Liberty Pointe

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 provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 08/2021 with diagnoses including severe malnutrition, difficulty with walking, depression, and alcohol abuse. S/he was subsequently admitted to hospice on 11/11/25, with admitting diagnosis of right upper limb cancer with metastases. Observations were made of the resident's care on 12/03/25. Interviews with the resident, facility staff, and the resident’s outside provider were conducted. The service plan, updated on 11/11/25, was reviewed. Resident 2's service plan lacked clear instruction to staff in the following areas: * Number of staff needed to assist with activities of daily living; * Physician Orders for Life Sustaining Treatment status; * Instructions on specific changes of condition to report to hospice; * Instructions on how to elevate the head of the bed to improve breathing; * Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety; * Instructions on what types of skin impairments to report and to whom; * Instructions on to whom to report weight gain or loss and changes in appetite; * Instructions on meal intake monitoring; * How a person expresses memory loss; and * Instructions for aspiration precautions and interventions while choking. The need to ensure service plans provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (RN), Staff 9 (Regional Director of Operations), and Staff 10 (Regional Director of Operations) on 12/04/25 at 11:48 am. They acknowledged the findings. 2. Resident 3 moved into the facility in 12/2021 with diagnoses including dementia, chronic obstructive pulmonary disease with exacerbation, and depression. The resident’s service plan, dated 11/29/25, was reviewed, and staff were interviewed. The service plan lacked clear direction regarding the delivery of services in the following areas: * Incontinence care, including brief changes performed in bed, frequency staff should check for incontinence, and supplies used; * Bed bath instruction; and * 1:1 activity instruction, frequency, and who should provide the activity. The need to ensure the resident’s service plan provided clear direction regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (RN), Staff 9 (Regional Director of Operations), and Staff 10 (RN Consultant) on 12/04/25 at 1:24 pm. They acknowledged the findings. 3. Resident 4 moved into the facility in 09/2025 with diagnoses including anxiety. The resident’s service plan, dated 09/22/25, was reviewed, and staff were interviewed. The service plan lacked clear direction regarding the delivery of services in the following areas: * Bladder and bowel continence; * Transfer assistance, including the use of a front wheeled walker and gait belt versus using the power wheelchair; * The use of briefs and incontinence pads during the night; * Preference of staff standing by when the resident is in the bathroom; * Preference of minimal disturbance from staff; * Resident 4's morning routine; and * The number of staff needed to evacuate the resident if the elevator was not functioning. The need to ensure the resident’s service plan provided clear direction regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (RN), and Staff 10 (RN Consultant) on 12/04/25 at 9:32 am. They acknowledged the findings.

1) Resident 2, 3 and 4 service plans were reviewed and updated on 12/4/2025 2) Completed an in-service with the service planning team to review the OAR's as they pertain to service planning to address updates, ensuring they are reflected of resident needs and preferences and provide clear direction to staff. 3) IDT will audit 2 random service plans weekly for accuracy and current person centered care needs for 8 weeks then quarterly thereafter, 4) RCC, RN DHS and Executive Director responsible

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

Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 1 sampled resident (# 3) who required an altered diet texture. Findings include, but are not limited to: Resident 3 moved into the community in 12/2021 with diagnoses including dementia. During the acuity interview on 12/01/25, the resident was identified to receive a mechanical soft textured diet. The resident’s record was reviewed, including current, signed provider's orders. Observations were made, and interviews with staff were conducted. The following was identified: Resident 3 had a signed physician order for a “Mechanical Soft texture” diet, which pertained to all meals and snacks the facility prepared and served the resident. On 12/03/25 at 9:31 am, Staff 12 (Staffing Coordinator) provided Resident 3 half of a ham and cheese sandwich which was not observed to be prepared as mechanical soft. The resident was observed to consume the half sandwich. S/he cleared his/her throat and coughed multiple times. Staff 12 reminded Resident 3 to eat slowly. During the observation, Staff 12 reported the resident was to receive meals cut into small pieces. On 12/03/25 at 10:51 am, Staff 8 (Dietary Manager) reviewed Resident 3's meal order ticket which had both "mechanical soft" and "chopped" highlighted, which indicated the texture of the meal provided. Staff 8 reported he was unsure which texture the resident received or had a physician’s order for. On 12/03/25 at 12:15 pm, the resident was observed eating a cut-up turkey burger on a bun which was not prepared as mechanical soft. On 12/04/25 at 10:45 am, Staff 11 (LPN) confirmed the resident was on a mechanical soft diet. The need to ensure the facility followed prescriber’s orders related to diet texture was reviewed with Staff 1 (ED), Staff 2 (Assistant ED), Staff 3 (RN), Staff 9 (Regional Director of Operations), and Staff 10 (RN Consultant) on 12/04/25 at 1:24 pm. They acknowledged the findings.

1) Dietary Manager was immediately in-serviced on dietary textures and resident orders to ensure accuracy. All dietary staff and staff delivering meals will be in-serviced on diet textures and the importance of following physician orders on 12/29/2025. 2) Modified diets will be monitored through direct meal observations by Dietary Manager, Executive Director or designee. 3) Observations will occur daily for 2 weeks, then weekly for 4 weeks and random observations there after 4)Dietary Manager, Executive Director, Assistant Executive Director

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

Based on observation, interview and record review, conducted on 05/20/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool for 3 of 6 sampled residents (#5, 6, and 7). Findings include, but are not limited to: A review of the facility's Resident List Report, dated 05/20/24, indicated the current census was 48 residents. A review of the facility's ABST tool indicated the following: * The facility adopted the ODHS ABST tool, which included all 22 distinct ADLs. * There were 45 residents entered into the tool. Residents 5, 6, and 7 were unaccounted for. * The facility's ABST generated staffing time to meet the predictable scheduled needs of residents 24 hours a day. During an interview, Staff 1 (Executive Director) stated the following: -When residents were out of facility at the hospital, Staff 1 deleted them from the facility's ABST. -Resident 6 and Resident 7 were currently out of the facility at the hospital. -Resident 5 was currently in the facility but had been out of the facility at the hospital for approximately 30 days. S/He had forgotten to add Resident 5 back into the tool when Resident 5 returned to the facility. A review of the posted staffing plan exceeded the ABST and indicated the following: In the RCF, there were: * Day shift (6am - 2pm): six CG and one MT, one activity worker, and one "other worker"; * Evening shift (2pm - 10pm): five and half CG, one MT, one activity worker, and one "other worker"; and * Night shift (10pm - 6am): three CG and one MT. In the MCC, there were: * Day shift (6am - 2pm) : one CG and one MT; * Evening shift (2pm - 10pm): one CG and one MT;  and * Night shift (10pm - 6am): one CG and one MT. Throughout the site visit on 05/20/24, the Compliance Specialist observed in the MCC there were two CG and one MT on day shift and in the RCF on day shift there were eight CGs, two MTs, one activity worker, and one resident care coordinator. During an interview, Staff 19 (Caregiver) stated Resident 6 had been out of the facility in the hospital for about a week and a half. Resident 7 went out to the hospital last night during night shift. Resident 5 was currently in the facility. A review of Residents 1, 2, and 3 service plans, dated 05/13/24, 04/05/24, and 03/05/24 respectively, and ABST profiles indicated the following: * Resident 1's profile was last edited on 05/20/24 and matched their service plan. * Resident 2's profile was last edited on 05/20/24 and matched their service plan. * Resident 3's profile was last edited on 05/20/24 and matched their service plan. At 11:35 am, Resident 1 was out of the facility unable to be interviewed. In an interview at 12:21 pm, Resident 2 stated his/her care needs were being met. S/He had a shower and his/her hair was groomed today. It was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 05/20/24.

Tag info Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 05/20/24.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified:     Abbreviations possibly used in this document:   ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation, interview, and record review, it was determined the facility failed to ensure proper food storage, proper preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility kitchen was toured on 10/06/23, observations of the facility kitchen, including food storage areas, food preparation, food service, and interviews with staff were conducted during the annual kitchen inspection. a. Observations of food storage identified the following: * Multiple food containers in the dry food storage, two door reach-in refrigerator and walk-in freezer were not properly covered, labeled and dated; and * Sauce(s) that required refrigeration after opening were stored on racks in the kitchen. b. Observations of food preparation and food service identified the following: * Alcohol wipes were not being used to sanitize the food thermometer after each use; * Staff 4 (Cook), had a sanitation cloth saturated with a chemical base sanitizer laying partially on a cutting board used to cut up food during meal service; * Staff 4 used tongs to serve fries from the tray line and used the same tongs to stir ground beef throughout the meal service; and * The facility failed to have enough dishware and utensils which resulted in some residents being served food on paper plates and plasticware. c. Review of employee infection control practices identified the following: * Staff 3 (Dietary Manager), failed to have a valid Oregon Food Handler card; and * Staff 4 failed to use and store sanitation cloths properly. c. Sanitation of equipment identified the following: * The chlorine sanitation level in the warewash machine was over 110 parts per million (PPM); * The quaternary sanitation levels for the sanitation buckets and 3 compartment sink were over 200 ppm; * Dish racks in the warewashing area were stored on the floor; * Garbage cans were not enclosed after use; * Multiple floor drains were visibly dirty with food waste; * Steam table, prep counters, plate warmer, and microwave were visibly dirty and were not sanitized prior to food preparation and food service; * Janitorial closet door was open and cleaning equipment was not properly stored; * Toasters, coffee machine, coffee counter, food service carts, handwashing sink and single compartment prep sink were visibly dirty and were not sanitized after use; * Ice machine was visibly dirty on the exterior and interior; * The walk-in refrigerator and freezer floors were visibly dirty with food debris and spillage; and * Spice containers and spice cart was visibly dirty. d. The following areas within the kitchen required repair: * The plate warmer was not fully operational; * The walk-in freezer had a buildup of ice that formed near the condenser, blower cage and freezer door frame; * The exit door and screen were broken and had rips in the screen; and * The floor drain below the three compartment sink had issues with flooding. The kitchen was toured, and the above areas were discussed with Staff 1 (ED), Staff 2 (Assistant ED ) and Staff 3 (Dietary Manager) on 10/06/23 at 1:25 pm. They acknowledged the findings.

Food Storage Staff were in-serviced on proper food storage on 11/01/2023 DM obtained Oregon food handlers card on 10/10/2023 Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program Food Preparation Staff were in-serviced on food preparation standards 11/01/2023 Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program Infection Control Staff were in-serviced on infection control practices 11/01/2023 Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program Sanitation of Equipment Staff were in-serviced on proper sanitizing of equipment and storage of equipment on 11/01/2023 Ecolab serviced kitchen machines and sanitizers on 10/09/2023, new garbage can lids were purchased 10/30/2023. Janitorial closet was organized and staff in-serviced on proper storage and keeping door closed on 11/01/2023. Ice machined, walkin refrigerator and freezer were cleaned on 10/09/2023 Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program Kitchen repair required Maintenance work order clip board hung in kitchen, Maintenance Director to do weekyl inspections; staff in-serviced to write repair items on board 11/01/2023 Walkin freezer de-iced of ice buildup 10/30/2023, plate warmer to be repaired on 11/30/2023, exit door fixed, exit door screen removed, floor drain below three compartment sink fixed on 10/30/2023 Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program

Based on observation and interview, it was determined the facility failed to ensure proper food storage, proper preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility kitchen was toured on 12/12/23, observations of the facility kitchen, including food storage areas, food preparation, food service, and interviews with staff were conducted during the first revisit kitchen inspection. a. Observations of food storage identified the following: * Multiple dry good food containers were left open and undated, and cold food storage in the walk-in refrigerator were not properly covered, labeled and dated; and * The floor of the dry food storage area had multiple single service food items that had fallen on the floor and underneath the food racks. b. Observations of food preparation and food service identified the following: * Staff 4 (Cook), placed a visibly soiled oven mitt on a cutting board used to prep food items during meal service. The oven mitt was observed to directly touch food just prior to being placed on the residents plate; and * Food (tortilla shells) while inside the plastic manufacturers packaging was heated in the microwave and then served to multiple residents. c. Review of employee infection control practices identified the following: On multiple occasions, Staff 4 (Cook) failed to ensure gloves were single use and gloves were changed between dirty and clean tasks. d. Sanitation of equipment identified the following areas had a build up of dust, debris, grease and food particles: * The steam table and shelf below the steam table; * Stainless steel cart used in the dishwasher area was visibly soiled with clean dishes on it; * The rack next to the handwash sink had bins of clean dishes with a buildup of food particles that had fallen into the bins; * Shelf below the microwave was visibly dirty and had clean dishes stored on it; * The interior and exterior microwave was not sanitized prior to food preparation, reheating of food and food service; and * Steel rack to the left of the oven had a build up of dust, grease and sticky residue. The rack had clean dishes and equipment stored on it. e. The following areas within the kitchen required repair: * The plate warmer was not fully operational; and * The walk-in freezer had a buildup of ice that formed near the condenser and blower cages. The kitchen was toured, and the above areas were discussed with Staff 1 (Executive Director), Staff 3 (Dietary Manager) and Staff 5 (Dietary Manager trainee) on 12/12/23. They acknowledged the findings.

Food Storage All kitchen staff will be in-serviced on 01/10/2024 on proper food storage protocols Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program Staff in-serviced on 01/10/2024 on proper cleaning standards Kitchen cleaning audits will be completed weekly for four weeks then monthly as part of our ongoing QA program Food Preparation All kitchen staff in-serviced on proper food preparation and serving protocols on 01/10/2024 Admin and or designee will observe 5 meal preparations/food services weekly for four weeks then monthly after as part of our ongoing QA program Infection Control All kitchen staff in-serviced on infection control practices and correct sanitation protocols on 01/10/2024 Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program Sanitation of Equipment Debris areas were sanitized on 12/12/2023 All kitchen staff will be in-serviced on 01/10/2024 on proper sanitation of equipment, racks and storage areas Kitchen audits will be completed weekly for four weeks then monthyl as part of our ongoing QA program Kitchen Repair HVAC repairs scheduled for 01/10/2024 01/02/2024 Appliance repair company assessed plate warmer, parts ordered scheduled repair for unit on 01/12/2024

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 C 240

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 C240.

Refer to C240

Based on observation and interview 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 240.

Refer to C240

The findings of the kitchen inspection, conducted 10/06/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit to the kitchen inspection of 10/06/23, conducted 12/12/23 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 second revisit to the kitchen inspection of 10/06/23, conducted 02/23/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include but are not limited to:                                                                                                                                                                                                                                               On 10/11/22 the survey team conducted a group interview with facility residents. During the interview multiple residents expressed complaints about the facility including, experiencing call light response time of over 30 minutes and lack of resolution from administration. In an interview on 10/12/22, Staff 1 (ED) confirmed knowledge of resident complaints regarding long call light response times and was interviewed about the facility's grievance resolution policy. Staff 1 provided the survey team with overage reports used by the facility daily to identify any call lights not taken within 20 minutes. According to Staff 1, the process was to include follow up to each resident who experienced call light response times of over 20 minutes. On each of the forms provided, the area that included follow up to the resident was left blank. The facility lacked documented evidence of thorough investigation and resolution of resident's complaints of long call light response times. Staff 1 acknowledged the need to improve the facility's method for responding to and resolving resident complaints. The need to ensure the facility implemented effective methods of responding to and resolving all resident complaints was discussed with Staff 1, Staff 2 (Regional RN Consultant) and Staff 3 (Regional Director of Operation) on 10/12/22. They acknowledged the findings.

1. Call light exeption report form was updated to accurately capture call lights exceeding 20 min threshold and provide administrative follow up with resident on form 2. All residents and Staff will be educated on the grievance process by 11/7 and reminded where to locate the grievance forms in the community. Call light exception logs will be reviewed daily with IDT and overages addressed with resident and staff involved within 3 days. 3. The call light exception forms will be reviewed daily at stand up. The grievance process will be reviewed weekly with IDT for the next 8 weeks and monthly thereafter.   4. Social Services Director, Executive Director

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident care needs, were followed and provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 1, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 12/2018 with diagnoses including difficulty in walking and muscle weakness. Observations and interview with Resident 4 during the survey revealed the resident required a walker or a wheelchair for mobility. Observations of the resident, interviews with the resident and staff, review of the current 09/06/22 service plan and clinical records during the survey, revealed Resident 4's service plan was not reflective of the resident's status in the following areas: * Use of a power wheelchair; and * Use of a seatbelt while in the power wheelchair. The need to ensure the service plan was reflective of the resident's needs was discussed with Staff 1 (ED), Staff 2 (Regional RN Consultant) and Staff 3 (Regional Director of Operations) on 10/12/22. Staff acknowledged the findings. 2. Resident 5 was admitted to the facility in 11/2018 with diagnoses including multiple sclerosis and paraplegia. Observations of Resident 5 during the survey revealed the resident was dependent on staff for most ADLs and used an air mattress while in bed. Observations of the resident, interviews with the resident and staff, review of the current 09/13/22 service plan and clinical records during the survey, revealed Resident 5's service plan was not reflective of the resident's status and did not provide clear instruction to staff  in the following areas: * Use of seatbelt while in power wheelchair; * Use of wedge to support leg while in bed; and * Use of bilateral heel protectors at night. The need to ensure the service plan was reflective of the resident's needs and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (Regional RN Consultant) and Staff 3 (Regional Director of Operation) on 10/12/22. Staff acknowledged the findings. 3. Resident 1 was admitted to the MCC in 04/2022 with diagnoses including alcohol dependence with alcohol-induced persisting dementia, cerebral infarction (stroke) and dysphagia (swallowing problems). Observations were made, interviews with the resident, the resident's family and staff were conducted and the resident's current service plan, dated 09/30/22, was reviewed. The service plan was not reflective, did not provide clear direction to staff and/or was not adhered to in the following areas: * Behavioral interventions and what could trigger behaviors; * Communication strategies including the use of gestures and clarifying questions by the staff to improve the resident's comprehension; * Ability to self direct medications; * Toileting assistance including when the resident was independent and when s/he required assistance; * Urinal use; * Shower preferences; and * Swallow strategies including cueing and assistance required. The need to ensure service plans were reflective of the current needs of the resident, provided clear caregiving instruction to staff and were followed was discussed with Staff 1 (ED), Staff 2 (Regional RN Consultant), Staff 3 (Regional Director of Operations), Staff 5 (RCC) and Staff 19 (RCC) on 10/12/22. They acknowledged the findings.

1) Resident 4 service plan was reviewed and updated on 10/13/2022 Resident 5 service plan was reviewed and updated on 10/13/2022 Resident 1 service plan was reviewed and updated on 10/13/2022 2) Provide an in-service with the service planning team to review the OAR's as they pertain to service planning to address updates, that they are reflective of the residents needs, give clear direction to staff and staff to follow those directions 3) IDT will audit 2 random service plans weekly for accuracy and current person centered care needs for 8 weeks then quarterly thereafter 4) RCC, RN DHS, and Executive Director is responsible

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to: Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room. Observations of staff during the survey revealed multiple instances where staff failed to wear their face mask properly (exposing their nose, or nose and mouth) while providing care to residents, while directing activities in a common area and while preparing food. 1. On 10/12/22 at 2:31 pm, Staff 3 (Regional Director of Operations) and a member of the survey team observed a staff member providing ADL care to a resident with his/her mask exposing both the nose and mouth. 2. On 10/11/22 at 10:50 am, Staff 4 (Cook) was observed without wearing a face mask while in the facility kitchen preparing lunch for the residents.   3. On 10/12/22 at 2:15 pm, Staff 4 and Staff 10 (Cook) were observed without wearing face masks while in the facility kitchen, in close proximity to one another and standing over a food prep table with uncovered food. The need to ensure staff consistently wore a face mask was reviewed with Staff 1 (ED), Staff 2 (Regional RN Consultant), Staff 3, Staff 5 (RCC) and Staff 19 (RCC) on 10/12/22. They acknowledged the findings.

1) Staff members were in-serviced on proper PPE usage on 10/12/2022 with return demonstration and understanding 2) Provide an in-service to All Staff pertaining to infection prevention and control policy related to proper PPE usage. Any staff struggling to wear a standard mask properly will use an adhesive mask. 3) IDT will perform 5 PPE audits per day for 6 weeks, auditing mask useage, then weekly thereafter   4) RCC, RN DHS, Executive Director responsible

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 instructions and parameters for 1 of 3 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the MCC in 04/2022 with diagnoses including alcohol dependence with alcohol-induced persisting dementia, cerebral infarction (stroke) and other symptoms and signs involving cognitive function and awareness. The resident's 10/01/22 through 10/10/22 MAR and most current service plan, dated 09/30/22, were reviewed and revealed the following: * The resident had PRN orders for Benzocaine Gel 20% and Ibuprofen 400 mg to manage tooth pain; * The resident had PRN orders for Acetaminophen 500 mg and Lidocaine Cream 4% for pain; and * The resident's service plan and MAR indicated that s/he was able to self-direct PRN medications. An interview, with Resident 1 and Staff 3 (Regional Director of Operations) on 10/12/22 at 2:31 pm, confirmed the resident was unable to recall and/or verbalize his/her PRN pain medications independently, s/he was unable to verbalize which medication s/he would prefer when given a choice, and s/he was unable to recall if staff had offered him/her a choice between these medications in the past. Following the interview, Staff 3 verbally confirmed Resident 1 was unable to self-direct his/her PRN medications and the MAR would be changed immediately. The need to ensure MARs were accurate and included resident specific instructions and parameters was discussed with Staff 1 (ED), Staff 2 (Regional RN Consultant), Staff 3, Staff 5 (RCC) and Staff 19 (RCC) on 10/12/22. They acknowledged the findings.

1) Resident 1's MAR was updated to reflect PRN pain medication non-verbal indicators on 10/13/22. 2) All MCU residents will have non-verbal indicators for all PRN pain medications by 11/1/2022. Med Techs will be in-serviced on identifying non-verbal pain indicators and how to determine PRN use by 11/1/22 3) New or updated PRN pain medication orders will be reviewed daily at standup meeting to ensure non-verbal indicators are listed on the order and MAR. 4) RCC and RN DHS responsible

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 C260, C295 and C310.

See POC for Z165.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms which negatively impacted the resident or others in the community for 1 of 1 sampled resident (#1) with documented behaviors. Findings include, but are not limited to: Resident 1 was admitted to the MCC in 04/2022 with diagnoses including alcohol dependence with alcohol-induced persisting dementia and restlessness and agitation. Resident 1's record documented behaviors including agitation and verbal and/or physical aggression toward residents and staff. The resident's most current service plan, dated 09/30/22, lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 10/12/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED), Staff 2 (Regional RN Consultant), Staff 3 (Regional Director of Operations), Staff 5 (RCC) and Staff 19 (RCC) on 10/12/22. They acknowledged the findings, and no additional documentation was provided.

1) Resident 1's service plan was reviewed and updated on 10/12/2022.   2) An in-service will be provided with the service planning team to review the OAR's as they pertain to service planning to address updates, that they are reflective of the residents needs, give clear direction with approach and person-centered behavior interventions 3) IDT will audit 2 random service plans weekly for accuracy and current resident person-centered care needs for 8 weeks then quarterly thereafter   4) RCC, RN DHS, Milieu Counselor, Executive Director responsible

The findings of the re-licensure survey, conducted 10/10/22 through 10/12/22, 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 10/12/22, conducted on 01/26/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.