Better Living RCF

Based on observation and interview, it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors and were available for inspection. Findings include, but are not limited to:



During a tour of the facility on 04/14/25 at 10:00 am the following postings were not accessible:

* Resident Rights and Protections, including the LGBTQIA2S+ Rights and Protections; and
* The LGBTQIA2S+ Nondiscrimination Notice.


The need to ensure all required postings were accessible in a conspicuous location was discussed with Staff 1 (Administrator) on 04/15/25 at 4:15 pm. He acknowledged the findings.

OAR 411-054-0025 (5) Facility Administration: Required Postings

(5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following:
(a) Facility license.
(b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility.
(c) The current facility staffing plan.
(d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable.
(e) The Ombudsman Notification Poster.
(f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections.
(g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted.
(h) Other notices relevant to residents or visitors required by state or federal law.

This Rule is not met as evidenced by:

Based on interview and record review, the facility failed to take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of a resident’s human immunodeficiency virus status for 1 of 1 sampled resident (#1), whose records were reviewed. Findings include, but are not limited to:

Resident 1 moved into the residential care community in 10/2020 with diagnoses including Type 2 diabetes mellitus and history of stroke.

Review of the resident’s service plan dated 10/03/24 included information regarding the resident’s human immunodeficiency virus status.

The need to ensure the facility took steps to minimize the likelihood of accidental disclosure of a resident’s human immunodeficiency virus status was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (RN) and Staff 6 (RCC) on 04/17/25 at 3:45 pm. They acknowledged the findings.

OAR 411-054-0025 (8) Facility Administration: Records

(8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records.
(a) The facility must develop and implement a written policy that prohibits the falsification of records.
(b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding:
(A) A resident’s sexual orientation;
(B) Whether a resident is LGBTQIA2S+;
(C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status.
(c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if a resident is affected by a disclosure of information.
(d) Resident records must be kept for a minimum of three years after the resident is no longer in the facility.
(e) Upon closure of a facility, the licensee must provide the Department with written notification of the location of all records.
Name:

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

During the survey entrance on 04/14/25 at 9:45 am, observations of the entry and exit drive to and from the main building entrance showed the facility was using the entry and exit drive as a parking lot with multiple cars impeding the ability for emergency personal and medical transportation vehicle from being able to pick up and drop off residents without needing to back up the vehicles.

During an observation on 04/15/25 at 1:30 pm, a medical transportation vehicle was seen unloading an unsampled resident in a wheelchair from


the back of the vehicle, close to the street entrance. The vehicle was unable to pull forward due to multiple cars parked in the entry drive.

During an interview and observation on 04/15/25 at 1:34 pm, with Witness 1 (medical transportation driver), it was reported “I have to back out of the driveway [which was located on a three-lane road with traffic traveling in two different directions and a pedestrian walking/bike path]. The driver further reported “other drivers use the middle turn lane, wait for traffic on both sides to clear and back the vehicle into the drive. This is difficult and very unique to this place, it would definitely help if these vehicles could be moved, and I could pull in and out without having to back out. It would be safer for unloading [people], for sure.”

On 04/15/25 at approximately 1:35 pm, the facility was asked to immediately move the vehicles, refrain from using the entry and exit drive as a parking lot and post no parking signs.

On 04/15/25 at approximately 4:40 pm, the entry drive was cleared of vehicles and no parking signs were posted in the drive.
The need to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of
residents was discussed with Staff 1 (Administrator) on 04/15/25 at 4:30 pm.

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OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure a resident move-in evaluation addressed all required components for 1 of 1 sampled Resident (#2), whose move-in evaluation was reviewed. Findings include, but are not limited to:



Resident 2 was admitted to the facility in 03/2025 with diagnoses including CVA, right side weakness, heart disease, depression, anxiety and diabetes.

The move-in evaluation, dated 02/27/25, was reviewed, and there was no documented evidence the following required elements were addressed:

* Visits to health practitioner(s), ER, hospital or NF in the past year;
* Vital signs if indicated by dx, health problems, or medications;
* Activities of daily living including dental status;
* Ability to use the call system;
* Non-pharmaceutical interventions for pain;
* Nutrition habits, fluid preferences & weight if indicated;
* List of treatments, type, frequency and level of assistance needed;
* History of dehydration or unexplained weight loss or gain;
* Environmental factors that impact the resident’s behavior including but not limited to: noise, lighting, room temperature;
* Pronouns; and
* Gender identity.

The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Administrator), Staff 4 (RN) and Staff 6 (RCC) on 04/16/25 at 2:25 pm. They acknowledged the findings.

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure resident service plans were reflective of residents' needs, provided clear direction to staff regarding care and services, were updated at least quarterly and with significant changes of condition, were accessible to staff and were followed 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 3 was admitted to the facility in 02/2024 with diagnoses including cognitive deficits and traumatic brain injury.

Resident 3’s clinical record was reviewed during the survey and showed the resident’s service plan was last updated on 10/18/2024.

In a 04/15/25 interview with Staff 6 (RCC), she confirmed the service plan for Resident 3 had not been updated at least quarterly as required.

The need to ensure resident service plans were updated at least quarterly was discussed with Staff 1 (Administrator) on 04/17/25 at 4:05 pm. He acknowledged the findings.

2. Resident 2 was admitted to the facility in 03/2025 with diagnoses including CVA, right side weakness, heart disease, depression, anxiety and diabetes.

Observations of the resident, interviews with staff and resident, and review of the resident's most recent service plan, dated 03/26/25 was completed. The service plan was not reflective of the resident's current care needs, and did not provide clear direction to staff in the following areas:

* Non-pharmaceutical interventions for pain;
* List of treatments, type, frequency and level of assistance needed in relation to bilateral heel boots and oxygen use;
* Trapeze use; and
* Side rail use.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 4 (RN) and Staff 6 (RCC) on 04/16/25 at 2:25 pm. They acknowledged the findings.

3. Resident 1 moved into the residential care community in 10/2020 with diagnoses including history of stroke and diabetes.

Observations of the resident, interviews with staff and resident, and review of the resident's most recent service plan, dated 10/03/24 were completed.

The service plan was not updated quarterly, therefore was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not followed by staff in the following areas:

* Clear instructions for fluid intake and diet texture at each meal and during activities that included food and fluids;
* Risk and precautions related to use of bilateral side rails;
*Strictly avoiding any consumption of meals while in bed;
*Use of adult supportive clothing;
*Use of trapeze;
* Weight bearing status;
* Use of home health agency;
* Frequency of free water flush via gastrointestinal tube (g-tube); and
* Weekly skin checks and monitoring by the community RN.

The need to ensure service plans were updated quarterly, reflective of the resident's current care needs, provided clear direction to staff and were followed was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (RN) and Staff 6 (RCC) on 04/17/25 at 10:45 am. They acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition had determined actions or interventions, interventions documented and communicated to staff, and conditions were monitored weekly through resolution for 2 of 2 sampled residents (#s 1 and 3) who experienced changes of condition. Findings include, but are not limited to:

Resident 1 moved into the residential care community in 10/2020 with diagnoses including Type 2 diabetes mellitus and history of stroke.

The resident’s service plan dated 10/03/24, temporary service plans (TSP’s), “Care history” (tool used to monitor and chart on changes of condition) and “observation notes” (tool used by the facility to chart on a resident’s condition) were reviewed during the survey.

The following changes of condition lacked determined actions or interventions, interventions documented and communicated to staff, and/or conditions were not monitored weekly through resolution:

* 01/15/25 - Resident sent out to the ER and returned for g-tube being dislodged;
* 01/15/25 - Bruise to lower left stomach;
* 01/16/25 - Discontinued weekly semaglutide injection (diabetic management medication);

01/31/25 - Rash to left breast fold;
* 02/03/25 - Resident sent out to ER and returned for g-tube being dislodged;
* 02/11/25 - Discontinued scheduled Alendronate and Magnesium Oxide;
* 02/11/25 - Removal of mole/wart on left temple;
* 02/23/25 - Resident sent out to ER and returned for g-tube being dislodged; and
* 02/24/25 - Resident received a flu vaccine.

The need to ensure the facility had a system in place to identify changes of condition, determine what action or interventions were needed for the resident, communicate the interventions to staff on each shift and monitor the conditions at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (RN) and Staff 6 (RCC) on 04/17/25 at 10:45 am. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 02/2024 with diagnoses including cognitive deficits and traumatic brain injury.

Resident 3's clinical record noted the resident experienced the following short-term changes of condition:

* 01/21/25 - Redness to crease of left elbow;
* 02/07/25 Medication order change, discontinue quetiapine 25 mg two times daily (for agitation), change citalopram to 20 mg daily (for depression); and
* 03/21/25 Medication order change, restart quetiapine 25 mg two times daily (for agitation) and once daily PRN.

The facility lacked documented evidence the 01/21/25 skin concern, and the 02/27/25 and 03/21/25 medication order changes were monitored at least weekly with progress noted through resolution.

The need to ensure residents who experienced a short-term change of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 5 (RCC) on 04/17/25 at 4:05 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment for 1 of 2 sampled residents (#1) who experienced a significant change of condition related to weight gain. Findings include, but are not limited to:

Resident 1 moved into the residential care community in 10/2020 with diagnoses including history of stroke and diabetes. During the acuity interview on 04/14/25 the resident was identified as having a modified diet and had a g-tube for hydration.

Observations of lunch meal service on 04/15/25, Resident 1 consumed 100% of the meal.

During dinner on 04/16/25 at 4:35 pm, the resident was observed with a large portion of pasta with chicken and vegetables. A follow up interview on 04/17/25 at 8:25am with Staff 14 (MT) confirmed Resident 1 ate 100% of the dinner meal.

Weight records from 12/04/24 through 04/11/25 were reviewed and the following was identified:

* 12/04/24 - 189.5 pounds;
* 01/05/25 - 187 pounds;
* 02/13/25 - 191 pounds;
* 03/04/25 - 196 pounds;
* 04/04/25 - 204 pounds; and
* 04/11/25 - 205 pounds.

Between 01/05/25 and 04/04/25 the resident had a 17 pound or 8.33 % severe weight gain within three months. This constituted a significant change of condition and required an RN assessment.

During an interview on 04/15/25 at 10:38 am, Staff 4 (RN) confirmed there was no RN assessment completed. Staff 4 further stated “the facility reviewed monthly weights and six-month weight records. So, a system improvement would be to start reviewing weight records quarterly at three months.”

The need to ensure the facility had a system in place to ensure an RN assessment was completed for all significant changes of condition was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (RN) and Staff 6 (RCC) on 04/17/25 at 10:45 am. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure supportive devices with restraining qualities had a thorough assessment completed by an RN, PT or OT prior to use which included, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use and precautions of the device and the use of the device included in the resident’s service plan for 2 of 3 sampled residents (#s 2 and 3) with supportive devices with restraining qualities. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 02/2024 with diagnoses including left-sided contracture spasticity, cognitive deficits and traumatic brain injury.

On 04/15/25 at 11:35 am, Resident 3 was observed in the common room of the facility sitting in his/her wheelchair. There was a lap table attached to the left and right side of the wheelchair frame via L-shaped brackets and tension rollers. At 11:42 am, Staff 17 (Universal Worker) was observed tightening the tension rollers to the right and left of the lap table, securing the table to the wheelchair frame. Staff 17 then took hold of the lap table at the center and pulled at it. The lap table was observed to be secured to the wheelchair.

On 04/15/25 at 12:12 pm, assessment documentation for Resident 3’s use of the lap table was requested. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the lap table in the resident's evaluation and service plan.

During an interview on 04/16/25 at 10:37 am, Staff 1 (Administrator) stated staff were to leave the right side of the lap table unsecured to the frame so Resident 3 could slide the table away using his/her right hand.

The need to ensure supportive devices with restraining qualities had a thorough assessment completed by an RN, PT or OT prior to use which included, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use and precautions of the device and the use of the device included in the resident’s service plan was discussed with Staff 1 (ED), Staff 4 (RN) and Staff 5 (RN) on 04/17/25 at 4:05 pm. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 03/2025 with diagnoses including CVA, right side weakness, heart disease, depression, anxiety and diabetes.

During the acuity interview on 04/14/25, Resident 2 was identified as having two side rails on his/her bed.

Observations of the resident and the resident's room on 04/14/25 showed the side rails were on each side of the bed in the up position and represented a device with restraining qualities. Interview with Resident 2 on 04/14/25 at 2:00 pm and observation of incontinence care on 04/15/25 at 10:20 am, acknowledged the resident was utilizing the bed rails for bed mobility.

Review of Resident 2's record revealed there was no documented evidence the devices with restraining qualities had been assessed by an RN, PT, or OT, or other less restrictive alternatives evaluated prior to use of the devices, instruction to caregivers on correct use of and precautions for the device, and the use of the side rails in the resident's service plan.

During an interview on 04/16/25 at 11:50 am, Staff 1 (Administrator) and Staff 4 (RN) stated the assessment was not on file.

The need to ensure supportive devices with restraining qualities had a thorough assessment completed by an RN, PT or OT prior to use which included, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use and precautions of the device and the use of the device included in the resident’s service plan was discussed with Staff 1, Staff 4 and Staff 6 (RCC) on 04/16/25 at 2:25 pm. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and meet the fire safety evacuation standards during the overnight shifts, based on resident acuity. Findings include, but are not limited to:

a. During the acuity interview at 10:13 am on 04/14/25 the following was reported:

* The facility was a residential care facility with a current census of 17 residents;
* 14 residents required a two-person assist to transfer, with 13 of them requiring a Hoyer lift;
* One resident was identified as having support for behavioral symptoms;
* One resident was identified as having support for cognitive impairments; and
* Observations of the community, conducted from 04/14/25 to 04/17/25, revealed multiple sampled and unsampled residents used wheelchairs for mobility.

b. There were 12 residents who were served under a Specific Needs Contract which required a separate staffing plan of a minimum of three direct care staff with additional care staff for unscheduled needs;
* There were five additional residents who were not served under the Specific Needs Contract who required a separate ABST and staffing plan; and * Review of staffing schedules from 04/08/25 through 04/15/25 revealed the facility did not meet their posted staffing plan of 4 direct care workers on the overnight shifts from 04/08/25 through 04/16/25. On each of the nine shifts, the facility had a total of three staff on shift; and
* Overnight shift staffing from 04/08/25 through 04/16/25 was insufficient to meet the fire evacuation standards for multiple sampled and unsampled residents based on their acuity.

The facility failed to ensure they had two separate staffing plans and failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

The need to have a sufficient number of direct care staff to meet the scheduled and unscheduled needs of the residents and fire evacuation standards was discussed on 04/17/25 at 4:05 pm with Staff 1 and Staff 2 (Program and HR Director). They acknowledged the findings.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 3 sampled residents (#s 1,
2 and 3) and multiple unsampled residents, failed to develop a staffing plan for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract, and to develop two distinct ABST reports to develop an accurate staffing plan for each shift, that met the scheduled and unscheduled needs of all residents. Findings include, but are not limited to:

1. Resident 1’s ABST was reviewed during the survey and identified the following:

Resident 1’s current ABST, updated on 12/04/24 and on 04/14/25 during the survey, inaccurately captured care time and care elements that staff were providing in the following care areas:

* Ambulation;
* Transfers;
* Supervising, cueing or supporting while eating;
* Incontinent care; and
* Communication.


2. Resident 2’s ABST was reviewed during the survey and identified the following:

Resident 2’s initial ABST last updated on 03/27/25, inaccurately captured care time and care elements that staff were providing in the following care areas:

Transfers.

The need to ensure the facility's ABST accurately captured care time and care elements that staff were providing to the resident was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (RN) and Staff 6 (RCC) on 04/17/25 at 10:45 am. They acknowledged the findings.

3. Resident 3’s ABST was reviewed during the survey and showed the ABST was not reflective for care times needed for communication supports.

The need to ensure the facility’s ABST accurately captured care time that staff were providing to the resident was discussed with Staff 1 (Administrator) on 04/17/25 at 4:05 pm. He acknowledged the findings.

4. The ABST was reviewed for multiple five unsampled residents and showed the ABST was not reflective for care times needed for transfers.

The need to ensure the facility's ABST accurately captured care time and care elements that staff were providing to the resident was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (RN) and Staff 6 (RCC) on 04/17/25 at 4:05 pm. They acknowledged the findings.

5. The facility had a Specific Needs Contract for 12 residents who had medically complex needs and five residents who were not served under the Specific Needs Contract at the time of survey.

Review of the ODHS ABST showed the facility did not prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract.

Review of the ODHS ABST, posted staffing plan and staffing scheduled from 04/08/25 through 04/15/25 found the facility was not staffing to the Specific Needs staffing requirements and failed to staff to meet the scheduled and unscheduled needs of the residents not served under the Specific Needs Contract.

The need to ensure the facility's developed two distinct ABST reports to develop an accurate staffing plan for each shift, that met the scheduled and unscheduled needs of all residents was discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (RN) and Staff 6 (RCC) on 04/17/25 at 4:05 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the posted staffing plan and Acuity-Based Staffing Tool (ABST) met the staffing requirements outlined in OAR 411-054-0070(1) and complete or update and review the ABST evaluation for each resident before a resident moved in and no less than quarterly at the same time the resident's service plan was updated for 2 of 4 sampled residents (#s 1 and 2) whose ABST records were reviewed. Findings include, but are not limited to: ?

1. Review of Resident 1’s ABST and clinical records during the survey identified the facility failed to update and review the acuity-based staffing tool (ABST) no less than quarterly at the same time the resident’s service plan was updated.

The above findings were discussed with Staff 1 (Administrator), Staff 4 (RN), Staff 5 (RN) and Staff 6 (RCC) on 04/17/25 at 10:45 am. They acknowledged the findings.


2. Resident 2 was admitted to the facility on 03/26/2025 with diagnoses including CVA, right side weakness, heart disease, depression, anxiety and diabetes.

The facility’s ABST data was retrieved on 04/14/25 and reviewed during the survey 04/14/25 through 04/17/25. Resident 2 did not have an ABST evaluation completed prior to moving into the facility.

The need to ensure residents’ ABST evaluations were completed prior to move-in was discussed with Staff 1 (Administrator), Staff 4 (RN) and Staff 6 (RCC) on 04/16/25 at 2:25 pm. They acknowledged the findings.

Refer to C360

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 interview and record review, it was determined the facility failed to ensure fire drills were conducted and recorded according to Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months from fire drills. Findings include, but are not limited to:

Six months of facility fire drill and fire and life safety records from 10/2024 to 04/2025 were reviewed on 04/15/25 and revealed the following:

a. The facility lacked documented evidence unannounced fire drills were conducted and recorded at least every other month.

b. Fire drill records lacked documentation of the escape route used.

c. Staff 1 (Administrator) confirmed at 1:15 pm on 04/16/25 there was no documented evidence staff were trained in fire and life safety procedures on alternate months from fire drills.

The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed with Staff 1 on 04/1725 at 4:05 pm. He acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures at lease annually. Findings include, but are not limited to:

Facility fire and life safety records were reviewed on 04/15/25. The facility lacked documented evidence residents were instructed in general safety procedures, evacuation methods, and responsibilities at least annually.

The need to ensure residents were instructed in fire and life safety procedure at least annually, was discussed with Staff 1 (Administrator), on 04/17/25 at 4:05 pm. He acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. Findings include, but are not limited to:

Documentation of the facility’s emergency preparedness plan including evidence that a drill of the plan was conducted at least twice a year was requested on 04/16/25 at 11:26 am. There was no documented evidence the facility conducted a drill of the plan at least twice a year. Staff 1 (Administrator) confirmed at the same time that the facility was not conducting a drill of the plan at least twice a year.

The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required was discussed with Staff 1 on 4/17/25 at 4:05 pm. He acknowledged the findings, and no further information was provided.
Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. Findings include, but are not limited to:

Documentation of the facility’s emergency preparedness plan including evidence that a drill of the plan was conducted at least twice a year was requested on 04/16/25 at 11:26 am. There was no documented evidence the facility conducted a drill of the plan at least twice a year. Staff 1 (Administrator) confirmed at the same time that the facility was not conducting a drill of the plan at least twice a year.


The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required was discussed with Staff 1 on 4/17/25 at 4:05 pm. He acknowledged the findings, and no further information was provided.

OAR 411-054-0093 (1-5) Emergency and Disaster Planning

An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss.
(1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC.

(2) The emergency preparedness plan must:
(a) Include analysis and response to potential emergency hazards including but not limited to:
(A) Evacuation of a facility;
(B) Fire, smoke, bomb threat, or explosion;
(C) Prolonged power failure, water, or sewer loss;
(D) Structural damage;
(E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake;
(F) Chemical spill or leak; and
(G) Pandemic.
(b) Address the medical needs of the residents including:
(A) Access to medical records necessary to provide care and treatment; and
(B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation.
(c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff.

(3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested.

(4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills.

(5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the building was maintained free of drop-offs, ensured all toxic chemicals were properly stored and the entry and exit drive was maintained in a manner which allowed for vehicles to pick up and drop off residents without the need for vehicles to back up. Findings include, but are not limited to:

The interior and exterior of the residential care community was toured on 04/14/25 through 04/16/25. The following was identified:

The laundry room door was observed unlocked on 04/14/25 and 04/15/25. There were multiple gallon size cleaning agents and disinfectants inside the laundry room.

Drop offs from the walking path and the planting bed were observed to be upwards of 2 ¼ inches.
The entry and exit drive was blocked by parked vehicles.

The need to ensure the building was maintained free of drop-offs, all toxic chemicals were properly stored and the entry and exit drive was maintained in a manner which allowed for vehicles to pick up and drop off residents without the need for vehicles to back up was discussed with Staff 1 (Administrator) on 04/15/25 at 4:15 pm and on 04/16/25 at approximately 1:35 pm. He acknowledged the findings.


Refer to C 160.

OAR 411-054-0200 (3) General Building Exterior

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:

The interior and exterior of the residential care community was toured on 04/14/25 at 10:00 am and the following was identified:
* Multiple doors, doorframes and baseboards throughout the interior building had chipped paint, scrapes, and scuffs; and
* Black matter was observed on the exterior siding of the building located in the secured courtyard area.

The need to ensure all interior and exterior materials and surfaces were kept clean and in good repair was discussed with Staff 1 (Administrator) on 04/15/25 at 4:15 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, interview, and record review, it was determined the facility failed to ensure all individuals had the right to freedom from restraints. Findings include, but are not limited to the following:

Refer to C 340.

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom

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

This Rule is not met as evidenced by:

Based on observation, record review, and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units for 1 of 4 sampled residents (#3). Findings include, but are not limited to:

Review of records for Resident 3 revealed no documented evidence the resident had been provided a key to his/her room.

During a 04/16/25 at 2:16 pm interview with Staff 1 (Administrator), he confirmed Resident 3 had not be provided a key to his/her unit.

The need to ensure all residents were provided keys to their units was discussed with Staff 1 on 04/17/25 at 4:05 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, it was determined the facility failed to apply an individually-based limitations when the facility failed to assess or evaluate a resident use of a device with restraining qualities. Findings include, but are not limited to:

Refer to C340.

OAR411-004-0040(1) Limitations: Threats To Health And Safety

(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.

This Rule is not met as evidenced by:

Based on observation and interview it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors and were available for inspection. Findings include, but are not limited to:

Refer to C152

?

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings

(5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following:

(f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections.

(g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted.

This Rule is not met as evidenced by:

Based on interview and record review the facility failed to take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of a resident’s human immunodeficiency virus status. Findings include, but are not limited to:

Refer to C 155.

OAR 411-054-0025 (8)(b)(A-D)(c) Facility Administration: Records

(8) RECORDS. The facility must ensure the preparation, completeness, accuracy, and preservation of resident records.

(b) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding:
(A) A resident’s sexual orientation;
(B) Whether a resident is LGBTQIA2S+;
(C) A resident’s gender transition status; or
(D) A resident’s human immunodeficiency virus status.
(c) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (b) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. Facilities must notify residents or resident representatives if the facility inadvertently or accidentally discloses such information to unauthorized persons.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure initial evaluation addressed all required elements including the pronouns and gender identity. Findings include, but are not limited to:

Refer to C252.

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 interview and record review, conducted during a site visit on 09/16/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 2 of 3 sampled residents (#'s 2 & 4). Findings include, but are not limited to:A review of the facility implemented ABST indicated 17 residents were entered into the tool. A review of the resident roster indicated 17 residents lived in the facility. 6 of the 17 residents on the roster were not entered into the ABST.Resident 2 moved in on 02/07/24 and was not entered into the tool until 09/16/24.Resident 4 moved in on 08/07/24 and was not entered into the tool.In an interview on 09/16/24 at 1:30 pm, Staff 1 (Assistant Administrator) stated s/he had not added Resident 4 to the ABST yet.A review of the facility's posted staffing plan indicated the following:· Day - 5 caregivers, 1 med tech;· Swing - 4 caregivers, 1 med tech; and· Night - 2 caregivers, 1 med tech.A review of facility 09/2024 schedule indicated facility was consistently staffing at the posted staffing plan.During interviews on 09/16/24, Resident 2, Resident 3 and Resident 4 did not express any missed needs.The facility failed to fully implement and update an ABST.The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (Administrator) on 09/16/24.

The findings of the kitchen inspection, conducted 05/24/24, 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 05/24/24, conducted 07/26/24, 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 observation, interview, and record review it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen were made from 9:32 am to 11:55 am on 05/24/24. The following was identified:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * The kitchen walls;* The floors under shelving and appliances;* The open metal shelving and carts, and the white-coated shelving throughout the kitchen;* The small appliances on the metal shelf to the left of the oven;* The oven vent, knobs, interiors, and the sides of the ovens;* The sink spray handle;* The area between the sink backsplash and the wall;* The kitchen drains;* All utensil storage bins and trays;* The lids and exterior of plastic dry storage bins in the dry good storage;* The corrugated roll-up door over the kitchen pass;* The exterior sides and interior floor of the freezer; and* The ceiling, refrigerator, freezer, and ice machine vents.b. Knives and spatulas were observed with taped handles, worn plastic, and/or missing pieces of the rubber part of the spatulas.c. Multiple food items in the dry storage area and a bin on top of the microwave were open or not securely closed, as well as not dated when opened.d. Multiple items were observed in the reach-in refrigerator that were not dated when opened and/or were not securely closed.e. A watermelon in an open box was stored on the floor in the dry goods storage area.f. Scoops and spoons were found stored in bins of raisins, brown sugar, and dry gravy mix.g. There were baking trays and racks stored on the floor between the oven and the wall.h. The shelf under the fryers to the left of the oven was covered in cardboard, creating a potential fire hazard and an uncleanable surface.i. Multiple caregivers were observed serving food and assisting residents with feeding without protective barriers over their clothing. Aprons (clean barriers) are required for caregiving staff when preparing and/or serving food to residents, to prevent potential spread of infectious agents that could arise from caregiving tasks.j. Eggs used for soft-cooked entrees were not pasteurized, and were stored above fruits and vegetables in the refrigerator.k. The facility's policy for sick employees was requested at 9:55 am. Staff 1 (Assistant Administrator) provided a document which did not address facility guidelines for when an employee was to not work (e.g., with symptoms of illness such as cough and fever), and did not address guidelines for the employee returning to work (e.g., symptom-free for 24 hours).The above areas were reviewed with Staff 1 on 05/24/24. He acknowledged the findings.

The findings of the re-licensure survey, conducted 06/13/22 through 06/15/22 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 Home and Community Based Services Regulations OARs 411 Division 004.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 re-visit to the re-licensure survey of 06/15/22, conducted 8/18/22 through 8/19/22, 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.

Based on interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a physician or other legally recognized practitioner were carried out as prescribed for 1 of 2 sampled residents (#4) whose records were reviewed. Findings include, but are not limited to:Resident 4 was admitted to the facility 12/2021 with diagnoses including hypertension, Diabetes, and acute respiratory failure. Review of Resident 4's MAR, dated 06/01/22 through 06/12/22, and physician orders, dated 04/07/22 identified the following:*The MAR listed carvedilol 25 mg (for blood pressure), with instructions to withhold administration if the resident's heart rate was below 60. There were five occasions where the medication was given, following a pulse reading below 60.On 06/14/22 the need to ensure all orders from a physician or other legally recognized prescriber were documented in resident MARs and carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN). 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 1 and 4) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 02/2021 with a diagnosis of Alzheimer's disease. Resident 1's 06/01/22 through 06/12/22 MARs were reviewed during the survey. The following PRN medications lacked clear parameters for administration: * PRN Morphine 20 mg/1 ml and PRN tramadol 50 mg were both prescribed to treat pain and lacked clear parameters for the sequence of administration. * PRN Tramadol 50 mg and PRN Trazodone 50 mg were both prescribed for sleep and lacked clear parameters which medication was to be administered first.The need to ensure MARs included clear parameters for multiple PRN medications that were prescribed to treat the same condition was discussed with Staff 1 (Administrator) on 06/14/22. She acknowledged the findings.
2. Resident 4 was admitted to the facility 12/2021 with diagnoses including hypertension, Diabetes, and acute respiratory failure. Review of Resident 4's MAR, dated 06/01/22 through 06/12/22 identified the following:*The MAR lacked a reason for use of magnesium oxide 400 mg (for constipation); and*The MAR listed two instances where Resident 4 refused Pepto Bismol (oral liquid for indigestion). However, this was not a routine medication, but a PRN which the resident was approved to self-direct.On 06/14/22 the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Review of facility records on 06/14/22 identified the following deficiencies:There was no documented evidence fire and life safety instruction was provided to staff on alternating months.On 06/15/22 the need to provide fire and life safety instruction to staff, in accordance with the OFC was discussed with Staff 1 (Administrator) and Staff 3 (Marketing Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Review of facility records on 06/14/22 identified the following deficiencies:There was no documented evidence that annual training on fire safety was provided to residents. On 06/15/22 the need to provide and document fire and life safety instruction for residents, at least annually, in accordance with the OFC was discussed with Staff 1 (Administrator) and Staff 3 (Marketing Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not contain drop-offs, to prevent a tripping hazard for residents. Findings include, but are not limited to:The facility's outdoor courtyard/patio area was toured on 06/13/22. Drop-off's, up to three inches in depth were observed along the patio and pathways.The need to ensure all exterior pathways were maintained free of drop-offs was discussed with Staff 1 (Administrator) on 06/13/22. She acknowledged the findings.