 through 12/31/24 MAR/TAR showed the Desitin cream was applied twice. There was no further information on where or why the cream was applied. The need to ensure medication/treatment administration records were complete and included resident specific parameters for PRN use was discussed with Staff 1 (ED) and Staff 6 (Memory Care Coordinator) on 02/27/25. The staff acknowledged the findings. 3. Resident 1 moved into the community in 02/2024 with diagnoses including dementia and type 1 diabetes. Review of Resident 1's 02/01/25 through 02/25/25 MAR and corresponding physician orders identified the following medications lacked resident-specific parameters: * Glucose (Raspberry) 4-400 Gram unit tab chew (glucose) for low blood sugar, lacked parameters for what constituted low blood sugar; and * Insulin Aspart Flexpen sliding scale, lacked parameters for when to hold the medication. The need to ensure MARs were accurate, including providing resident-specific parameters and instructions for medications, was reviewed with Staff 1 (ED), Staff 6 (Memory Care Coordinator), and Staff 24 (Regional Director of Operations) on 03/03/25. They acknowledged the findings. 4. Resident 4 moved into the community in 01/2025 with diagnoses including dementia and anxiety. Review of Resident 4’s 02/01/25 through 02/25/25 MAR and corresponding physician orders identified the following: a. Lidocaine 4% patch (for back pain) lacked resident-specific instructions for location of patch placement. b. Seven medications staff administered on 02/16/25 at 8:00 pm lacked the initials of the person administering the medication. c. Two PRN medications for constipation, PEG Powder and Senna, lacked resident-specific parameters, including order of administration. The need to ensure MARs were accurate, including providing resident-specific parameters, initialing the MAR when medication was administered, and order of administration for multiple PRN medications with the same indication, was reviewed with Staff 1 (ED), Staff 6 (Memory Care Coordinator), and Staff 24 (Regional Director of Operations) on 03/03/25. They acknowledged the findings.

RN,ED,MCC will review med room for observation,This will insure no loose med cards,expired meds,Meds in different locations in tne med room.Asigned additional training on med management on Oregon Care Partners for Med Techs. 90 day orders completed timely. Medication audit by pharmacy 3/25/25. Daily audits of the med room by RN,ED,MCC to observe everything is put where it belongs. Daily med counts observed by RN or ED,or MCC. Daily audit of the med room and med counts will be observed. Weekly full med carts audits. Quartley med audits by pharmacy. Continued oversight on all MAR and Book to insure accuracy. ED,RN,MCC,Pharmacy (Red Rock)

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.

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 ensure PRN psychotropic medications used to treat a resident's behavior had written, resident-specific parameters, and non-pharmacological interventions were attempted prior to administering the medication for 2 of 2 sampled residents (#s 2 and 4) who were prescribed PRN medication to address behaviors. Findings include, but are not limited to: 1. Resident 4 moved into the community in 01/2025 with diagnoses including dementia and anxiety. a. The facility failed to ensure there were specific parameters for staff describing how Resident 4 expressed anxiety and agitation, and in what order the following psychotropic medications should be administered: * Lorazepam 0.5 mg every two hours as needed for anxiety or agitation; and * Haloperidol 1.5 ml every four hours as needed for agitation. b. The facility administered the PRN Haloperidol 15 times during February. There were no non-pharmacological interventions on the MAR for staff to attempt prior to administering. The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and agitation, instruction on order of administration, and non-drug interventions for staff to attempt prior to the administration of PRN psychotropic medications was reviewed with Staff 1 (ED), Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. They acknowledged the findings. 2. Resident 2 was admitted to the facility in November 2021 with diagnoses including Alzheimer’s disease. Review of the resident's 02/01/25 through 02/25/25 MARs and progress notes, and 12/06/24 physician orders showed the following: * Quetiapine 50 mg, (antipsychotic medication), ½ tablet daily, PRN for “mood.” The Quetiapine was administered six times between 02/01/25 and 02/25/25. The MARs did not contain resident-specific parameters for staff describing when to give the medication, what behavior they were watching for and listed only the generic reason for use of “mood.” The need to ensure resident-specific information on how the behaviors or condition present for the resident, prior to administration of a PRN psychotropic medication should be administered, was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. The staff acknowledged the findings.

RN audit all phychotropic meds. Parameter on how to give the phychropic medicine. RN will In-sure all phychotropic meds have 3 non pharmacutical interventions prior to administering. ED and MCC will make sure interventions are also listed in the residents care plans to help staff assist in interventions. RN,ED,MCC will meet weekly to go over all residents on phychotropic meds and audit all interventions in place,see what is effictive and what is not,make adjustments as needed. Weekly meeting will take place. or anytime a phychropic is added to a residents orders. RN will over see the phychortopics and ED,MCC will assist with additional oversight,and follow up on intervdentions that are put in place.

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.

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 an assessment by a PT, OT or RN was completed for assistive devices with potentially restraining qualities for 2 of 3 sampled residents (#s 4 and 5) who had a supportive device. Findings include, but are not limited to: During the entrance conference on 02/25/25, Residents 4 and 5 were identified as having bilateral side rails on their beds, which had potentially restraining qualities. Observations of the residents and the residents’ rooms showed 1/2 side rails were on the beds and in the up position. There was no documented evidence of: * Assessment completed by a RN, Physical Therapist or Occupational Therapist; * Other less restrictive alternatives attempted prior to their use; * Instructed caregivers on the correct use and precautions related to use of the device; and * Service plan directions for the use of the side rails. In interviews on 02/27/25 and 02/28/25, Staff 6 (Memory Care Coordinator) stated assessments of the sampled residents’ side rails were not completed. The lack of an assessment for the residents’ side rails was discussed with Staff 1 (ED), Staff 6, and Staff 24 (Regional Director of Operations) on 03/03/25. They acknowledged the findings.

Room audits of all residents for any devices with restraining qualities. Audit to insure we have the required orders RN assessments for any and all devices with restraining qualities. After initial audit and follow up. RN,ED,MCC will do a room by room walk through weekly. MCC will follow up on any orders that arre needed. after intial audit a weekly audit will be completed to stay in compliance.Imediate follow up if 3rd party brings in any devices. RN,MCC will follow up to make sure we have everything we need to be compliant,orders,assessments. RN,MCC,ED

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual care plan and service plan for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to: The facility's ABST was reviewed and discussed with Staff 1 (ED) on 02/26/25 and 02/27/25. Review of Residents 1, 2, 3, 4 and 5’s ABST input revealed multiple ADLs were not reflective of the residents' evaluated care needs. The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1, Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. They acknowledged the findings. No further information was provided.

Update all care plans to capture accuratly in the ABST Making sure the care plans are up to date and detailed on the care we are providing. Completing care plans on time and quartly as well as addressing COC timley. Will help in accuratley adding all details to the ABST for each resident needs. Weekly meeting with the MCC as well as Updating the ABST anytime anything changes for a resident. Updating if there is a COC and updating at the residnets quartley review. MCC and ED will monitor and update as needed.

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

OAR 411-054-0037 (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 observation, interview, and record review, it was determined the facility failed to ensure resident ABST entries were updated at least quarterly and with a significant change of condition. Findings include, but are not limited to: Review of the facilities ABST entries was completed and showed the following: * The staffing tool showed there were sixteen residents whose ABST entries were not updated at least quarterly or with a significant change of condition, in conjunction with the residents’ service plan. The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1, Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. They acknowledged the findings. No further information was provided.

Update all residents care plans to make sure all needs of residents have been captured. Audit and update ABST with all current care needs for residents. Update the staffing needs based on the ABST report. Staff according to the ABST and not below. Adding the unscheduled needs of residents. Staffing will be reviewed daily to insure we do not fall below. ABST will be updated with and changes to a reidents needs. Audit weekly and address in our weekly clinical audit meeting, to go over any possible changes or updates. ED,MCC,RN

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.

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 direct care staff were trained in the use of abdominal thrust and First Aid within 30 days of hire for 2 of 3 sampled direct care staff (#s 8 and 9) whose training records were reviewed. Findings include, but are not limited to: On 02/26/25, staff training records were reviewed with Staff 2 (Business Office Manager). The following were identified: There was no documented evidence Staff 8 (CG), hired 12/16/24, and Staff 9 (CG/MT), hired 01/07/25, had demonstrated competency in First Aid and abdominal thrust training. The need to ensure direct care staff demonstrated competency in First Aid and abdominal thrust within 30 days of hire was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator) and Staff 24 (Regional Director of Operations) on 03/03/25. They acknowledged the findings.

Meeting held for training ecpectations,job required trainings. All staff completing required trainings by 5/1/2025. All training will be tracked by BOM. All new Hires will have all training required with in 30 days completed prior to starting on the floor training. All trainings through the first 30 days will be completed priot to starting on the floor training.This will help in the accountability of getting training completed timley. With every new hire, they will not be added to the on the floor training schedule untill all trainings are completed. ED sign off for for start of on the floor training. BOM to insure all trainings are complete prior to ED signing off for the new hire to start floor training. BOM to track and follow up with all required annual trainings. ED to assist with staff compliance and corrective action for non compliance.

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.

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 in accordance with the Oregon Fire Code on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed between 08/2024 and 02/2025, showed: * No fire drills were documented as completed, at least every other month, in the memory care unit; and * Staff interviewed were unsure where the designated meeting place was in case of evacuation/emergency. The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from life safety training, was discussed with Staff 1 (ED), Staff 3 (Maintenance Director) and Staff 6 (Memory Care Coordinator) on 02/27/25. The staff acknowledged the findings.

Training with maintenance Director on job duties and expectations of required drills,safety meeting, Fire Life and Safety. ED will create a monthly calendar of required Fire Life and Safety trainings required, ED will assist in all Drills to make sure they are completed and completed properly according to C420. ED will over see Maintenance Director to insure all required Drills,Fire Life and Safety meetings and training are complete and documented according to policy. Will meet monthly to create for the following month, to have everything planned a month ahead of time. ED will assist in approval for all topics and training agendas. ED will Train Maintenance Director on how to work within the Memory Care Community during fire drills,evacuateations drills.

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 411-054-0090 (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 in fire and life safety procedures within 24 hours of admission and annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (ED) on 02/25/25. There was no documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission and again at least annually. The need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and again annually was discussed with Staff 1, Staff 3 (Maintenance Director) and Staff 6 (Memory Care Coordinator). The staff acknowledged the findings.

Fire Life and Safety for residents: We will conduct for every resident by maintenance and MCC. All new residents will receive fire and life safety within the first 24 hours of admission. Maintenance Director will confirm this was completed within the first 24 hours of admission. ED will follow up to insure accuracy. After the intial Fire and Life Safety have all been completed. All new residnets will have completed within the first 24 hours of admission. ED,Maintenance Director,MCC

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.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces and surrounding pathways were maintained in good repair. Findings include, but are not limited to: Observations of facility pathways and patio areas on 02/25/25 and 02/26/25 identified the following: * Multiple drop-offs of 2-3 inches were noted along pathway edges around the perimeter of the secured courtyard. The need to ensure pathways around the facility were in good repair with no potential tripping hazards were shown to and discussed with Staff 1 (ED) and Staff 6 (Memory Care Coordinator) on 02/26/25. The staff acknowledged the findings.

The outside courtyard will be rebarked by re-inspection To bring all surfaces around the walking path level. Maintenance Director and ED will monitor as weather shifts to insure all surfaces are maintained and address any drop offs around the walking path. Maintaince Director will do a walk through weekly around all walking paths to address, re-rake any areas that are more the 1/2 inch lower then the walk way. ED will do the walk through with the maintenance director and follow up if there is works that needs to be completed.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

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 the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 02/25/25 and 02/26/25 showed the following areas in need of cleaning or repair: * Multiple carpet stains were noted to the carpet in the living room and in the hallway between the dining room and medication room; * Multiple sofas, armchairs and curved back dining chairs were noted to have stains, spills and/or tears to the seats and fabric arms; and * Numerous long deep gouges were noted in the laminate floor in the dining room and common area. Additionally, there were black scuffs and streaks along the laminate flooring as well. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) and Staff 6 (Memory Care Coordinator) on 02/26/25. The staff acknowledged the findings.

Ordered and received new Living room furniture. Carpets have been cleaned and are on a weekly carpet cleaned schedule. Any Spills to be reported and cleaned same day. Quotes received for Flooring replacement. Working on getting the proper approval to have the work completed. Daily walk through to address any immediate needs.follow up with Housekeeping and care staff for wiping down furniture freakquentally. Daily walk throughs and asign tasks to maintenace housekeeping, to address concerns daily. ED will follow up with a final walk through to insure the concen was addressed and completed.

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.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Based on observation, interview , and record review, it was determined the facility failed to ensure residents had the right for freedom from restraints. Findings include, but are not limited to: Refer to C330 and C340.

Facility will insure all residents have privacy by installing new door locks and providing each resident with a key, By installing locks on the shared bathroom pocket doors. New residents will be given a key to their apartment,a nd shown how to operate the locks on the shared bathroms to insure privacy. At move in with each new resident, They will receive a key for their apartment. ED will follow up with the new resident to insure they have received their key.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

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, it was determined the facility failed to ensure privacy and dignity related to no locks on bathroom doors for residents who had shared bathrooms. Findings include, but are not limited to: Observations on 02/25/25 of shared bathrooms revealed there was no locking mechanisms on shared bathroom doors to ensure privacy. On 02/26/25, the observations and the need to ensure shared bathroom doors had locks were reviewed with Staff 1 (ED) and Staff 6 (Memory Care Coordinator). The staff acknowledged the findings.

Shared bathrooms have pocket doors and during construction locks were not installed. We have received quotes to have pocket door locks installed in shared batrhoom. We are gaining approval for thoes locks to be installed Locks will be installed in all pocket doors shared bathrooms. After all locks have been intalled, maintenance director will maintain insuring the locks are in operating condition, during routine maintenance. ED will over see the instalation of pocket door bathroom locks in shared bathrooms.

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.

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 and interview, it was determined the facility failed to ensure all residents who lived in the facility were provided a key to their unit. Findings include, but are not limited to: Throughout the survey, 02/25/25 through 03/03/25, Resident 4 was observed using a key to access his/her apartment. In an interview on 2/27/25 at 11:45 am, Staff 1 (ED) reported that not all residents were given a key to their unit. The need to ensure all residents were provided keys to their units was discussed with Staff 1 on 2/27/25. She acknowledged the findings.

All Residents room locks are being changed so that every resident will have a key to their apartment. Locks are being changed and keys will be disbursed by Re-Inspection date. After the intial lock change with all current residents, All new residents will be given a key to their apartment. At admission of any new residents. ED will follow up with the Maintenance Director to insure the resident was given akey of their own for theor apartment.

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.

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 interview and record review, it was determined the facility failed to conduct an initial resident evaluation prior to move-in for 1 of 1 sampled resident (#4) who had recently moved into the community. Findings include, but are not limited to: Resident 4 moved into the community in 01/2025 with diagnoses including dementia and anxiety. There was no documentation a resident evaluation had been completed before the resident moved into the community. In an interview on 02/26/25 at 10:15 am, Staff 6 (Memory Care Coordinator) reported she did not know an initial evaluation needed to be completed when a resident moved from the assisted living community to the memory care community. The need to ensure initial evaluations were completed prior to move-in was discussed with Staff 1 (ED) and Staff 2 on 02/27/25. They acknowledged the findings.

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 C150, C231, C242, C362, C363, C372, C420, C422, C510, C513, H1517, and H 1518.

ED is shadowing the RN CBC training to assist in overall compliance. ED is take additional training for ABST compliace,COC, AHCA Long term care tracker, ED will be holding daily,weekly,monthly,quatrley meetings with RN,MCC, maintenance Director, to insure they are completing all job requirements according to CBC guidelines. ED will hold daily,weekly,monthly,quartley meeting in all departments so that ED is continuely monitoring all required duties are being completed efficiently.

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 411-057-0155(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 sampled newly-hired direct care staff (#s 8, 9, and 19) demonstrated competencies within 30 days of hire, 3 of 3 sampled long-term direct care staff (#s 14, 15, and 16) completed required annual in-service training, and 1 of 3 sampled long-term non-care staff completed required annual training. Findings include, but are not limited to: Staff training records reviewed on 02/26/25 at 3:00 pm with Staff 2 (Business Office Manager) identified the following: 1. Staff 8 (CG), Staff 9 (CG/MT), and Staff 19 (CG), hired on 12/16/24, 01/07/25, and 01/01/25, respectively, lacked documentation of demonstrated competency in any duty to which they were assigned. 2. Staff 14 (MT), Staff 15 (MT), and Staff 16 (CG), hired on 09/08/22, 10/16/18, and 07/17/22 respectively, lacked documented evidence of completing required annual in-service training as follows: * Staff 15 and 16 lacked a minimum of 16 hours of in-service training on topics related to the provision of care for persons in a CBC setting, including at least 6 hours related to dementia care topics. * Staff 14 lacked LGBTQIA2S+ training. * Staff 15 lacked Home and Community Based Services, infectious disease, and LGBTQIA2S+ training. 3. Staff 25 (Culinary Services Director) lacked LGBTQIA2S+ training. The need to ensure all required training was completed within the specified time frames was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator), and Staff 24 (Regional Director of Operations) on 03/03/25. They acknowledged the findings.

All compentcies have been re-done. All Comps will be completed by the end of the first week of training and turned into the ED. BOM will follow up with department managers,and new employees to make sure their trainings have been completed and documented. BOM will notify any new hires they will not be goin onto their own schedule until the comps have been completed. ED will review comps and approve new hire for going onto their own schedule. With each new hire and the end of their 1st week of training. BOM will monitor and over see,BOM will follow up with department managers, ED will assist and review that all required trainging comps have been completed priot to being put on their own rotation.

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.

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

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C270, C280, C290, C300, C302, C303, C310, C330, and C340.

ED will audit all new resident assessments to insure one has been completed accuratley. ED will implment ED review prior to any move in's. No move ins will take place without the ED assessment review. ED will make a chart note of the review and approval to move forward. The review will take place with every new resident prior to move in date. ED will be responsible for the review, to make sure the assessment has been completed prior to move in.

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. This is a repeat citation. Findings include, but are not limited to: Refer to C260 and C303.

Refer to POC for C260 and C303.

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

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 observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's service or care plan for 3 of 5 sampled residents (#s 1, 3, and 4) whose records were reviewed. Findings include, but are not limited to: Resident's 1, 3, and 4's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator), and Staff 24 (Regional Director of Operations) on 03/03/25. They acknowledged the findings.

ED will review all careplans to insure each resident has a nutrition and hydration plan. All residents care plans will reflect the nutrition and hydration plan. With each change to the care plan. MCC will insure that part is updated with any changes during a COC or quartley review. ED will review any updated care plans to insure this is added and changed to reflec the current wants of the resident. Care plans will be completed timley and updated per the changes of the residents needs. The ED will review the care plan anytime a change is needed. ED will review during weekly and quartley meetings. All residents care plans are being updated immediately to reflect the nutrition and hydration plan. Then any COC,or changes in resdients likes or dislikes, this part of the care plan will be updated. This will also be addressed again at the quartley review. MCC will add the nutrition and hydration to the care plans, ED will review to insure all is captured accuratley. ED will continue to review all care plans as they are updated, ED will oversee that the care plan updates are being completed timley.

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.

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 interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individual activity plan based on their activity evaluation, for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose activity plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, 4, and 5’s activity evaluations and service plans were reviewed. Though the activity evaluation offered some information about the residents’ past and current interests, the facility had not evaluated the residents’: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for participation; and * Activities that could be used as behavioral interventions. There was no individualized activity plan developed for each resident based on their activity evaluation which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. The need to develop individualized activity plans which were based on a thorough assessment of the resident's interests, abilities and needs was discussed with Staff 1 (ED), Staff 6 (Memory Care Coordinator), and Staff 24 (Regional Director of Operations) on 03/03/25. They acknowledged the findings.

Revised the company form for acitivites to meet Oregon requirements. All new individualized activity plans are being completed on all residents. We will update the activity calendar to reflect all current needs of residents activity plans. Once all residents activity plans have been updated. ED is implmenting that the residents activity plan be updated with any changes to the residents ADL's, COC,quartley reviews. MCC will evaluate if changes in the activity plan need to be made. ED will review any changes made, to insure accuracy. The activity plan will be updated with any change of the resdients ADL's, COC, or at their quartley review. ED will monitor and review to insure compliance and accuracy.

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 interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individualized activity plan based on their activity evaluation, for 1 of 2 sampled residents (# 7). This is a repeat citation. Findings include, but are not limited to: Resident 7’s activity evaluation and service plan were reviewed. Though the activity evaluation offered some information about the residents’ past and current interests, the facility had not evaluated the resident’s: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for participation; and * Activities that could be used as behavioral interventions. There was no individualized activity plan developed for the resident based on their activity evaluation which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities. The need to develop an individualized activity plan based on an evaluation of the resident's interests, abilities, and needs was discussed with Staff 4 (Assisted Living RCC), Staff 26 (Health Services Director/RN), Staff 27 (Assisted Living RN), and Witness 3 (RN Consultant) on 07/01/25 at 2:00 pm. They acknowledged the findings.

1. The resident identified in the survey have been reviewed for their individual activity preferences and their service plans have been updated to reflect these changes. 2. Activities Director or MCC will complete " Then and Now" packet capturing individulized activity likes and dislikes along with emotional needs and preferences Activities and MCC will review " Then and Now" and transcribe into individualized charts. 3. Activities director will review as needed or quarterly with care plan meetings. 4. Administrator will review packets as needed or quartely.

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.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C260, C303, and Z164.

Refer to POC for C260 and C303.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 08/22/23 revealed the following: a.  An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Can opener blade and casing; * Commercial meat slicer; * Industrial and table top mixer; * Open stainless steel shelving throughout kitchen; * Floors underneath shelving and equipment; * Walls behind equipment; * Service/utility carts; * Dish machine top; * Walls in dry storage area; * Walls behind and near the dish machine; * Fan over steam table and range; * Ceiling vent; and * Walk in freezer floor. b. Commercial meat slicer and industrial stand mixer were not covered when not in use. c. Green and white cutting boards were found with deep scoring and staining. d. Exterior and interior of the oven, range top, and grease trap of grill were found with food debris build up and grease. Convection oven interior and exterior were found with food debris build up and grease. e. Kitchen staff were observed handling clean dishes after handling dirty dishes without washing or sanitizing hands. f. Ice machine was observed with visible black and pink substances on interior of machine. g. Cafe bar straws were stored without cover or individual wrappers. Disposable single service straws and utensils were stored with food contact portions open to potential contamination. h. Tables in the dining area were set with cutlery with food surface contact areas exposed to potential contamination. i. Ready to eat food items were observed on plate without cover or serving utensil in the cafe bar. Staff  2 (Dining Services Director) and the Surveyors toured the kitchen. Staff 2 acknowledged the above findings. On 08/22/23 at 11:30 am, the memory care kitchenette area was toured and the following was identified: a. Spills, splatters, dust and food debris were present in the oven, cupboards and drawers. b. Silverware was stored in container with food contact surfaces facing upright. Memory care staff were observed touching food contact surfaces with fingers to obtain silverware for place settings. c. The refrigerator temperature was at 48 degrees Fahrenheit. There was a temperature log for that refrigerator to validate temperatures were being monitored. However, for the month of August, the daily temperatures were each recorded at 42 degrees Fahrenheit or higher. Protein rich food items where checked by survey team and temperatures were found at 52 degrees. Memory care staff were interviewed and acknowledged the medication technician was responsible for monitoring the temperature. The kitchen manager for the main kitchen acknowledged that the memory care staff had not informed her of the out of range temperature readings.  Non shelf stable food items in refrigerator were discarded and maintenance contacted. Facility stated they would not be using that refrigerator until appropriate temperatures could be maintained. The areas in need of cleaning, repair and attention were reviewed with Staff 1 (Administrator) , Staff 2 and Staff 3 (Memory Care Administrator) on 08/22/23 at 1:10 pm. They acknowledged the findings.

All areas noted in section A have been cleaned, and added to a rotating cleaning schedule to ensure ongoing compliance Slicer & Mixer are covered and will remain covered when not in use White & green cutting boards have been ordered to replace old ones with deep scoring and staining All kitchen staff have been trained on proper handwashing standards as it related to ready to eat food after touching potentially contaminated items Oven has been cleaned inside & out Ice machine was emptied and cleaned inside & out - filter replaced, monthly cleanings will continue Individually wrapped straws have been ordered and placed out for resident use Silverware is now wrapped with surface contact areas fully wrapped Refrigerator temperature has been corrected. Pastry holder ordered for café bar as well as serving utensils placed 2. In-service occured 8/29/23 for proper food handling and sanitation standards - full kitchen cleaning occurred 9/5/23 Task sheets put into place to ensure cleaning tasks are not fallen behind on 3.The Director of Dining Services will be responsible for monitoring cleanliness & ensuring task sheets are completed daily/weekly 4. Training and competency evaluation for kitchen staff and direct care staff on kitchen and kitchenette cleanliness and food service. Dining Service Director will oversee MC dining service and cleanliness. Administrator will do weekly sanitation, food service audit and observation.

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 C240.

All areas noted in section A have been cleaned, and added to a rotating cleaning schedule to ensure ongoing compliance Slicer & Mixer are covered and will remain covered when not in use White & green cutting boards have been ordered to replace old ones with deep scoring and staining All kitchen staff have been trained on proper handwashing standards as it related to ready to eat food after touching potentially contaminated items Oven has been cleaned inside & out Ice machine was emptied and cleaned inside & out - filter replaced, monthly cleanings will continue Individually wrapped straws have been ordered and placed out for resident use Silverware is now wrapped with surface contact areas fully wrapped Refrigerator temperature has been corrected. Pastry holder ordered for café bar as well as serving utensils placed 2. In-service occured 8/29/23 for proper food handling and sanitation standards - full kitchen cleaning occurred 9/5/23 Task sheets put into place to ensure cleaning tasks are not fallen behind on 3.The Director of Dining Services will be responsible for monitoring cleanliness & ensuring task sheets are completed daily/weekly 4. Training and competency evaluation for kitchen staff and direct care staff on kitchen and kitchenette cleanliness and food service. Dining Service Director will oversee MC dining service and cleanliness. Administrator will do weekly sanitation, food service audit and observation.

The findings of the kitchen inspection, conducted 08/22/2023, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 08/22/23, conducted 11/01/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 11/28/22 revealed splatters, spills, drips, dust and debris noted on: - Can opener blade and casing; - Stand mixer; - Interiors of drawers; - Open stainless steel shelving throughout kitchen; - Underneath shelving and equipment; - Floors throughout kitchen; - Plate warmer; - Service/utility carts; - Dish machine top; - Walls behind and near the dish machine; - Baking rack in main kitchen area; - Walls and outlet by food prep area; - Fan over steam table and range - Vents in ceiling; - Walk in freezer floor.   * Exterior of the range, range top, grease trap of grill were found with grease and food debris build up. Left oven cover in need of repair. * White cutting boards found with deep scoring and staining. (small portable and long attached on/near steam table). * Dish washing racks were observed stored on the floor. * Kitchen staff was observed serving food with long painted and/or acrylic nails and not wearing gloves. * Kitchen staff observed in kitchen and doing prep and service items without hair being restrained. * Kitchen staff was observed prepping ready to eat food (applesauce in bowls) after touching potentially contaminated items (drawers/fridge handles/etc) directly after returning from dining room service tray delivery without washing hands. * Staff 3 was working in kitchen with expired food handlers card (9/30/2022) Staff 2 (Dietary Manager) and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings. On 11/28/22 at 12:45 the memory care kitchenette area was toured and found to have spills, splatters, dust and food debris in the freezer, cupboards and drawers. The bottom cupboard on the right of the fridge was in need of repair. The refrigerator temperature was at 48 degrees Fahrenheit. There was no temperature log located for that fridge to validate temperatures were being monitored to ensure food was being stored at appropriate temperatures. There were observed potentially hazardous food items in the fridge. Memory care staff were interviewed and acknowledged they had not been monitoring or recording temperatures of that refrigerator. The kitchen manager for the main kitchen acknowledged that the memory care staff were the ones to be monitoring that refrigerator. The areas in need of cleaning, repair and attention were reviewed with Staff 1 (Administrator). He acknowledged the findings.

1. Can opener blade and casing cleaned. Stand mixer cleaned. Interiors of drawers cleaned. Open stainless steel shelving throughout kitchen cleaned. Underneath shelving and wquipment cleaned. Floors throughout kitchen cleaned. Plate warmer cleaned. Service/Utility carts cleaned. Dish machine top cleaned. Baking rack in main kitchen area cleaned. Walls and outlet by food prep area cleaned. Fan over steam table and range cleaned. Vents in ceiling cleaned. Walk in freezer floor cleaned. Exterior of the range, range top, grease trap of grill cleaned. Oven cover has been repaired. White cutting boards with deep scoring and staining have been ordered Dish washing racks are stored on shelf (dunage rack) All kitchen staff have been trained on proper glove use as it relates to long painted and/or acrylic nails - Gloves will be worn while prepping and serving food. Kitchen staff have been training and are adhering to proper hair restraints All kitchen staff have been trained on proper handwashing standards as it relates to ready to eat food after touching potentially contaminated items All kitchen staff have their food handlers card Spills, spatters, dust and food debris in freezer, cupboards and drawers cleaned. Cupboard next to freezer will be repaired. Refrigerator temperature has been corrected. All potentially hazardous food items in the fridge has been discarded - date/lables are being used. Freezer / refrigerator temp logs is being used to record temperatures. In-service scheduled week of December 19, 2022 for proper food handling and sanitation standards The Director of Dining Services will be responsible for monitoring refrigerator temps 2. Training and competency evaluation for kitchen staff and direct care staff on kitchen and kitchenette cleanliness and food service. Dining Service Director will oversee MC dining service and cleanliness. Administrator will do weekly sanitation, food service audit and observation. 3. Weekly 4. Dining Service Director, Memory Care Director and Administrator

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 C 240.

Refer to C240

The findings of the kitchen inspection, conducted 11/28/2022, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 11/28/22, conducted 02/07/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, the facility failed to ensure 1 of 1 sampled resident (#3) was treated with dignity and respect and given the opportunity to select or refuse to consent to physician orders. Findings include, but are not limited to: Resident 3 was admitted to the facility in July 2021 with diagnoses including Alzheimer's disease. During an interview with Staff 5 (MT) on 10/05/21 at 6:15 pm, she reported the resident had a history of refusing medications. Staff 5 indicated if the resident refused his/her medications, she put it in his/her dessert to "disguise" it, but did not tell the resident. During an observation and interview on 10/06/21 at 8:20 am, Staff 14 (MT) revealed she had dissolved the resident's morning medication in his/her coffee "for a few weeks" because of frequent refusals. On 10/05/21 and 10/06/21, Staff 2 (Memory Care Coordinator) and Staff 1 (Administrator) were informed Resident 3's medication had been administered without his/her consent. The need to ensure the resident was treated with dignity and respect and provided the opportunity to select or refuse to consent to physician orders was discussed. They acknowledged the findings. On 10/06/21, Staff 1 indicated the practice would be stopped immediately and a new plan to address resident medication refusals would be implemented.

C200 resident rights; Resident # 3 has the right to refuse his medications, we have made community instructions to med techs to give resident # 3 and all residents the right to refuse their medications. We have implemented training for medication technicians regarding resident right to refuse their medications. We are also training on why a resident would have a crush order, it is not to trick the resident its due to not being able to swallow the pill form. We have updated resident #3 care plan and community instructions on the MARS. In order to prevent this from happening again, all crush orders must be approved by the RN in advance prior to the request for a crush order being requested. So we can determine if the resident has a true swallowing issue and needs a crush order to prevent tricking the resident into taking medications. RN and Administrator to monitor when 2nd checking new orders for residents as they are received this will require ongoing monitoring.

Based on interview and record review, it was determined the facility failed to ensure incidents and resident altercations were promptly investigated to rule out abuse and reported to the local SPD office as appropriate for 2 of 3 sampled residents (#s 2 and 3) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in June 2019 with diagnoses including dementia. The resident's care plan dated 08/17/21 and interviews with care staff between 10/04/21 and 10/06/21 indicated the resident was dependent for all ADL care and had frequent falls. The resident was unable to direct his/her own care. Review of incident investigations and progress notes from 07/01/21 through 10/04/21 showed the following: * A progress note dated 09/07/21 indicated the resident had a swollen and puffy face. There was no additional information about the potential injury. * A progress note dated 09/29/21 indicated a bump was discovered on the resident's head, near the hairline. The area was "bluish" in color and appeared to be bruised. There was no additional information on the cause of the bump/bruise. * A progress note dated 10/01/21 indicated the resident had a "black eye," and the resident stated it was from running into the tables. There was no additional information about the cause of the injury. Investigations of the 09/07/21, 09/29/21 and 10/01/21 injuries of unknown cause were not completed to rule out potential abuse and were not reported to the local SPD office when appropriate. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings. The facility was asked to report all three injuries of unknown cause to the local SPD office. Confirmation of the reports were provided prior to survey exit. 2. Resident 3 was admitted to the facility in July 2021 with diagnoses including Alzheimer's disease. Interviews with staff and review of progress notes dated 07/09/21 through 10/04/21 and incident investigations revealed the following: * On 08/21/21, "Resident...yelling at other residents and threatening other residents...stating [s/he] was going to kick the shit out of all of us ....would walk around dining room telling other residents to shut their mouths or [s/he] would shut them for them...other resident in dining room started to become afraid." * On 08/22/21, Resident told another resident to "shut up and she need to leave no one likes her here ...went to hit another resident." The MT documented that she prevented the other resident from being hit. There was no documented evidence the facility investigated the incidents to rule out  potential abuse. The need to investigate all potential incidents of abuse was discussed with Staff 1 (Administrator) and Staff 2 (Memory Care Coordinator) on 10/05/21. They acknowledged the findings.

C231 Abuse investigation and reporting;   Resident # 2 has moved to her daughter's house she is on hospice to pass away. Resident # 3 care plan and interventions have been added to assist staff We have also requested to have an order to have a behavior specialist come in to assist with his redirection when he is upset in order to try to prevent future outbursts. The Memory Care Coordinator is taking the administrator class on 10/18/21 to 10/21/21. Administrator, Health Services Director and Memory Care Administrator are taking the Elder abuse, investigation and reporting OCP class and have received and are studying the abuse reporting guide to make sure we are properly reporting incidents that could be potential abuse including verbal threats. Monitoring by the administrator that all incidents are appropriately reported by the memory care administrator to APS as needed.

Based on interview and record review, the facility failed to ensure that move-in evaluations for 2 of 2 sampled residents (#s 3 and 4) addressed all required elements and were updated as needed within 30 days of admission. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in July 2021 with diagnoses including Alzheimer's disease. The move-in evaluation, dated 07/09/21, failed to address the following required elements and was not updated as needed within 30 days of admission: * Physical health status: visits to health practitioner(s), ER, hospital, or nursing facility in the past year; * Personality, including how the person copes with change or challenging situations; * Complex medication regimen; and * Environmental factors that impact the resident's behavior, including noise, lighting, and room temperature. The need to ensure move-in evaluations addressed all required elements and were updated as needed within 30 days of admission was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings. 2. Resident 4 was admitted to the facility in August 2021 with diagnoses of Alzheimer's dementia. The move-in evaluation, dated 08/23/21, failed to address the following required elements and was not updated as needed within 30 days of admission: * Physical health status: visits to health practitioner(s), ER, hospital, or nursing facility in the past year; * Personality, including how the person copes with change or challenging situations; * Complex medication regimen; and * Environmental factors that impact the resident's behavior, including noise, lighting, and room temperature. The need to ensure move-in evaluations addressed all required elements and were updated as needed within 30 days of admission was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

C252 New Move in evaluations. The current initial, quarterly and Change in condition resident evaluation form has been updated on our electronic system with the addition of missing questions, such as how a person copes with change or challenging situations, complex medication details, and the impact of environmental factors, we have also added in the behaviors section how do each of the potential behaviors affect the resident and what does it look like and how is it best dealt with. We have added additional details that also connect with the care plan. The current form that requests the past physicians' visits, hospitalizations, diagnosis's and medication list will be attached to the initial evaluation a to be addressed when creating the service plan. All residents who move from Waverly Place Assisted Living will be processed as if they are coming from a separate facility. We will be ending the chart and starting over in the electronic system as well as the hard copy binders. The new memory care coordinator is taking the Administrators class 10/18/21 to 10/21/21 in order to have a better understanding of the rules and regulations. This will be monitored by the Administrator when move in takes place.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services and was followed by staff for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Findings include, but are not limited to: The facility utilized documents labeled Service Plan and Care Plan to direct staff on the care of the residents. Staff 1 (Administrator) indicated the two documents were completed together, should contain the same information and date. The documents were available for staff review in binders located in the kitchenette of the memory care unit. 1. Resident 1 was admitted to the facility in January 2021 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the care plan dated 08/17/21, showed the care plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas: * Transfer assistance, bowel incontinence and toileting needs; * Trapeze use; * Falls and safety interventions; and * Pain. The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were followed was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings. 2. Resident 2 was admitted to the facility in June 2019 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the care plan dated 08/17/21, showed the care plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas: * Transfer assistance, toileting; grooming and dressing; * Meal assistance, health shakes and finger foods; * Falls and safety interventions; and * Daily walks and mobility assistance. The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were followed was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings. 3. Resident 3 was admitted to the facility in July 2021 with diagnoses including Alzheimer's disease. Observations of the resident, interviews with staff and review of the care plan dated 08/30/21, showed the care plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Behavioral interventions related to exit seeking, destruction of property, resistance to care, belief that s/he was being poisoned, going into other resident rooms, verbal and physical aggression; * Cell phone use; and * Toileting/continence. The need to ensure resident service plans were reflective of current care needs, provided direction to staff and was followed was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings. 4. Resident 4 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease. Interviews with staff and review of the 07/09/21 care plan revealed it was not reflective of the resident's care needs related to use of dentures. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

C260 Residents #1, 3, and resident 4 care plans have been updated to reflect the needs of the resident and provide clear direction to the staff both on paper and the eletronic hand held devises. Resident # 2 has moved to her daughter's house she is on hospice to pass away. We currently working on re-assessing all memory care residents with the improved assessment that will assist us in building a better person centered care plan that includes how to better address the resident diagnosis by the caregiver on the electronic POC devices and on the care plan itself. All staff will read and sign the hard copy of the quarterly care plans and will be filed into the charts along with a copy that is readily accessible to all staff. Memory Care Coordinator is taking Oregon Care Partners Course to improve Service Plans. Our new RN has completed the Role of the RN class 10/14/21 and will continue to attend OHCA trainings in order to meet the ongoing needs of the community. Both Health Services Director and the Administrator will audit assessments and care plans monthly for accuracy in order to offer person center care plans that meets the needs of the residents and give clear instructions for care by staff.

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, and the condition was monitored to resolution at least weekly 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 1 was admitted to the facility in January 2021 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the resident's 07/08/21 service plan, 07/01/21 through 10/04/21 progress notes, and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Multiple injury and non-injury falls; * Emergency room visit and pain; * Scrapes and abrasions to multiple body parts; * Agitation and destructive behaviors; and * New medications and medication changes. The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in June 2019 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the resident's 07/19/21 service plan, 07/01/21 through 10/04/21 progress notes, and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Multiple injury and non-injury falls; * Swollen and puffy face; * Bruises to the arm, hip, buttocks and head; * Weight loss; and * New medications and medication changes. The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings. 3. Resident 3 was admitted to the facility in July 2021 with diagnoses including Alzheimer's disease. Review of the resident's 07/09/21 through 10/04/21 progress notes, incident investigations and interviews with staff revealed the resident experienced short-term changes of condition related to behaviors during the time frame reviewed. Progress notes dated 07/17/21 through 10/04/21 indicated the resident experienced the following short term changes related to behaviors: * Refusing meals; * Trying to get into other residents' rooms; * Destruction of property; * Yelling and threatening other residents and staff; * Resident to resident altercations on 7/30/21 and 9/6/21; * Believing s/he was being poisoned; and * Hitting, pulling, and kicking the courtyard gate. There was no documented evidence the facility evaluated the resident, determined and documented what actions and interventions were needed for all the changes, communicated them to staff on all shifts, monitored the effectiveness of the existing behavioral interventions, and updated the service plan when the resident's behaviors continued to escalate. The need to ensure the resident was evaluated when s/he experienced short-term changes of condition related to behaviors, actions and interventions were determined, documented and communicated to staff on all shifts, service plan updated and the resident monitored consistent with his/her evaluated needs was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (RN) on 10/05/21. They acknowledged the findings. 4. Resident 4 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease. Review of the 08/24/21 through 10/04/21 progress notes, interviews with staff and observations of the resident, indicated the resident had experienced the following short-term changes of condition: * Making statements to staff that s/he wanted to die; * Exit seeking; * Increased anxiety; and * Aggression to staff. There was no documented evidence the facility evaluated the resident, determined and documented what actions and interventions were needed for the resident, communicated them to staff on all shifts, updated the service plan and monitored the resident. The need to ensure the resident was evaluated when s/he experienced short-term changes of condition related to behaviors, determined what actions and interventions were needed for the resident and communicated them to staff on all shifts, updated the service plan and monitored the resident consistent with his/her evaluated needs was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (RN) on 10/05/21. They acknowledged the findings.

C270 Change of Condition and monitoring; The facility hired a new RN due to the previous RN having quit without notice. The new RN has completed the Role of the RN class on 10/14/21. Residents # 1, 3, 4 care plans have been updated to reflect changes and the RN is monitoring the residents. Resident # 2 has moved to her daughter's house she is on hospice to pass away. The "wisdom to act" featured is going to utilized on the electronic devices to notify the Administrator, RN and RCC of changes in condition with residents the Administrator, RN and RCC will take the training and implement the use and training to the staff. This feature is able to be used by the care givers and med techs to quickly relay changes. This will be monitored by the memory care administrator for effective use as well as audits of weekly monitoring on a regular basis by administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 2 of 2 sampled residents (#s 1 and 2) who experienced a significant change. Resident 2 experienced a severe weight loss with ongoing significant loss, without intervention. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in June 2019 with diagnoses including dementia.   Progress notes and physician communications dated 07/01/21 through 10/04/21, and interviews with care staff on 10/04/21 and 10/05/21 showed the resident required one person, full assistance with care. The resident had an overall decline in condition in June 2021. The resident was noted to have intermittent edema and poor to fair meal intake. a. Review of the resident's "Weight Report" from March 2021 through September 2021 showed the following: * The resident experienced a 18.5 lb weight loss from March 2021 to September 2021 which constituted a 15% severe weight loss in six months. * The resident experienced an 8.5 lb weight loss from June 2021 to September 2021, which constituted a 7.5% significant weight loss in three months. * The resident experienced a 5.9 lb weight loss from August 2021 to September 2021, which constituted a 5.39% significant weight loss in one month. A current weight was requested for the resident. The resident's weight was noted as 95.6 lbs on 10/06/21. This represented an additional 7.9 lb weight loss from September 2021 to October 2021, which constituted a 7.63% severe loss in one month. The resident's 08/17/21 service plan indicated the resident had nutritional shakes three times daily due to weight loss to help maintain his/her weight. Weights were to be done weekly for monitoring. The service plan did not reflect the resident's need for finger foods, assistance with utensils and assistance with fluids. Physician orders dated 08/02/21 included orders for weekly weights and staff were to notify the RN if a there was a three pound weight variance from the previous weight. There was no order for any nutritional shakes or supplements on the most recent physician orders. The resident's 09/01/21 through 10/04/21 MAR showed three of the five opportunities for weekly weights were not recorded on the MAR. The MAR contained no information regarding any health shake or nutritional supplements for the resident. Staff interviews conducted 10/04/21 to 10/06/21 revealed the resident frequently required staff to feed him/her the meal. Staff indicated the resident ate better when finger foods were an option as s/he became more confused with the use of utensils. The staff further indicated the resident had become very small and lost a great deal of weight in the last month or so. Four staff interviewed indicated they did not provide any health shakes or other shakes to the resident and stated the resident did not receive any type of shake during their shifts. Observations of the resident on 10/04/21 through 10/06/21 showed the resident was inconsistently assisted with meal intake. Snacks were observed on three occasions. The resident was provided a half a sandwich on each of the three occasions, the resident ate over 75% of the sandwiches provided. The resident did not independently seek out food or fluids during observations but could drink once the cup was in his/her hand and staff cued him/her. A water cup was kept near the resident and filled on 10/04/21, the resident inconsistently had fluids available during the remainder of the observations. When the resident was asleep or very groggy staff made minimal attempts to awaken the resident and provide food at meal times. The resident was observed to ignore utensils and use his/her fingers for 2 of 3 meals, intake was 25% or less of the meal. Staff were observed to fully feed the resident his/her meal on one occasion, intake was approximately 25%. On 10/06/21 the resident was observed not to receive a breakfast meal due to grogginess. The resident was observed to feed herself the lunch meal, items that required utensils had a moderate success rate getting to the resident's mouth. The resident ate 100% of a roll for the 10/06/21 lunch meal. In interview on 10/05/21, Staff 3 (Health Services Director/RN) indicated she did not have any assessment of the resident's weight loss. Staff 3 stated she started work with the facility in September 2021. The facility failed to ensure an RN assessment was completed timely for the ongoing weight loss with documented findings, resident status and interventions made as a result of the assessment. The resident experienced an ongoing significant to severe weight loss without consistent documentation and implementation of interventions, RN assessment and consistent meal and fluid assistance from staff. b. On 05/25/21 the resident was admitted to hospice services due to a decline in his/her condition and increased care needs. The facility failed to ensure an RN assessment was completed related to the resident's decline and the hospice admission which documented findings, resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed timely, related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings. 2. Resident 1 was admitted to the facility in January 2021 with diagnoses including dementia. On 06/25/21 the resident was admitted to hospice services due to a decline in his/her conditions, increased falls and care needs. The facility failed to ensure an RN assessment was completed related to the resident's decline and the hospice admission which documented findings, resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed timely, related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

C280 - Significant change in condition - RN assessment.  The facility is prepared to hire a temporary RN should the RN quit that has dedicated hours to fill in as the Role of RN at Waverly Place Assisted Living. Administrator will make sure that the fill in RN has information readily available to monitor changes in conditions. The current new RN has completed the Role of the RN class and understand the duties the RN. The memory care coordinator is taking her administrator class oct 18 - Oct 21st 2021 she will be better equipped to assist the RN so the RN can effectively perform her duties to maintain compliance. Resident # 1, is being monitored, and each individual need has been addressed with the PCP, Hospice or Home Health care plans and community instructions have been updated. Resident # 2 has moved to her daughter's house she is on hospice to pass away. Memory Care Administrator will monitor weekly to assure that proper documentation and monitoring is happening throughout the community. Administrator will meet with RN weekly to discuss current change in condition monitoring.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#5) who received insulin injections by unlicensed staff. Findings include, but are not limited to: Delegation records for Resident 5, reviewed with Staff 2 (RN) on 10/04/21, indicated the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 2 (Memory Care Coordinator), Staff 7 (MT) and Staff 17 (MT) to include: * Nursing assessment and condition of the client to determine if the client's condition was stable and predictable; * The rationale for deciding the task of nursing care could be safely delegated to unlicensed persons; and * Frequency the client should be reassessed, including rationale. The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (Administrator) and Staff 2 on 10/05/21. They acknowledged the findings.

282 - Delegation.  The RN now has a better understanding of the Role of the RN she has completed the class on 10/14/21. Since finishing the class RN is in the process of re-delegating all the medication technicians. The RN used the same forms and process as the previous RN who quit left behind, being new to the role she did not know she did not have the correct information. She has since learned how to properly delegate. Including an assessment of each of the diabetic resident's history to determine if their condition is stable and predictable. Also, a bio & history of med techs she is delegating insulin tasks in order to determine they are safely delegated. RN will monitor the delegation tasks monthly and resident assessments as required per State of Oregon.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure documentation of visits were maintained in the residents' records, and that recommendations were implemented for 2 of 2 sampled residents (#s 1 and 2) who were receiving home health services from outside providers. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in January 2021 with diagnoses including dementia. During the acuity interview on 10/04/21, Resident 1 was identified as receiving outside provider services related to hospice. Observations of the resident, interviews with staff and review of outside provider notes and progress notes from 07/01/21 through 10/04/21 were completed. The resident was admitted to hospice services on 06/25/21 related to a decline in condition and increased falls. Hospice nursing visits were to occur one to three times per week as needed for general care and catheter care. Hospice nursing visit notes were not consistently documented and/or recommendations were not implemented as follows: * There were no visits documented for 07/16/21, 08/13/21, 09/07/21 and the week of 09/13/21; * Nursing recommendations on 07/30/21 instructed staff to have the resident's weight available for the next visit; * Nursing recommendations on 09/02/21 instructed staff to monitor Foley catheter output and let hospice know if the urine output decreased; and * Nursing recommendations on 09/24/21 instructed staff to monitor urine output and notify hospice if output was less than 200 ml and push fluids.   There was no evidence the recommendations were implemented and/or communicated to staff.   The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in June 2019 with diagnoses including dementia. During the acuity interview on 10/04/21, Resident 2 was identified as receiving outside provider services related to hospice. Observations of the resident, interviews with staff and review of outside provider notes and progress notes from 07/01/21 through 10/04/21 were completed. The resident was admitted to hospice services on 05/25/21 related to a decline in condition. Hospice nursing visits were to occur one to three times per week as needed for general care. Hospice nursing visit notes were not consistently documented and/or recommendations were not implemented as follows: * There were no visits documented for 07/20/21, 08/13/21, 09/07/21 and the week of 09/13/21; * Nursing recommendations on 08/17/21 instructed staff to apply barrier cream with brief changes; * Nursing recommendations on 08/20/21 indicated "barrier cream to buttocks PRN to prevent skin breakdown;" and * Nursing recommendations on 09/29/21 indicated the resident had a bruise to the head and instructed staff to "investigate cause" and monitor for changes in mentation or sleepiness. There was no evidence the recommendations were implemented and/or communicated to staff.   The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

C290 Outside providers - Resident #1 care plan and MARS community instruction has been updated to reflect the previous notes. Hospice was contacted regarding inconsistent visits and not leaving notes. Outside provider notes will be documented in a 3-point check system by MT, then MCC and then last the RN to assure that the instructions are clear and accurate and that the instructions for care are available to care staff. Resident # 2 has moved to her daughter's house she is on hospice to pass away. MCC and RN will monitor the resident chart for notes and changes weekly until resolved.

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 2 of 2 sampled residents (#s 1 and 2) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in January 2021 with diagnoses including dementia.   Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 08/04/21 included the following orders: * Morphine 20 mg/1.0 ml, take 0.25 ml every 30 minutes PRN for pain.   The resident's Controlled Substance Disposition logs and MARS, reviewed from 09/01/21 through 10/04/21 showed the following: * On 09/05/21 two Morphine doses were recorded on the MAR, but were not documented on the disposition log; and * On 09/06/21 three doses were recorded on the MAR, but only two doses were documented on the disposition log. Comparison of the medication bottle to the disposition log, showed the amount of medication left was reflected accurately on the log. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN). The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in June 2019 with diagnoses including dementia.   Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 08/02/21 included the following orders: * Lorazepam 0.5 mg, take one tablet every four hours PRN for nausea/shortness of breath. The resident's Controlled Substance Disposition logs and MARS, reviewed from 09/01/21 through 10/04/21 showed the following: * On 09/03/21 a dose of Lorazepam was recorded on the disposition log, but not on the MAR; * On 09/11/21 a dose of Lorazepam was recorded on the MAR, but not on the disposition log; and * An undated entry included staff signature and one tablet dispensed, was noted on the disposition log. Comparison of the medication dosing card to the disposition log, showed the amount of medication left was reflected accurately on the log. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

C302 - Tracking Controlled Substances - RN and RCC will utilize a weekly med room audit form that includes monitoring of the eldermark MAR system and comparing it to the narc book weekly. All medication technicians being re-assigned the eldermark training regarding the proper use of the electronic MARS. Administrator will follow this process to maintain compliance with monthly monitoring of audit forms.

Based on interview and record review, the facility failed to ensure medication orders were carried out as prescribed and that written, signed practitioner orders were documented in the resident's record for all medications that the facility was responsible to administer for 1 of 4 sampled resident (#3) whose facility record was reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in July 2021 with diagnoses including Alzheimer's disease. Review of Resident 3's current physician orders included the following medications: * Famotidine (stomach upset); * Lexapro (psychotropic); * Multivitamin (supplement); and * Zyprexa (psychotropic) During interviews with Staff 5 (MT) and Staff 14 (MT) on 10/05/21 and 10/06/21, they reported they administered the resident's medications crushed in dessert or dissolved in juice/coffee on multiple occasions.  There was no documented evidence the facility had an order to administer the medication in that manner. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

C303 MD Orders - Resident # 3 has an order for crushed medications however resident does not have a swallowing issue and has the right to refuse his medications facility has requested that this order be d/c. Staff training will consisted of the following; OCP medications and dementia this class will help them understand that an order must be obtained to administer medications in any other form other than the way they are packaged in whole form. Training to educate the MT that a crushed order is for a resident with swallowing issues, and that the RN must be notified prior to a crush order being requested. Memory Care Administrator will monitor that all orders are followed as prescribed the PCP as they are received.

Based on interview and record review, it was determined the facility failed to ensure the physician was notified when a resident refused to consent to a medication order for 1 of 1 sampled resident (# 3) whose record was reviewed: Findings include, but are not limited to: Resident 3 was admitted to the facility in July 2021 with diagnoses including Alzheimer's disease. Review of the resident's current physician orders, 09/01/21 through 10/04/21 MAR and physician communications revealed the resident had refused to consent to multiple medication orders, including: * Lexapro (psychotropic) four times; * Famotidine (upset stomach) eight times; * Quetiapine (psychotropic) twice; and * Zyprexa (psychotropic) five times. There was no documented evidence the facility had notified the physician when the resident refused to consent to the medication orders. The need to ensure the physician was notified when a resident refused to consent to a medication was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN). They acknowledged the findings.

C305 - Resident Right to Refuse - Staff training on the following;   If a resident refuses his/her medication a fax must be sent immediately following the refusal and documented ion the chart and, on the MARs, as why the medication was not given. A specific fax transmittal form has been created to notify the PCP of medication refusals. MCC Administrator will monitor the MAR's to make sure that the PCP's are being noticed, this will be an ongoing process.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident-specific parameters for PRN medications for 2 of 4 sampled residents (#s 1 and 2) whose medication records were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in January 2021 with diagnoses including dementia. Review of the resident's 07/01/21 through 10/04/21 progress notes, physician communications, and the 09/01/21 through 10/04/21 MARs showed the following: * Morphine 20 mg/ml take 0.25 ml, PRN for shortness of breath; and * Lorazepam 0.5 mg take one tablet every four hours PRN for shortness of breath. There were no parameters to direct staff which medication to give to the resident first for shortness of breath. * Morphine 0.25 ml every 30 minutes and Tylenol 650 mg every four hours, were ordered PRN for pain. There were no parameters to direct staff which medication to give to the resident first for pain. * Milk of Magnesia, Docusate Sodium/Senna and Bisacodyl Suppository PRN for constipation. There was no information for staff on when to start the medication, which medication to use first and in what order. The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in June 2019 with diagnoses including dementia. Review of the resident's 07/01/21 through 10/04/21 progress notes, physician communications, and the 09/01/21 through 10/04/21 MARs showed the following: * Morphine 20 mg/ml take 0.25 ml, PRN for restlessness and anxiety; and * Lorazepam 0.5 mg take one tablet every four hours PRN for restlessness and anxiety. There were no parameters to direct staff what the resident's restlessness and anxiety looked like or what medication to use first. * Morphine 0.25 ml every 30 minutes, Tramadol 50 mg three times a day six hours apart, and Tylenol 650 mg every eight hours were ordered PRN for pain. There were no parameters to direct staff which pain medication to give to the resident and in what order. * Multiple blanks related to the resident's hourly toileting schedule, which was tracked on the MAR. There was no additional information to indicate what occurred on the unsigned days. The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

C310 - Accurate MARS - Resident # 1 MARS has been updated with resident specific instructions for the administration of this PRN pain medication. Resident # 2 has moved to her daughter's house she is on hospice to pass away.   When new PRN pain medications are ordered when MCC and RN are doing 2nd and 3rd check they will confirm that the resident specific parameters are included with the order and entered on the MARS. A complete audit of all memory care PRNs will be looked at and resident specific parameters will be requested and entered in the MARS for accurate administration of the medications. MCC and RN will monitor the parameters for PRN's as they come in from the PCP's and make sure they are entered into the MARS.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 3 of 3 sampled residents (#1, 2 and 4) who were prescribed a PRN medication to address behaviors. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in January 2021 with diagnoses including dementia. Review of the resident's 09/01/21 through 10/04/21 MARs and progress notes and 08/04/21 hospice orders showed the following: * Haloperidol (antipsychotic medication) 5.0 mg half a tablet, every four hours PRN agitation. The Haloperidol was administered once on 09/06/21. The MARs did not contain resident-specific parameters for staff describing how the resident expressed agitation. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medications. The need to ensure there were resident-specific descriptions of how the resident expressed agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN). The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in June 2019 with diagnoses including dementia. Review of the resident's 09/01/21 through 10/04/21 MARs and progress notes and 08/02/21 hospice orders showed the following: * Lorazepam (antipsychotic medication) 0.5 mg tablet, take one tablet every four hours PRN restlessness and anxiety. The Lorazepam was administered seven times between 09/01/21 and 10/04/21. The MARs did not contain resident-specific parameters for staff describing how the resident expressed restlessness or anxiety. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medications. The need to ensure there were resident-specific descriptions of how the resident expressed agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN). The staff acknowledged the findings. 3. Resident 4 was admitted to the facility in August 2021 with a diagnoses of Alzheimer's disease. Review of the resident's 09/01/21 through 10/04/21 MAR and 08/23/21 current physician orders revealed the following: * An order for Clonazepam 0.25 mg daily PRN for anxiety. The facility administered Clonazepam seven times between 09/01/21 and 09/15/21. There were no resident-specific descriptions regarding how the resident expressed anxiety and no non-drug interventions for staff to attempt prior to administration of the medication. * A 09/15/21 order for Lorazepam 0.5 mg daily PRN anxiety was added to the MAR on 09/17/21. Lorazepam was administered five times between 09/17/21 and 10/04/21. Clonazpepam was administered once. The MAR lacked resident-specific descriptions regarding how the resident expressed anxiety and non-drug interventions to attempt prior to the administration of medication. Additionally, there were no parameters listed on the MAR which instructed staff which anxiety medication to administer first. The need to ensure there were resident-specific descriptions of how the resident expressed anxiety, non-drug interventions for staff to attempt prior to the administration of psychotropic medications and parameters which instructed staff which medication to administer first listed on the MAR was reviewed with Staff 1 (Administrator),  Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

C330 Psychotropic Medications - New RN has completed the Role of the RN on 10/14/21 and understand the role. MCC has is currently taking the administrators course and will have a clear understanding of the rule. Resident # 1 care plan and community instructions on the MARS has been updated to include how the residents expresses agitation and the addition of 3 non-drug interventions to try prior to administering the PRN.   Resident # 2 has moved to her daughter's house she is on hospice to pass away. Resident # 4 care plan and community instructions on the MARS has been updated to include how the residents expresses anxiety as well as what medication to administer first. and the addition of 3 non-drug interventions to try prior to administering the PRN.   RN along with MCC administrator will go through all memory care resident charts and update all PRN psychotropics with non-drug interventions specific to the resident.  This will be monitored by the RN as new orders are received from the Physicians.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were conducted according to the Oregon Fire Code (OFC).  Findings include, but are not limited to: Fire and life safety records were reviewed with Staff 16 (Maintenance Director) on 10/05/21. Staff 16 reported the facility was not evacuating or relocating residents during fire drills, therefore, the facility's fire drill documentation did not include the following elements: * Escape route used; and * Number of occupants evacuated. The need to ensure all fire drills were conducted in accordance with the OFC, was discussed with Staff 1 (Administrator), Staff 2 ( Memory Care Coordinator) and Staff 16 on 10/05/21. They acknowledged the findings.

420 - Fire Drills - In order to comply, we are; 1.) Two normal fire drills week one. 2.) Week two practice runs of the evacuation route on different shifts. 3.) Week three and every week after 1 drill per week on different shifts until December. 4.) Starting December 1, 1 drill with evacuation every other week. 5.) Beginning January 1, 1 drills with evacuation per month. Documented drills will be on every shift. This will be monitored monthly by the administrator.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were conducted according to the Oregon Fire Code (OFC).  Findings include, but are not limited to: Fire and life safety records were reviewed with Staff  16 (Maintenance Director) on 10/05/21. Staff 16 reported the facility was not evacuating or relocating residents during fire drills. The facility lacked documented evidence of the following: * Alternate exit routes were used during fire drills; and * Annual fire and life safety training for residents, including all required training topics. Two of three facility staff interviewed on 10/05/21 were unaware of the designated point of safety. The need to ensure all fire drills were conducted in accordance to the OFC, was discussed with Staff 1 (Administrator) and Staff 2 (Memory Care Coordinator) and Staff 16 on 10/05/21. They acknowledged the findings.

C422 - Fire and Life Safety Weekly meetings 1:1 with each current resident will be conducted to go over safety training, fire and other natural disasters. Meetings will consist of general safety procedures, evacuation methods, responsibilities during fire drills, where the designated meeting place is outdoors. Upon new move in within 24 hours safety training will be dome with the resident that covers safety training, fire and other natural disasters, general safety procedures, evacuation methods, responsibilities during fire drills, where the designated meeting place is outdoors along with responding to questions the residents may have. Each resident will receive printed instructions for future reference, each training will be documented and kept in the resident file and in a resident training binder by room number. Administrator, Director of maintenance and other designated staff will provide training. Administrator will maintain all training records and monitor monthly.

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 C 200, C 231, C 420 and C 422.

Z142 - Referral Memory Care Coordinator is currently taking the 40 Hour Administrators Course in order to get her Administrators License. Administrator is enrolled in the 40 Hour courses and will attend this as a refresher 11/15/21 to 11/19/21 in order to be more effective in achieving compliance. Administrator will take the OCP Elder Abuse Prevention, Investigation and Reporting and Resident rights course. To maintain compliance with C200 & C231 Administrator has implemented new scheduled document trainings to achieve compliance for C420 and C422 trainings that include resident evacuation and education.

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 training prior to beginning job duties and demonstrated competency in their job duties within 30 days of hire, and 1 of 3 long-term staff  failed to complete the required number of hours of annual training. Findings include, but are not limited to: Staff training records were reviewed on 10/06/21. 1. Training records lacked documented evidence the following pre-service orientation elements were completed: a. Staff 8 (CG), hired 07/28/21: * Abuse reporting requirements; b. Staff 10 (MT), hired 07/09/21: *Abuse reporting requirements; and *Standard precautions for infection. 2. Training records lacked documented evidence that competency was demonstrated within 30 days of hire for the following: a. Staff 8 (CG), hired 07/28/21: *Changes associated with normal aging; and *General food safety serving and sanitation. b. Staff 12 (CG), hired 07/16/21 : * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment observation and reporting. 3. Training records for Staff 9 (CG), hired 05/09/19, lacked documentation of completion of 10 hours annual training related to the provision of care in community based care and 6 hours of training related to dementia care. The need to ensure all required training was completed within the specified time frames was discussed with Staff 2 (Memory Care Coordinator) on 10/06/21. She acknowledged the findings.

Z 155 Staff # 8, #9, #10, and #12 are currently working on staff training for compliance. We have ended our contract with Relias due to not being assigned the proper training modules for compliance. We have printed the class list from Oregon Care Partners and have created a new hire online training checklist along with other trainings we require. We are also re-building our record keeping binder by month/date hire so we have the appropriate trainings annually. We are auditing all of the staff to make sure we are compliant and making sure they have the appropriate training as required. Administrator will oversee the training and the record keeping monthly to maintain compliance.

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 270, C 280, C 282, C 290, C 302, C 303, C 305, C 310 and C 330.

Memory Care Coordinator is currently taking the 40 Hour Administrators Course in order to get her Administrators License. This will help her understand the health care rules and maintain compliance with the rules. Administrator is enrolled in the 40 Hour courses and will attend this as a refresher 11/15/21 to 11/19/21 in order to be more effective in achieving compliance. RN has completed the Role of the RN class and now has a better understanding of her Role. All three will enroll in continuing education as offered by OHCA and OCP in order to understand and implement the health care rules as required.   Administrator will monitor monthly that ongoing trainings are documented and kept on file. for review.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 4 of 4 sampled residents (#1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3 and 4's current service plans were reviewed during survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

Z163 - Residents # 1, # 3 and # 4 care plans have been updated regarding the individual nutrition and hydration needs of each resident. By adding more detailed food preferences and beverages. We are going to update all resident care plans. In the initial assessment we have added additional questions to address the nutritional and hydration needs of the residents. Resident # 2 has moved to her daughter's house she is on hospice to pass away. This will be monitored and updated by the memory care coordinator/administrator monthly by making changes to the care plans as the resident needs change.

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3 and 4's service plans offered some information about the resident's interests, but the facility had not fully evaluated the resident's: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. Observations on 10/04/21 and 10/05/21 showed multiple residents wandering the halls, calling out and napping in the TV area for large chunks of the day without consistent interaction or intervention from staff. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities. The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN). The staff acknowledged the findings.

Z164 Activities - The resident service plans for residents # 1, 3 & 4 have been updated to include more detailed information in regard to current abilities and skills, emotional and social needs and patterns, Physical abilities, adaptations for the resident to participate and things that can help with behaviors. Resident # 2 has moved to her daughter's house she is on hospice to pass away. Memory Care coordinator is going through each memory care resident and adding all the addressed items to all the care plans. As new residents move in, we will include in the initial assessment current abilities and skills, emotional and social needs and patterns, Physical abilities, adaptations for the resident to participate and things that can help with behaviors. The assessment form is currently being updated. As the resident has changes in their needs the memory care coordinator will update the care plans with the input of the cativity director. the administrator will monitor random care plans for accuracy and changes monthly.

Based on observation, interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 4 sampled residents (# 4) with documented behaviors. Findings include, but are not limited to: Resident 4 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease. Review of the resident's current service plan, 08/23/21 through 10/04/21 progress notes, interviews with staff and observations of the resident revealed the following: The resident's 08/24/21 service plan did not identify the resident exhibited behavioral symptoms which negatively impacted the resident or others. The following behaviors were documented in the resident's clinical record: 08/24/21: "Exit seeking;" 08/29/21: "Increased anxiety...pacing the hallways;" 08/29/21: "Exit seeking this afternoon;" 09/11/21: On alert for suicidal comment: "You can help me die;" 10/02/21: "Increased agitation and aggression this shift, resident yelling at staff and other residents...slapped staff members hand;" On 10/05/21, Resident 4 was observed pushing on the exit door and pressing buttons on the exit keypad. S/he stated multiple times that s/he wanted to leave and became upset and yelled at staff who attempted to redirect the resident. During interviews with Staff 4 (CG) and Staff 13 (CG) on 10/05/21, they indicated the resident had engaged in exit seeking behaviors since admission to the facility and had stated that mornings and on multiple occasions s/he had a desire to die. There was no documented evidence the facility had developed an individualized service plan for behavioral symptoms for the resident related to suicidal thoughts and verbalizations, exit seeking, agitation and aggression. The need to develop individualized behavior plans for residents with behavioral symptoms that negatively impacted the resident or others in the community was discussed with Staff 1 (Administrator) and Staff 2 (Memory Care Coordinator) on 10/05/21. They acknowledged the findings.

Z165 - Individualized Behavior - Resident # 4 has been re-assessed with the new improved assessment and his care plan has been updated to reflect his behaviors. We requested an order from his PCP for a behavior specialist to come in to give us additional tools and staff training in order to be able to handle his behaviors. All residents in memory care are being re-assessed to include individualized behaviors that are relative to each residents' behaviors.   Memory Care Coordinator and the Administrator will monitor plans on a regular basis to reflect the ongoing needs and changes. Administrator will be notified of new behaviors and care plan changes.

The findings of the re-licensure survey, conducted 10/04/21 through 10/06/21 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. 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 re-visit to the re-licensure survey of 10/06/21, conducted 01/10/22 through 01/12/22, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.