Murray Highland

Based on interview and record review, it was determined the facility failed to ensure resident evaluations addressed all required elements for 1 of 1 sampled resident (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 1 moved into the facility in 05/2025 with diagnoses including dementia, depression, and chronic pain.

The resident's move-in evaluation was reviewed and lacked the following required elements:

* List of current diagnoses;
* List of medications and PRN use;
* Mental health issues, including history of treatment and effective non-drug interventions;
* Personality, including how the person copes with change or challenging situations;
* Ability to use the call system;
* Non-drug interventions for pain;
* History of dehydration;
* Recent losses;
* Smoking, ability to smoke safely;
* Alcohol and drug use;
* Environmental factors that impact the resident's behavior including, but not limited to, noise, lighting, room temperature;
* Preferred pronouns; and
* Gender identity.

The need to ensure all required elements were addressed on the resident's move-in evaluation was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged the findings.

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of the residents’ needs and included a written description of who should provide the services and what, when how, and how often the services should be provided for 3 of 4 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 05/2025 with diagnoses including dementia, type 2 diabetes mellitus, depression, and chronic pain.

The resident's service plan, dated 06/25/25, and MARs, dated 07/01/25 through 08/12/25, were reviewed, and staff were interviewed. The service plan lacked clear direction to staff which included a written description of who should provide the services and what, when, how, and how often the services should be provided in the following areas:

* What triggered Resident 1's anxiety and effective non-drug interventions;
* How the resident exhibited episodes of being hyperglycemic and hypoglycemic;
* How staff should assist and reassure Resident 1 with forgetfulness and difficulty concentrating;
* How to prompt the resident in order to help with forgetfulness, difficulty understanding, and communicating needs;
* Staff assistance with leisure activities and where the supplies were located; and
* Non-drug interventions for pain relief.

The need to ensure the service plan provided clear caregiving instruction to staff which included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged the findings.

2. Resident 2 moved into the facility in 04/2025 with diagnoses including dementia and basal cell carcinoma.

The resident's service plan, dated 07/23/25, Change in Service Plan, dated 04/11/25, and progress notes, dated from 04/11/25 through 08/06/25, were reviewed, and staff were interviewed. The service plan lacked clear direction to staff which included a written description of who should provide the services and what, when, how, and how often the services should be provided in the following areas:

* Facial hair and how staff were to assist the resident;
* What needs the resident had that staff should attempt to anticipate;
* Where staff could locate non-alcoholic beer and root beer relating to behavior interventions;
* Interventions for staff to use when Resident 2 became angry with them;
* Direction on how to redirect and reassure the resident if s/he became confused, disruptive, aggressive, or socially inappropriate;
* How Resident 2 showed anxiety and non-drug interventions staff could utilize for the behavior; and
* The potential for skin lesions and to whom they should be reported.

The need to ensure the service plan provided clear caregiving instruction to staff which include a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged the findings.

3. Resident 3 moved into the facility in 10/2024 with diagnoses including dementia.

The resident's service plan, dated 07/23/25, and progress notes, dated 03/28/25 through 08/01/25, were reviewed, and staff were interviewed. The service plan lacked clear direction to staff which included a written description of who should provide the services and what, when, how, and how often the services should be provided in the following areas:

* The use of compression stockings;
* How Resident 3 helped with dressing and toileting;
* Interventions for staff to use to manage and reduce sundowning;
* How staff were to provide extensive intervention to support the resident's dementia related conditions;
* How staff could help Resident 3 when s/he felt disoriented;
* Interventions for redirection out of other residents' rooms; and
* Non-drug interventions related to resisting care, verbal behaviors, hallucinations, and delusions.

The need to ensure the service plan provided clear caregiving instruction to staff which include a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure medications that were given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (# 3) who was prescribed and administered a PRN psychotropic medication. Findings include, but are not limited to:

Resident 3 moved into the facility in 10/2024 with diagnoses including dementia. The resident's MARs, dated 07/01/25 through 08/12/25, and progress notes, dated 03/28/25 through 08/01/25, were reviewed and staff were interviewed. The following was noted:

Resident 3 had a physician's order for quetiapine (to treat agitation and aggressive behavior), 25 mgs, PRN. The resident received the PRN medication on:

* 07/02/25;
* 07/08/25;
* 07/10/25;
* 07/15/25; and
* 08/07/25.

There was no documented evidence that non-pharmacological interventions were tried and failed prior to the administration of the PRN psychotropic.

On 08/14/25 at 2:25 pm, Staff 5 (MT) reviewed the electronic medication program with the surveyor and confirmed there were no non-pharmacological interventions listed for staff to try prior to administering the PRN, nor was there a place to document when non-pharmacological interventions were tried and failed prior to the administration.

The need to ensure medications given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented as ineffective prior to the administration of psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was completed before a resident moved in to the community and/or no less than quarterly at the same time the resident’s service plan was updated for 3 of 4 sampled residents (#s 1, 2, and 3) and multiple unsampled residents whose ABST updates were reviewed. In addition, the facility failed to use the results of the ABST to develop and routinely update the facility’s posted staffing plan. Findings include, but are not limited to:

On 08/12/25 the facility provided the ABST Entrance Questionnaire and the corresponding documentation that was requested. The following was identified:

1. The residents’ ABST updates were reviewed on 08/12/25 and the following was noted:

a. Resident 1, Resident 2, and four unsampled residents’ data was not entered into the ABST prior to move-in.

b. Resident 3 and 14 unsampled residents’ ABST information had not been updated quarterly at the same time their service plans were updated.

2. The facility had two, 12-hour shifts. The following was noted:

a. The posted staffing plan reflected:

* Day Shift: One MT and two CGs;
* Night Shift: One MT and one CG; and
* 9:00 am to 9:00 pm: An additional CG.

b. The ABST reflected five out of seven days, from 6:00 am to 6:00 pm, were not staffed per the tool’s calculated resident minutes.

The need to ensure residents’ data in the ABST was entered prior to move-in and updated quarterly when the service plan was updated, and the need for the facility to use the results of the ABST to develop, and routinely update, the facility’s posted staffing plan was discussed with Staff 1 (ED) and Staff 2 (RCC) on 08/14/25 at 2:40 pm. They acknowledged findings.

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.

This Rule is not met as evidenced by:

Based on observation and interview, the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include but are not limited to:

The interior of the facility was toured on 08/12/25 at 11:30 am. The following were identified:

* Walls, baseboards, and corner walls had paint chips and gouges in multiple areas throughout the facility;
* Five dining chair seat cushions had scuffed and peeling seats making them uncleanable;
* Floor planks in front of Room 15 had separated and raised;
* The television room floor showed a four-inch by four-inch hole in one plank with multiple damaged areas; and
* The television room hall showed a four-foot long area of separated planks.

The areas in need of repair were reviewed with Staff 1 (ED) during an environment walk through on 08/13/25 at 2:00 pm. He acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure individual privacy for residents who shared a bathroom. Findings include but are not limited to:

During environmental observations on 08/12/25, multiple shared units were observed to have a shared bathroom without the ability to lock the door.

In a tour with Staff 1 (ED) on 08/13/25 at 11:00 am, it was confirmed the shared units did not have a lockable bathroom door.

The need to ensure residents were provided with individual privacy in his or her own unit was discussed with Staff 1 and Staff 2 (RCC) on 08/14/25 at 2:30 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure residents had a key to their unit. Findings include, but are not limited to:

On 08/12/25, an observation showed an unsampled resident attempt to enter his/her room and was unable to enter due to the door being locked.

During an interview with Witness 1 (Family Member/POA) on 08/14/25, it was reported their family member did not receive a key at move-in.

In an interview on 08/14/25, Staff 1 (ED) confirmed keys were not provided to residents.

The need to ensure the individual and only appropriate staff had a key to access their unit was reviewed with Staff 1 on 08/14/25 at 2:00 pm. He acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, the facility failed to ensure move-in evaluations addressed all required elements, including pronouns and gender identity, for 1 of 1 sampled resident (# 1) whose move-in evaluations were reviewed. Findings include, but are not limited to:

Refer to: C 252.

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.

This Rule is not met as evidenced by:

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

Refer to: C 513.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on 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 330, and C 363.

OAR 411-057-0160(2b) Compliance with Rules Health Care

(b) Health care services provided in accordance with the licensing rules of the facility.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed based on the activity evaluation for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, and 4’s records were reviewed during the survey.

There was no resident-specific activity plan which detailed what, when, how, and how often staff should offer and assist the residents with individualized activities. Individualized activity plans were not included on the resident's activity plan or service plan.

The need to ensure residents’ individualized activity plans were developed was discussed with Staff 1 (ED) on 08/14/25 at 11:00 am. He acknowledged the findings.

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.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 09/07/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 09/07/23, conducted 10/30/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 09/07/23 at 11:10 am, the facility kitchen was observed and the following was noted: * The refrigerator interior walls had food splatter/spills;* Food items were uncovered in refrigerator (sliced oranges) and in the freezer (individual desserts);* An open bag of dinner rolls in the freezer;* Scoops were in food product sacks (stored in bins), items included, granulated sugar, powdered sugar and oatmeal; * One garbage can was uncovered when not in use;* The hood vents above stove/grill were greasy/dusty, per Staff 1 (Cook/PIC) the hood was commercially cleaned with last cleaning on 04/17/23, next scheduled service in 26 weeks; * One staff was not using any type of hair restraint; and* Several non-kitchen staff entered the kitchen throughout the inspection.The areas of concern were observed and discussed with Staff 1 on 09/07/23. The findings were acknowledged.

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

The findings of the on-site investigation, conducted 06/27/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRCM: Resident Care ManagerRN: Registered Nurse

Based on observation, interview, and record review, conducted during a site visit on 06/27/23, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: In an interview on 06/27/23, Staff 1 (Administrator) and Staff 2 (RCM) stated the facility had not adopted an ABST. Staff stated there are to be three caregivers (CG) and one medication aide (MA) on day and swing shift, and two CGs and one MA on night shift. On 06/27/23, it was observed the facility was staffed with three CGs and one MA on day shift. There was no documented evidence the facility was using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.On 06/27/23, these findings were reviewed with and acknolwedged by Staff 1 and Staff 2. Staff 1 stated the owner had a log-in but never sent it to the facility.The facility failed to adopt and fully implement an Acuity Based Staffing Tool (ABST).Verbal Plan of Correction: Effective immediately, the Administrator will enter all resident acuity information into the ODHS ABST and estimates it will be completed by end of day 06/28/23.

The findings of the change of ownership survey conducted 05/23/22 through 05/25/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 05/25/22, conducted 08/31/22, 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 and Division 57 for Memory Care Communities.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second revisit to the re-licensure survey of 05/25/22, conducted 12/01/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities.

Based on observation and interview, it was determined the facility failed to prepare and serve food in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to: A tour of the kitchen on 05/23/22 and the dining room on 5/25/22 showed the following areas in need of cleaning or repair:A. Main Kitchen* Scratches and chips in the tile flooring, creating an uncleanable surface; and* Broken lower shelving on each of three metal carts, including one supported by cans of food and one supported by a cardboard box.B. Dining Room* Worn varnish on beverage and snack cabinet countertop, exposing bare wood and creating an uncleanable surface; and* Buckling and separating vinyl flooring, including a separated area approximately 24" x ½", exposing underflooring.C. Refrigerator/freezer in the upstairs kitchen* Drips of dark purple sticky substance on walls of freezer and frozen to the outside of food packages.Findings were discussed with Staff 1 (Administrator) on 05/24/22 and 05/25/22. She acknowledged the findings.

2. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia.a. Observations of the resident, interviews with staff, service plan dated 03/08/22 and Temporary Service Plans (TSPs) were reviewed. The service plan was not reflective of the resident's current status or lacked caregiving instructions in the following areas: * Toileting assistance; * Frequency of incontinent checks; * Two person transfer assistance at times; * The ability to manage ambulation and mobility independently; * Mobility device currently used; * Dining; * Behavioral issues and interventions; * Duties of private caregivers; * Activities; and * Fall interventions. b. On 05/13/22, a TSP was initiated noting Resident 1 had a new roommate. The TSP was not resident specific as it directed staff to "take all vital signs" and "push fluids." The need to ensure service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, updated with changes, and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia with behavioral disturbance and history of stroke. Observations of the resident, interviews with staff, and review of the service plan dated 05/19/22, indicated the service plan failed to reflect the resident's current care needs relating to oral care.The need to ensure service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift, updated the service plan and monitored the resident consistent with the evaluated needs for 1 of 2 sampled residents (# 1) who experienced changes of condition. Resident 1 had repeated falls with injury. Findings include, but are not limited to:Resident 1 was admitted to the MCC in 03/2021 with diagnoses including history of falls and dementia. During the acuity interview, Resident 1 was identified as a fall risk and at times required two people for ADL assistance. The 10/27/21 service plan was reviewed and the following fall interventions were documented: * Room should be free of clutter, no cords should be out and lighting should be sufficient for ambulating; * Provide safety checks when in room especially at night; * Encourage the resident to stay in common area for better visual monitoring; * Use wheelchair for long distance transport; * Always turn pressure alarm on. Notify MT or nurse if alarm is not functioning well or low on battery; * Remind the resident to look behind him/her first before sitting; * Remind to always use front wheel walker for short distance ambulation; * Use one person assist for transfers; * Provide and remind to use call system at all times; * Ensure s/he is wearing proper footwear for all mobility; and * Leave bathroom lights on at night. The resident record was reviewed and noted nine falls between 10/25/21 and 05/21/22.The service plan was updated on 12/16/21 and 3/8/22. The fall interventions remained the same and noted the addition of a private caregiver from 2:00 pm - 6:00 pm daily.Temporary service plans dated 10/25/21 through 5/21/22 noted continued safety checks every one to two hours while the resident was in bed/apartment and chart interventions to prevent falls from reoccurring.Observations of Resident 1 throughout the survey showed light green bruising across his/her face, over the bridge of the nose and below the eyes. The resident's upper lip was swollen on the left side.On 05/25/22 at 1:09 pm, Staff 10 (CG) stated fall interventions included not laying the resident down in his/her room, the resident was kept in the common areas and had safety checks during the nights. Staff 10 stated the resident did not use a walker, did not have a pressure alarm but did have a "baby monitor." On 05/25/22 at 1:26 pm the resident's room was observed. The alarm component was located under the bed. The pressure pad component was observed between the fitted sheet and mattress, with the alarm cord disconnected. When the alarm was reconnected to the pressure pad, it was not functional when tested. There was also a "baby monitor" located to the left of the resident's television. On 05/25/22 at 1:32 pm, Staff 3 (RCC) confirmed the audio component of the "baby monitor" was located in the medication room.On 05/24/22 and 05/25/22, both Staff 1 (Administrator) and Staff 2 (Health Service Director) reported the resident often disconnects the alarm from the pressure pad. They were informed the pressure alarm was not in working order on 05/25/22.Resident 1 was identified to be at risk for falls and experienced multiple injury falls. There were multiple fall prevention interventions that were not reviewed with each fall to determine if they were in place and/or continued to be effective and the resident continued to fall. Resident 1's falls were reviewed with Staff 1 and Staff 2 on 05/25/22. No additional information was received.

2. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia and depression.The 04/01/22 through 05/23/22 MARs, TARs and physician orders were reviewed and the following orders were not carried as prescribed: * Lexapro (for depression) not administered on 05/10/22 and 05/12/22 due to the medication not being available; * Daily bowel monitoring parameters were not followed; * PRN bowel medications were not administered per orders; and * Lidocain cream (for pain) was not administered on 12 occasions due to the medication not being available. 3. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia.Resident 3's 05/01/22 through 05/23/22 MAR, TAR and physician's orders were reviewed. The physician's order reflected the following parameters for constipation: * Step 1 - Milk of Magnesia; * Step 2 - bisacodyl tablets; and * Step 3 - bisacodyl suppository. The parameters on the MAR directed staff to record bowel movements every shift, and to follow the bowel protocol if the resident had no bowel movement for two days. Per parameters, Resident 3 should have been administered Milk of Magnesia on the following dates and times:* Between 2:00 pm and 10:00 pm on 05/05/22; and * Between 2:00 pm and 10:00 pm on 05/10/22. Documentation on the MAR revealed bisacodyl tablets were administered on 05/05/22 at 12:26 pm and 05/10/22 at 12:16 pm. The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 06/2019 with diagnoses that included dementia with behavioral disturbance and history of stroke.The 04/01/22 through 05/23/22 MARs, TARs and physician orders were reviewed and the following orders were not carried as prescribed: * PRN Milk of Magnesia (for constipation) nightly, for no bowel movement in 48 hours or more was not administered on 04/11/22, 04/15/22, 04/23/22 and 05/20/22 per parameters; * PRN bisacodyl suppository (for constipation) daily, if no bowel movement greater than three days, was administered on 04/12/22 after two days of no bowel movement;* Between 04/21/22 and 04/26/22 the resident went five days with no bowel movement and no PRN bowel medications;* Scheduled guaifenesin syrup (for cough), three times daily for seven days was administered for eight days plus one dose; and* Scheduled nystatin (for candidiasis fungal infection of the oropharynx) by mouth four times daily for 10 days with specific direction to swish in mouth for at least 30 seconds before swallowing, however, a progress note dated 05/21/22 by Staff 6 (MT) states "Swab [his/her] mouth with the new med, [the resident is] unable to swiss [sic] the new med." Staff 6 confirmed the resident was not administered the medication per physician's orders on 05/24/22 at 12:10 pm. The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for all medications the facility was responsible to administer for 1 of 2 sampled residents (#4) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 4 was admitted to the facility in 08/2022 with diagnoses including Lewy body dementia.Signed physician orders dated 08/26/22 noted the following medications were to be administered to Resident 4:*Hydralazine 25 mg tag three times daily (for hypertension); and*Sotalol 80 mg twice daily (for atrial fibrillation).The 08/26/22 through 08/31/22 MAR was reviewed and noted both medications had been discontinued on 08/25/22. There was no documented evidence the resident received the medications as ordered from 08/26/22 through 08/31/22. During an interview on 08/31/22 at 4:10 pm, Staff 1 (Administrator) and Staff 12 (Health Services Director) acknowledged the medications were not being given as ordered.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included clear parameters for administration of prescribed medications for 2 of 3 sampled residents (#s 1 and 3) whose MARs and physician orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia. The 04/01/22 through 05/23/22 MARs, TARs and physician orders were reviewed and showed the following inaccuracies: * On 05/09/22, staff documented they did not attempt three non-drug interventions prior to administering the PRN psychotropic, but when interviewed, they stated they did attempt the interventions; * Scheduled Lidocaine cream (for pain) had parameters to "apply topically to affected area 3 - 4 times daily," and * PRN albuterol (for shortness of breath or wheezing) to "inhale 1 - 4 puffs by mouth." 2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including dementia. The resident's 05/01/22 through 05/23/22 MAR, TAR and physician's orders were reviewed and showed the following inaccuracies: * For the daily bowel monitoring parameters, the note directed staff to administer Miralax for no bowel movement in two days. The physician's order directed staff to administer Milk of Magnesia if the resident did not have a bowel movement in two days; * The directions to staff for the bisacodyl tablets stated, "Step 2" but the order note stated, "This is Step 1 of the Bowel Protocol. If not relieved in 24 hours, go to step 3;" * Milk of Magnesia was listed as "Step 1" and directed staff to administer the medication in three days if the resident had not had a bowel movement; and * The TAR reflects bisacodyl suppository to be "Step 3" and to administer if "constipation [was] not relieved with bisacodyl oral tablets," thus not having clear parameters for the four PRN bowel medications.The need to ensure the MARs were accurate and included clear parameters for administration of prescribed medications was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 2 sampled residents (#s 4 and 5) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 10/2020 with diagnoses including Alzheimer's dementia.Resident 5's 08/01/22 through 8/30/22 MAR was reviewed during the survey.The following medications were documented as being administered at 8:00 am daily:* Calcium Carbonate;* Losartan;* Memantine;* Metformin;* Sertraline; and* Vitamin D3. The following medication was documented as being administered at 7:00 am daily:* Levothyroxine.In an interview with Staff 6 (MT) on 08/31/22 she reported that the resident slept late and that morning medications were regularly given between 10 am and 11 am.The need to ensure MARs were accurate was discussed with Staff 1 (Administrator) on 08/31/21. She acknowledged the findings.
2. Resident 4 was admitted to the facility in 08/2022 with diagnoses including Lewy body dementia.Resident 4's 08/01/22 through 08/31/22 MARs were reviewed and lacked resident specific parameters to guide unlicensed staff in the following areas:*Acetaminophen 325mg 1 tablet PRN pain;*Acetaminophen 325mg 2 tablets PRN pain; *Morphine Sulfate 5mg PRN moderate pain; and*Polyethelene Glycol PRN constipation.Resident specific parameters for pain and bowel care medication was reviewed with Staff 1 (Administrator) and Staff 12 (Health Services Director) on 08/31/22 at 4:10 pm. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct drills every other month and failed to include required components on fire drill records. Findings include, but are not limited to:Review of fire and life safety records for December 2021 through May 2022 identified the following:1. Two fire drills had been completed during the six-month time frame reviewed.2. Fire drill records lacked the following components:* Location of simulated fire origin;* Escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;* Evidence alternate routes were used during fire drills; and* Number of occupants evacuated. The need to ensure the facility conducted fire drills every other month and included documentation of all required components was discussed with Staff 1 (Administrator) on 05/24/22 at 2:00 pm. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to re-instruct residents 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. Findings include, but are not limited to:On 05/24/22, this surveyor met with Staff 1 (Administrator) to review the facility's process and documentation for instructing residents on basic safety procedures. Staff 1 stated the facility did not have a process for providing instruction to residents at least annually in fire and life safety procedures. Staff 1 stated she understood the requirements and would be able to implement a procedure for providing instruction to residents quickly.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 303, C 310, Z 155 and Z 162.

Based on observation and interview, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse, and garbage was stored in closed containers. Findings include, but are not limited to:The facility grounds were toured on 05/25/22. There was refuse including cardboard boxes and a recliner observed in the front of the building, to the right by the smoking area. The need to ensure the building exterior was kept orderly and free of litter and refuse was discussed with Staff 1 (Administrator) on 05/25/22. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the design of the RCF supported special resident needs relating to the installation of handrails at one or both sides of resident-use corridors. Findings include but are not limited to:The interior of the building was toured on 05/25/22 at 11:50 am. The corridor between the medication room and the conference room was lacking a handrail.The need to ensure handrails were accessible to residents along corridors was discussed with Staff 1 (Administrator). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:Observation of the facility on 05/23/22 through 05/25/22 revealed:* Gouges in baseboards throughout the facility;* Scuffs and gouges along the corridors;* The bottom of multiple room doors were scuffed;* Multiple door frames had scuff marks on them; and* Room 4's door frame had exposed wood that was rough to the touch. The findings were reviewed with Staff 1 (Administrator) on 5/25/22. She acknowledged the findings.

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, C 420, C 422, C 510, C 511 and C 513.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation was completed and documented for 1 of 1 newly hired direct care staff (# 7) and annual training was completed and documented for 3 of 3 long-term direct care staff (#s 6, 9 and 10) whose training records were reviewed. Findings include, but are not limited to:Training records were reviewed on 05/24/22. Staff 7 (MT/CG) was hired on 02/15/22. Review of the facility training records revealed Staff 7 did not complete the following pre-service and competency training before providing care and services independently:* Abuse reporting requirements;* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.);* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* The use of supportive devices with restraining qualities in memory care communities; * Role of service plans in providing individualized care; * Changes associated with normal aging;* Conditions that require an assessment, treatment, observations and reporting; and * Other duties as applicable (Med pass, treatments).Staff 1 (Administrator) reported on 05/25/22 the topics would be addressed and the competencies demonstrated would be documented later that evening when Staff 7 returned to work. Staff 6 (MT/CG) was hired on 12/07/19, Staff 9 (CG) was hired on 01/11/19 and Staff 10 (CG) was hired on 09/16/19. Review of the facility training records revealed the following:* Staff 6 did not complete six hours of annual training related to dementia care;* Staff 9 did not complete 16 hours of annual training related to provisions of care in CBC, including six hours related to dementia care; and* Staff 10 did not complete ten hours of annual training related to provisions of care in CBC.The need to ensure all newly hired staff completed pre-service orientation and all veteran staff completed 16 hours of annual training was discussed with Staff 1 who acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired staff (#13) had documentation of completed orientation, pre-service dementia training and demonstrated competency in all required areas prior to working independently with residents. This is a repeat citation. Findings include, but are not limited to:Staff 13 (CG), hired 08/03/22, training records were reviewed with Staff 1 (Administrator) on 08/31/22 and revealed the following:a. There was no documented evidence Staff 13 had completed orientation prior to performing any job duties in the following areas:*Resident rights and values of CBC care;*Abuse reporting requirements;*Infectious Disease Prevention; and*Fire safety and emergency procedures.b. There was no documented evidence Staff 13 completed the pre-service dementia care training prior to providing care and services independently.c. There was no documented evidence Staff 13 demonstrated competency in required areas prior to providing care and services independently.During an interview with Staff 1 on 08/31/22, she verified the lack of training documentation. Staff 1 stated the employee was a re-hire and new hire paperwork had been completed, however was unable to provide written documentation.

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

2. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia.Resident 1's current service plan was reviewed during survey. The service plan lacked an accurate, individualized nutrition and hydration plan, including information related to the resident's food and fluid preferences.The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (Administrator), and Staff 2 (Heath Services Director) on 5/25/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia and history of stroke. Resident 2's current service plan was reviewed during survey. The service plan lacked an individualized nutrition and hydration plan, including information related to the resident's food and fluid preferences.The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (Administrator), and Staff 2 (Heath Services Director) on 5/25/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to:Though Resident 1, 2 and 3's service plans offered some information about the resident's interests, the facility had not fully evaluated the resident's:* Current abilities and skills;* Physical abilities and limitations; and* Adaptations necessary for the resident to participate.There were no specific activity plans which detailed what, when, how and how often staff should offer and assist the residents with individualized activities. The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 2 of 2 sampled residents (#s 1 and 3) with documented behaviors. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia.Resident 1's record documented behaviors including agitation, yelling and putting himself/herself on the floor for attention. An interview with Staff 10 (CG) on 05/25/22 at 1:09 pm revealed the service plan was not reflective of the interventions that were more successful with the resident. She identified the resident enjoyed any activity and taking the resident to the restroom. Staff 10 stated the resident responded well to constant one on one attention, but staff didn't have the time to be able to do that. She also stated that the intervention for staff to let the resident rest in his/her room was not safe due to being a high fall risk. 2. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia.The resident's service plan, dated 04/14/221, did not address any behaviors, thus lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.Staff 10 confirmed Resident 3's behaviors included refusing care. The resident preferred some staff over others, so in order for the resident to consent to care (e.g. assistance with ADLs), staff would switch to someone the resident responded to positively. The need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.