Holi Senior Living

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

HOLI Senior Living Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen on 06/17/26, from 10:45 am through 12:00 pm, revealed the following: 1. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, rust, and/or grease was visible on or underneath the following: * All floors under/behind cooking equipment (significant build-up of food debris), ware washing machine and center prep island; * Floors and thresholds of walk-in cooler; * Top of ware washing machine; * Interior upper recesses of commercial ice machine-black debris; * Legs, casters and shelves of center island prep tables; * Underside of commercial mixer head * Safety cage on commercial mixer; * Table -legs and shelves- that commercial mixer is stored on * Bottom shelves of all reach in coolers and freezers; * Food delivery carts; * Hinges and insulation strips on all doors of all reach in coolers and freezers; * Vent cover located on wall next to kitchen entrance door; * Condenser fan cover in walk-in cooler; * Hand held “Salad Shooter” - significant black debris on cord; * Metro rack style cart (all racks, legs and casters) used to transport portable steam table; * Portable steam tables, all exterior surfaces, controls knob and water well; * Floor sink under commercial ice machine; * Floor sink under two-compartment sink in ware washing area; * Canned food dispenser/holder on cooking line next to reach in freezer; * Black industrial fan cover and interior; * Hood vent filters above cooking equipment; and * Industrial can opener mounting plate. 2. Items in need of repair or replacement: * Multiple sauté pans with heavily worn non-stick surface which could result in physical contamination of food items; * Both convection ovens (under range burners) on hot cooking line; * Various small wares; * Cutting boards with worn finishes, potentially uncleanable; * Oven mitts heavily soiled and or with scorch/burn marks; * Water leaking from ware washing machine; and * Significant rust on walk-in cooler storage racks, rendering them unable to be cleaned/sanitized. 3. Sanitation and food handling: * Improper glove use; * Lack of facial hair restraints on cooking staff; * Lack of hair restraints on serving staff; * Lack of hand washing between changing gloves; * Lack of handwashing after touching face/hair; * Surface sanitation solution buckets without wiping towel; * Damp towels observed on multiple food service areas/towels not returned to surface sanitation solution buckets after use; * Kitchen staff unable to articulate effective minimum temperature for reheating food items; * The person in charge unable to articulate the two-stage cooling process; * Ware washing machine racks stored directly on floor; *Person in charge preparing food without facial hair restraint; * Kitchen staff observed to handle clean dishes without first washing hands after handling dirty dishes; * Oven rack stored directly on floor; *Improper probe thermometer use-probe thermometer not sanitized before use, potentially contributing to cross contamination; * Kitchen staff unable to articulate effective parts per million (PPM) range for quaternary sanitizing solution; and * Food prep area with raw chicken and raw egg handling not cleaned in a timely manner. 4. Food storage: * Multiple opened packaged food items in walk-in cooler without open dates; * Multiple prepared food items in reach in cooler; * Multiple prepared food items in reach in freezer uncovered, potentially impacting quality/palatability; * Brown sugar on countertop with serving spoon scored inside of the container, potentially contaminating the product; * Food item in walk-in cooler was opened/transferred from original container over fifteen days ago, rendering it potentially hazardous; * Improper food storage hierarchy in reach in freezer; * Food item in freezer was not properly closed, potentially affecting quality of food item; * Damaged #10 can intermingled with useable canned goods; * Frozen red substance on bottom shelf of reach in freezer; and * In dry storage, multiple bulk food containers without securely fastened lids. 5. Other areas of concern: * One member of kitchen staff had an expired food handler’s card. * Lack of palatability/visual appeal of observed lunch items-all foods were shades of tan or grey/white. Observations of the ALF kitchenette on 06/17/26, from approximately 1:00 pm through 1:20 pm, revealed the following: 1. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, rust, and/or grease was visible on or underneath the following: * Interior of toaster and the shelf the toaster was stored on; * Cabinet shelves and doors/top of doors; and * Black debris on interior surfaces of commercial ice machine. 2. Sanitation and food handling: * Lack of handwashing between changing gloves; * Ice scoop placed directly in ice machine on top of ice, potentially causing cross contamination; and * Ant infestation in cabinet holding canned sodas. 3. Food storage: * Improperly closed cereal; * Improperly closed cereal with an open date of approximately two months ago, rendering the food item beyond its use by date; * Multiple packaged food items without an open date in standing reach in cooler in dining room (next to microwave); and * Opened packaged food item with an open date of 02/24/26, rendering the product past its safe use by date. 4. Other areas of concern: * Dirty dishes were stored in the dedicated hand-washing sink. At approximately 01:30 pm surveyor met with Staff 1 (Interim ED) and Staff 2 (Dining Services Director) to review deficiencies. The findings were acknowledged by Staff 1 and Staff 2.

All identified sanitation, food storage, equipment, and food handling deficiencies were immediately corrected. The main kitchen and ALF kitchenette received a comprehensive deep cleaning. Expired, improperly stored, unlabeled, and out-of-date food items were discarded. Equipment and utensils that were damaged or unable to be effectively cleaned were removed from service and replaced or scheduled for replacement. Staff received immediate re-education on proper hand hygiene, glove use, hair restraints, food storage hierarchy, labeling and dating of food, temperature control, sanitizing procedures, and safe food handling practices. The facility has implemented a comprehensive food safety and sanitation program that includes documented daily, weekly, and monthly cleaning schedules, standardized food labeling and dating procedures, preventive maintenance and routine equipment inspections, and ongoing food safety education with competency validation for all dietary staff. Routine sanitation audits and food safety observations have been incorporated into the Quality Assurance process to ensure continued compliance with Oregon Food Sanitation Rules and applicable OARs. The Dining Services Director will review sanitation practices, food storage, food handling, equipment condition, and cleaning logs daily. Weekly sanitation audits will be completed for 90 days, followed by monthly Quality Assurance audits thereafter. The Dining Services Director will be responsible for implementing and monitoring all corrective actions, including daily review of sanitation practices, food storage, equipment condition, and completion of cleaning logs. The Executive Director will provide secondary oversight by reviewing weekly audit results, participating in the Quality Assurance process, and ensuring ongoing compliance with Oregon Food Sanitation Rules and applicable OARs.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Based on record review and interview, it was determined the facility failed to ensure 1 of 8 sampled staff who prepared food had active food handlers certificates. Findings include, but are not limited to: On 06/17/2026 employee records were requested and reviewed with Staff 1 (Interim Executive Director) to ensure staff had active food handler's cards on file. Staff 3 (Kitchen staff) did not have an active Oregon food handlers card. On 06/17/2026, Staff 1 acknowledged the need for all staff to have an active Oregon food handler card. Staff 3 is required to have an active food handler's card prior to returning to work. Refer to C240

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

Facility not in compliance with ALF/RCF rules. Refer to C240

All deficiencies identified under Tag C240 were corrected immediately. Corrective actions included the Memory Care kitchen and dining service operations to ensure compliance with Residential Care, Assisted Living, and Memory Care licensing requirements. Staff received education regarding food safety and sanitation expectations. Administrative oversight has been strengthened through routine monitoring of all dietary operations, including Memory Care. Food safety, sanitation, documentation, and regulatory compliance will be reviewed through ongoing Quality Assurance audits to ensure continued compliance with applicable Oregon Administrative Rules. The Dining Services Director will complete weekly compliance audits for 90 days. The Executive Director will review audit findings weekly and continue monthly oversight through the facility's Quality Assurance program thereafter. The Dining Services Director will monitor ongoing compliance with dietary operations and complete routine audits. The Executive Director will provide secondary oversight by reviewing audit findings, participating in the Quality Assurance process, and ensuring continued compliance with Residential Care, Assisted Living, and Memory Care licensing requirements.

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

Based on interview and record review, it was determined the facility failed to ensure 1 of 8 sampled staff (#3) who prepared food had active food handlers certificates. Findings include, but are not limited to: On 06/17/2026 employee records were requested and reviewed with Staff 1 (Interim ED) to ensure staff had active food handler's cards on file. Staff 3 (Kitchen staff) did not have an active Oregon food handlers card. On 06/17/2026, Staff 1 acknowledged the need for all staff to have an active Oregon food handler card. Staff 3 was required to have an active food handler's card prior to returning to work.

The employee identified without a current Oregon Food Handler Card was immediately removed from food preparation duties until a valid Food Handler Card was obtained and verified. A complete audit of dietary personnel records was completed to verify all staff performing food service possess current Oregon Food Handler Cards. The facility has implemented a Food Handler Card tracking system to monitor expiration dates. Verification of current certification will occur during the hiring process, orientation, and prior to expiration. Staff will receive advance notification of upcoming expiration dates, and employees will not be permitted to perform food service duties without a current Oregon Food Handler Card. The Dining Services Director will review Food Handler Card status monthly and during all new hire onboarding. Compliance will also be reviewed during routine personnel file audits and Quality Assurance meetings. The Dining Services Director will monitor Food Handler Card compliance, maintain certification records, and ensure staff remain eligible to perform food service duties. The Executive Director will provide secondary oversight by reviewing personnel audits, monitoring certification compliance, and ensuring ongoing adherence to Oregon requirements and facility policy.

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

Based on observation and record review, it was determined the facility failed to create an environment in which residents were treated with dignity and respect, were free from neglect, and received services in a manner that protected privacy for 5 of 6 sampled residents (#s 1, 2, 3, 5, and 6) and multiple unsampled residents. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Alzheimer’s disease and adjustment disorder with mixed anxiety and depressed mood. S/he was subsequently admitted to hospice in 06/2025, with admitting diagnosis of Alzheimer’s disease. During the acuity interview on 12/08/25, Resident 1 was reported as non-verbal, requiring a high degree of care, and receiving treatment for a stage 2 pressure ulcer (open wound). During an interview on 12/11/25 at 10:13 am, Staff 21 (MT) stated the facility RN was available anytime to report abnormal findings, and the MTs used their personal phones for communications with the RN. Staff 21 showed the surveyor her personal phone, which revealed resident’s private medical information. During an interview on 12/11/25 at 11:26 am Staff 18 (MT) confirmed the use of personal phones by facility MTs for communication, including video calls to assess skin impairments. The need to create an environment in which residents received services in a manner that protected privacy and dignity was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings. 2. Resident 2 moved into the MCC1 in 10/2025 with diagnoses including dementia. On 12/08/25 at 12:12 pm, Resident 2 was observed sitting in a wheelchair asking staff when s/he could take a bath. There was a MT located behind the resident to the left and Staff 14 (CG) was located in front of the resident to the right. Both staff members were within three feet of him/her and Resident 2 was speaking loud enough for staff to hear. When there was no response from either staff member, the resident propelled closer to Staff 14 and repeatedly asked if s/he could have a bath. Neither staff member addressed the resident’s question, looked at him/her while they were asking the question, or said anything to Resident 2. The need to ensure residents were being treated with dignity and respect was discussed with Staff 1 (ED). She acknowledged the findings. 3. The following observations were made in MCC2: a. On 12/08/25, between 2:10 pm and 2:39 pm, observations of an unsampled resident were made in the common area dining room. The resident was pacing around the community, going in and out of the restroom, and pushing on locked doors. When the resident went to go outside to the secured courtyard, a CG stated, “No, no, no! Too much rain,” and did not allow the resident to go outside. When the resident was not allowed to go into the courtyard, s/he turned to the CG, swatted at her, and stated, “Get away from me!” During an interview on 12/08/25, at 2:42 pm, the CG stated she did not know what the facility policy was relating to inclement weather and when it was not safe for residents to go outside. b. Resident 3 moved into the MCC2 in 06/2023 with diagnoses including dementia, adjustment disorder with anxiety, depression, and Alzheimer’s disease. On 12/11/25, at 9:30 am, Resident 3 was observed sitting at a dining room table. S/he got up and walked over to a beverage station to pour him/herself a cup of coffee. The container was empty. The resident took the empty cup to Staff 18 (MT). After the staff member confirmed there was no more coffee left in the container, she told the resident that she was going to get more from the kitchen. Staff 18 took the empty coffee container and the resident’s cup to the kitchen. When the MT returned, she told Resident 3 that the kitchen was brewing a fresh pot of coffee. The resident stated, “They better brew it fast.” At 9:53 am, Resident 3 still did not have a cup of coffee. A staff member brought an unsampled resident a blue cup. The resident had been drinking coffee from a blue cup before Staff 18 took it to the kitchen. This resembled the blue cup from which the resident was previously drinking coffee. When Resident 3 observed staff put the cup down for the unsampled resident, Resident 3 stated, “That’s mine! I already paid for that!” Staff told Resident 3 that the cup was full of oatmeal. The resident asked, “Can I get something to eat?” Staff talked to him/her about some snack choices, and Resident 3 agreed on a half of a sandwich. At 10: 05 am, Staff 18 handed Resident 3 a half of a sandwich on a plate, covered in plastic wrap, then walked out of the unit. The resident had the covered plate on his/her lap and was looking at it and turning the plate around. At 10:27 am, Staff 18 returned to the unit and the resident shoved the plate towards her and stated, “Take it away.” The sandwich was still on the plate and covered in plastic. There were three other staff members on the unit when Staff 18 left. No one offered to help Resident 3 unwrap the sandwich so s/he could eat it. c. On 12/11/25 at 9:40 am, an unsampled resident was observed taking his/her crushed medications in a pureed substance in a plastic cup with a plastic spoon. After s/he was finished swallowing the medications, Staff 18 took the resident to the dining room. The unsampled resident was observed to require meal assistance. The resident’s breakfast was on the table to which s/he was assisted. Staff 18 began to assist the unsampled resident with breakfast using the same plastic spoon the resident used when s/he was administered medications. The unsampled resident was observed to receive meal assistance with silver utensils for prior meals; thus, being assisted with plastic ware did not provide a homelike environment. Staff 18 stopped feeding the resident to do something else, and Staff 17 (CG) continued to assist the resident with eating. He continued using the plastic spoon until the unsampled resident was finished eating. The need to ensure residents were being treated with dignity and respect was discussed with Staff 1 (ED). She acknowledged the findings. 4. Resident 6 was admitted to the facility residential care unit in 11/2023 with diagnoses including heart failure and macular degeneration. The 10/11/25 service plan identified Resident 6 needed cues during meals due to difficulty seeing the meals in front of him/her, needed his/her food to be cut up, and needed nectar thick liquids. S/he preferred “a quieter environment and not excessive noise...” The following observations were made during lunch on 12/08/25 and 12/09/25: * Resident 6 repeatedly asked staff for assistance by saying, “Can you help me?” and/or would wave at a caregiver to come over to the table. Staff would stand over the resident while they provided intermittent assistance of one or two minutes at a time that involved identifying the food, where it was located, and/or cutting the food up into smaller bites. On 12/09/25 the resident attempted to get the attention of staff, saying, “Please help me” with a distressed, panicked look on his/her face. When no staff responded, a surveyor alerted a server to provide assistance; and * A television was playing a crime show during lunch at a loud volume. There were no residents watching the program. Resident 6 sat at the table closest to the television. On 12/09/25 at 11:00 am, Resident 6 was interviewed and indicated the following: * “I wish they would help me eat. They think I can do it, and I can, but it’s hard for me to see my food. I would eat more of my meal if they would just help me.”; * S/he would like to drink coffee “every now and then” but was told s/he had to drink the other pre-thickened beverages; and * The food was described as “average and usually cold” but “I’m hungry so I eat it.” Interviews with multiple staff on 12/08/25 and 12/09/25 indicated the resident wanted assistance with his/her meals but they have been told by management that residents who resided in “assisted living” and needed help eating would need to move downstairs to the memory care unit. In an interview on 12/09/25 at 11:30 am, Staff 7 (MT) indicated the resident could not have coffee because it was not thick enough and was not aware that thickener could be added to coffee to make it nectar thick. On 12/09/25 at 4:15 pm, Staff 1 (ED) indicated she had been recommending the memory care facility for Resident 6 but the family was not agreeable. Staff 1 reported she would communicate to staff to assist Resident 6 with his/her meals. The need to ensure residents were treated with dignity and respect regarding meal service was discussed on 12/10/25 at 2:40 pm with Staff 1. She acknowledged the findings. 5. Resident 5 was admitted to the facility residential care unit in 11/2025 with diagnoses including failure to thrive and cancer. During the acuity interview on 12/08/25, staff indicated the resident was bedbound. The 11/06/25 service plan indicated Resident 5 could feed himself/herself but needed “reminding/cueing to maintain adequate intake due to recent weight loss.” Observations of lunch service on 12/08/25 and 12/09/25 indicated the following: * Resident 5 was in bed sleeping with the head of bed raised about 10 to 20 degrees. A meal tray was on a bedside table out of reach of the resident, with only a plastic fork as an eating utensil; and * On 12/11/25 staff were observed delivering food to the resident which was covered with plastic wrap, placed out of the resident’s reach from his/her bed, and included only a plastic fork for a utensil. Lunch consisted of a thick slice of ham that was not cut up when served to the resident. An interview with Resident 5 on 12/09/25 at 2:30 pm indicated the following: * S/he did not prefer eating with plastic utensils; * “If my food was within reach, I would eat it”; and * The food was “so-so” and cold “most of the time.” Staff interviews on 12/08/25 through 12/11/25 indicated the following: * “I feel bad, sometimes [s/he] doesn’t eat for a few days but we are not supposed to assist [him/her] with eating,”; * “We have been told we are not supposed to [provide meal assistance for Resident 5] but the MT talked with the nurse and got permission to help [him/her] eat.”; * The residents who ate in their room “always” got plastic utensils and it was “usually just a fork or a spoon”; * “We always have to reheat the food because [s/he] likes it warm”; and * The kitchen was often late in getting food served to residents who ate in their rooms. “Breakfast doesn’t arrive sometimes until after 10:00 am and lunch after 1:30 pm. Some residents can’t have their medications until they eat, so that is a problem.” On 12/09/25 at 4:15 pm, Staff 1 (ED) indicated she would ensure Resident 5 would be provided assistance with his/her meals and she would communicate proper meal set-up to staff. The need to ensure residents were treated with dignity and respect regarding meal delivery and assistance was discussed with Staff 1 on 12/11/25 at 2:40 pm. She acknowledged the findings.

- Immediate notification was made to Medication Techs to discontinue using personal phones for communication where resident rights could be compromised. - Notices were posted in each Medication Room as a daily reminder.- Going forward, company cell phones, community iPads, community landlines, and medication tech laptops will be used for private communication. - This system was implemented before survey exit and will be continuously monitored by the Executive Director (ED), Wellness Coordinator, Wellness Director, and RN consulting company to ensure private communication occurs only on company devices. - A Caregiver/Medication Tech meeting will be held on 01/13/2026 to provide a refresher co urse on Resident Rights, emphasizing dignity, proper approach to residents with dementia, resident choice, and individualized needs. - Daily floor check-ins by the ED, Wellness Coordinator, and Wellness Director will ensure dignity and proper communication. - A Temporary Service Plan was implemented before survey exit to ensure residents needing feeding assistance are offered help at each meal and food is within reach if they choose to feed themselves. Care plans will reflect this as an ADL when needed. Weekly check-ins wi ll confirm assistance is provided as needed. -This will be monitored by the Executive Director, Wellness Coordinator, and Wellness Director.

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

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

Based on interview and record review, it was determined the facility failed to ensure an injury of unknown cause was reported to the local Seniors and People with Disabilities (SPD) office as suspected abuse when the facility’s investigation could not reasonably conclude that the physical injury was not the result of abuse for 1 of 1 sampled resident (# 2), who sustained an injury of unknown cause. Findings include, but are not limited to: Resident 2 moved into the MCC1 in 10/2025 with diagnoses including dementia. A review of the resident's clinical record, including progress notes and incident reports, identified the following: On 11/07/25, an incident form was created and noted, “a bruise [on the resident’s right] breast nipple.” The incident form included the question, “Is abuse suspected?” In response, staff wrote, “We don’t know at this time.” During the facility’s investigation, Resident 2 was asked what happened. The resident stated that s/he did not know. On 11/08/25, Staff 3 (Wellness Director /LPN) documented in a progress note that “care staff reported that resident has a bruise on [his/her] right breast.” Staff 3 documented the bruise was “below [his/her] right nipple” and was “approximately 1.5 [centimeters by] 1.5 [centimeters]” and was a “light purplish color.” On 12/09/25 at 10:24 am, Staff 3 was unable to locate documented evidence that the injury of unknown cause had been reported to the local SPD office. At the request of survey, the facility reported the incident on 12/09/25 at 12:38 pm and provided the documentation to survey at 1:07 pm. The need to ensure injuries of unknown cause were reported to the local SPD office as suspected abuse when the facility’s investigation could not reasonably conclude that the physical injury was not the result of abuse was discussed with Staff 1 (ED) and Staff 3 on 12/09/25 at 10:24 am. They acknowledged the findings.

- Incident reports will be reviewed promptly within 24 hours to ensure cases where abuse cannot be ruled out are reported timely. - Morning manager meetings will include discussions to confirm no reports are missed. - Daily checks of Incident Reports in Yardi by the ED, Wellness Coordinator, and Wellness Director will ensure compliance

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

Any/All reports that can not be rule out abuse and neglect will be investiaged and turned into APS within 24 hours. The system will be corrected by oversight of the ED, Wellness Director, and Wellness coordinator to disucss in morning clinical meetings if reports have been made that need to be reported each day. This will be evaluated daily or as reports are made to the facility. The ED, Wellness Director, and Wellness Coordinator will be responsible for contiuned monitoring.

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

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

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all required elements for 2 of 2 sampled residents (#s 2 and 5) and the initial evaluation was updated and modified as needed during the first 30 days following the resident’s move-in to the facility for 1 of 1 sampled resident (# 2) who had resided at the facility for over 30 days. Findings include, but are not limited to: 1. Resident 2 moved into the MCC1 in 10/2025 with diagnoses including dementia. a. The resident’s initial evaluation was reviewed and was lacking the following required elements: * Customary routines, including eating and bathing; * Interests, hobbies, social, leisure activities; * Ability to understand and be understood; * Non-pharmaceutical interventions for pain; and * Recent Losses. b. There was no documented evidence the initial evaluation had been updated and modified as needed during the first 30 days following Resident 2’s moving into the facility. The need to ensure the initial evaluation addressed all required elements and the initial evaluation was updated and modified as needed during the first 30 days following the resident’s admission was discussed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 12:35 pm. No additional documentation was received. 2. Resident 5 moved into the facility residential care unit in 11/2025 with diagnoses including failure to thrive and cancer. The resident's initial evaluation was reviewed, and it failed to address the following required elements: * Interests, hobbies, social, leisure activities; * Pain, including non-pharmaceutical interventions; and * Recent losses. The need to ensure the initial evaluation included all required elements was discussed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25. They acknowledged the findings.

- Initial evaluations will be reviewed by the ED, Wellness Coordinator, and Wellness Direc tor before admission to ensure completeness. - 30-day evaluations will be completed and double-checked. - Upcoming evaluations will be reviewed in daily morning meetings to ensure timely completion. -This will be monitored by the ED, Wellness Coordinator, and Wellness Director.

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services and/or were completed quarterly for 5 of 6 sampled residents (#s 1, 2, 3, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the MCC1 in 10/2025 with diagnoses including dementia. The resident's clinical record was reviewed, staff and the resident’s family were interviewed, and observations were made. The service plan did not provide clear direction to staff in the following areas: * The use of a walker; * The use of a gait belt; * Ability to use the call light; * Assistance needed for all grooming and personal hygiene needs; * Level of assistance needed for toileting; * Ability to consistently verbalize the need to use the restroom; * The use of protective undergarments; * Behavior interventions when s/he verbalized concerns about money; and * Emergency evacuation assistance needed. The need to ensure service plans were accurate and provided clear direction regarding the delivery of services was discussed with Staff 1 (ED) and Staff 3 (Wellness Director /LPN) on 12/11/25 at 12:35 pm. They acknowledged the findings. 2. Resident 3 moved into the MCC2 in 06/2023 with diagnoses including dementia, adjustment disorder with anxiety, depression, and Alzheimer’s disease. a. The resident's clinical record was reviewed, interviews were completed with staff, and observations were made. The service plan did not provide clear direction to staff in the following areas: * Exit seeking behavior; * Reminders to not put dirty clothes back in the closet; * Independently cleaned his/her body at the sink each day; * Person-centered interventions for behaviors; and * Preference of not being touched. b. The service plan that staff had access to was dated 08/13/25, thus had not been updated quarterly. The need to ensure service plans were accurate and provided clear direction regarding the delivery of services and were updated quarterly was discussed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 12:35 pm. They acknowledged the findings. 3. Resident 5 was admitted to the facility residential care unit in 11/2025 with diagnoses including failure to thrive and cancer. The resident’s record was reviewed, including the current service plan, dated 11/06/25, observations were made, and interviews with staff were conducted. The following was identified: The service plan was not reflective of the resident’s current care needs and/or lacked clear instruction in the following areas: * Meal delivery, including cutting up meat and vegetables, meal tray placement, and positioning when eating in bed; * Dining assistance, including as-needed cueing and assistance; * Food and fluid preferences; * Pain, including location, how the resident expressed pain, and pharmaceutical and non-pharmaceutical interventions; * Preferences for leaving the door open; * Skin treatments including applying barrier cream following brief changes; * How often to perform safety checks and repositioning when in bed; and * Outside providers who were providing services. The need to ensure service plans were reflective of the residents’ current care needs and included clear instructions to staff was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:40 pm. They acknowledged the findings. 4. Resident 6 was admitted to the facility residential care unit in 11/2023 with diagnoses including heart failure and macular degeneration. The resident’s record was reviewed, including the current service plan, dated 10/11/25, observations were made, and interviews with staff were conducted. The service plan was not reflective of the resident’s current care needs and/or lacked clear instruction in the following areas: * Dining assistance; * Aspiration precautions when drinking fluids in bed; * Use of side rails, including safety checks and when to position up and down; and * Use of pillow under leg when in bed. The need to ensure service plans were reflective of the residents’ current care needs and included clear instructions to staff was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:40 pm. They acknowledged the findings. 5. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Alzheimer’s disease and adjustment disorder with mixed anxiety and depressed mood. S/he was subsequently admitted to hospice in 06/2025 with admitting diagnosis of Alzheimer’s disease. Observations were made of the resident's care on 12/09/25. Interviews with the resident’s family member, facility staff, and the resident’s outside provider were conducted. The service plan, updated on 10/01/25, was reviewed. Resident 1's service plan lacked clear instructions to staff in the following areas: * Specific changes of condition to report to hospice; * Instructions to staff when resident refused care; * How the resident expressed hallucinations and delusions; and * Aspiration precautions and interventions while choking. The need to ensure service plans provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings.

-Service plans will be updated with accurate details in all areas not met and revised as changes occur, including needs, interventions, ADLs, and resident preferences. - Detail checks will occur during initial, 30-day, and quarterly evaluations. - The ED, Wellness Coordinator, and Wellness Director will monitor due dates in Yardi to ensure timely completion.

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

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility MCC1 in 09/2023 with diagnoses including Alzheimer’s disease and adjustment disorder with mixed anxiety and depressed mood. S/he was subsequently admitted to hospice in 06/2025 with admitting diagnosis of Alzheimer’s disease. During the acuity interview on 12/08/25, Resident 1 was reported to be non-verbal and require a high degree of care, including a pureed texture diet and assistance with meals. During the survey, from 12/08/25 through 12/11/25, the surveyor obtained permission from the facility and observed facility staff provide personal care and feeding to Resident 1. The resident required full assistance from staff. On multiple instances, staff donned gloves without first performing hand hygiene, did not change single-use gloves between clean and dirty tasks, and performed meal assistance without wearing aprons. On 12/08/25 at 12:44 pm, Staff 11 (CG) was observed to transfer Resident 1 from his/her wheelchair to the bed using a mechanical lift, placing a trash can on the resident’s bed, providing personal care, and administering cream treatment to the resident without changing soiled gloves. On 12/09/25 at 11:44 am, Staff 14 (CG) was observed placing a gloved finger in resident’s two food bowls and wiping the fingers with a napkin. When asked of the purpose, Staff 14 stated, “to check temperature.” The need to establish and maintain effective infection prevention and control protocols was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings. 2. Resident 6 was admitted to the facility residential care unit in 11/2023 with diagnoses including heart failure and macular degeneration. During the acuity interview on 12/08/25, the resident was identified to need cueing for meal assistance because of his/her poor vision. Multiple observations during meal service on 12/08/25 identified Resident 6 waving his/her hand to motion a staff member to come to the table and provide meal assistance. Between 1:02 pm and 1:16 pm, the resident asked and/or motioned for staff to come over to his/her table three times. Staff were observed to pick up his/her utensil and use it to either cut up the food, point at where the food was located, or scoop up a bite of food. Staff handed the utensil back to the resident to resume eating. Staff were not observed to perform hand hygiene prior to assisting Resident 6 or prior to resuming meal service. The need to ensure infection prevention and control protocols were maintained was discussed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:40 pm. They acknowledged the findings. 3 .During the survey, between 12/08/25 and 12/11/25, multiple meal observations were made of direct care staff providing meal service to residents in the two MCC units. On 12/08/25 at 11:55 am in MCC1, Staff 14 (CG) was observed sitting beside a resident who required assistance with his/her meal. Staff 14 had donned gloves prior to the observation. At 12:03 pm, kitchen staff brought three bowls covered in plastic wrap. Staff 14 took the wrap off and began to assist the resident with his/her meal. She stopped the assistance and got up to push the resident’s wheelchair closer to the table, touching the wheelchair grips. She sat back down at the table and continued to assist the resident with his/her lunch without changing the soiled gloves or performing hand hygiene prior to resuming meal assistance. Staff 14 was not wearing an apron or another protective barrier while assisting the resident to eat during his/her lunch. On 12/09/25 at 11:59 am in MCC2, Staff 23 (MT) was observed sitting beside an unsampled resident who required assistance with his/her meal. Staff 23 was wearing gloves but was not wearing an apron or any other protective barrier, nor was her hair restrained. Staff 23 was observed opening and shutting a cabinet door, delivering a plate of food and a beverage to a different resident, and handing another staff members keys attached to a lanyard without changing soiled gloves or performing hand hygiene. There were two CGs observed assisting residents in the dining room and delivering plates and beverages to residents who chose to eat their lunch in their units. Neither one of them were wearing an apron or any other protective barrier over their clothing. On 12/11/25 at 9:43 am in MCC2, Staff 18 (MT) was observed sitting beside an unsampled resident who required assistance with his/her meal. Staff 18 was wearing gloves but was not wearing an apron or any other protective barrier over her clothes, nor was her hair restrained. While the resident was eating, Staff 18 needed to take a lunch break, so Staff 17 (CG) began assisting the resident with breakfast. Staff 17 was wearing gloves but was not wearing an apron or any other protective barrier over his clothes. Staff 17 touched the television remote and used his walkie talkie while assisting the unsampled resident with his/her meal. Staff 17 did not perform hand hygiene or change his gloves between the tasks. The need to ensure infection prevention and control protocols were maintained was discussed with Staff 1 (ED) during the survey. She acknowledged the findings.

- Re-training on infection control will include proper glove use, sanitary habits, and mea l assistance. - Aprons will be provided to each department for easy use during meal periods. - In-person training will occur for Caregivers and Medication Techs, followed by all staff . - Daily checks will ensure compliance, especially during meal times. - All management will oversee staff compliance, with ED and infection control specialists responsible for enforcement.-

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

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

Based on interview and record review, it was determined the facility failed to ensure treatment orders were carried out as prescribed for 2 of 6 sampled residents (#s 3 and 6) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility residential care unit in 11/2023 with diagnoses including heart failure and macular degeneration. Review of Resident 6's current physician orders, dated 10/08/25, MARs, dated 11/01/25 through 12/08/25, and weight records, dated 06/2025 through 12/2025, revealed the following: Physician’s orders included “weigh [Resident 6] every 2 weeks” and report to the physician “any weight loss or gain of 3 [pounds].” According to the resident’s weight records, the following was identified: * 07/10/25: 142.6 pounds; * 07/29/25: 147.1 pounds; * 10/10/25: 142.26 pounds; and * 10/29/25: 147.1 pounds. On 12/11/25 at 2:40 pm, in an interview with Staff 3 (Wellness Director/LPN), she acknowledged there was no documented evidence the physician was notified of the 4.5 pound and 4.84 pound weight gains on 07/29/25 and 10/29/25, respectively. Additionally, weight records indicated the resident was weighed one time in 06/2025 and 09/2025, not every two weeks as the physician ordered. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 3 on 12/11/25 at 2:40 pm. They acknowledged the findings. No further documentation was provided. 2. Resident 3 moved into the MCC2 in 06/2023 with diagnoses including dementia, adjustment disorder with anxiety, depression, and Alzheimer’s disease. The resident’s physician’s orders, MARs, dated 11/01/25 through 12/08/25, and weight records, dated 05/2025 through 12/2025, reflected the following: a. Physician’s orders directed staff to weigh Resident 3 each month on the 21st during the morning. There was no documented evidence the resident was weighed in 06/2025, 08/2025, or 11/2025. b. Resident 3 received amlodipine and lisinopril each day at 8:00 am to help treat high blood pressure. Physician’s orders directed staff to take the resident’s blood pressure every day at 8:00 am and to hold the medications if his/her systolic blood pressure was “less than 110.” There was no documented evidence staff took Resident 3’s blood pressure 14 of the 37 days reviewed. Both medications were administered on those 14 days. In an interview at 1:17 on 12/09/25 with Staff 23 (MT), she demonstrated that the daily blood pressure was a separate task entry from administering blood pressure medications. Once the MT had entered the blood pressure, she couldn’t go back into the entry to see what the numbers were when she was administering medication. In an interview at 12:35 pm on 12/11/25 with Staff 3 (Wellness Director/LPN), he indicated that he reviewed MARs monthly but didn’t look at every single MAR. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 3 on 12/11/25 at 12:35 pm. They acknowledged the findings and no additional information was received.

-Weight and blood pressure orders will be reviewed by Wellness Director and than residnet put on alert to be closer monitored. -Refusals by resident will be documented, physican notified and approiate documenation and follow up will be done to ensure orders are being followed. Wellness director will ensure Med Techs know how to record properly in Yardi so that it can be properly tracked as well. -This will be evaluated per the order. Weights will be evaluated weekly to ensure none fall behind. For daily orders such as Resident 3's blood pressure, resident will be put on alert to ensure it is taken before medication is admistered. -The corrections will be done and monitored by the Wellness director and followed up on by the Wellness coordinator.

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

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

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (# 3) who had documented treatment refusals. Findings include, but are not limited to: Resident 3 moved into the MCC2 in 06/2023 with diagnoses including dementia, adjustment disorder with anxiety, depression, and Alzheimer’s disease. The resident’s 11/01/25 through 12/08/25 MARs, physician orders, and 09/04/25 through 12/05/25 progress notes were reviewed. The resident refused having his/her blood pressure taken on 10 occasions between 11/01/25 and 12/08/25. There was documented evidence the resident had refused medications on multiple days, as well; however, on 12/09/25 at 1:17 pm, Staff 23 (MT) confirmed that she faxed Resident 3’s medication refusals to the physician each time the resident refused them. Staff 23 stated she gave the verification of the faxes to Staff 3 (Wellness Director /LPN) for review. Staff 23 stated she did not notify the physician when the resident refused treatments. The need to notify the physician of resident treatment refusals was discussed with Staff 1 (ED) and Staff 3 on 12/11/25 at 12:35 pm. They acknowledged the findings.

-Internal service plan will be put in place for all refusals of medications, treatments, or any physcians order not completed to notify physican day of refusal and Wellness Director. -Re-training and notices in Med Rooms will be put in place as well to ensure this is standard practice. -The Wellness Director and Wellness Coordinator will evaluate, and monitor daily.

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

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

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included resident-specific parameters and instructions for PRN medications, included reasons for use, and were initialed by the person administering the medication for 2 of 6 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1's MAR, dated 11/01/25 through 12/08/25, and physician orders were reviewed and revealed the following PRN medications lacked instructions for sequential order of use: * Acetaminophen 325mg (for pain); * Acetaminophen rectal suppository (for pain); * Morphine 20mg/5ml (for pain); * Bisacodyl rectal suppository (for constipation); * Senna 8.6mg (for constipation); * Ondansetron 4mg (for nausea); and * Scopolamine transdermal patch (for nausea). The need to ensure MARs were accurate and provided instructions for PRN medications was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings. 2. Resident 3 moved into the MCC2 in 06/2023 with diagnoses including dementia, adjustment disorder with anxiety, depression, and Alzheimer’s disease. The resident’s MARs, dated 11/01/25 through 12/08/25, and physician’s orders were reviewed. The following inaccuracies were noted: a. Scheduled quetiapine was missing a reason for use. b. Initials of the person administering the medication or treatment were missing for the following: * Donepezil (for dementia) - 11/21/25; * Multiple vitamins with minerals (for eye health) - 11/21/25; * Sodium fluoride (for oral care) - 11/21/25; and * Bowel tracking - 11/02/25 and 11/21/25. The need to ensure MARs included reasons for use and were initialed by the person who administered medications and treatments were accurate was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director /LPN) on 12/11/25 at 12:35 pm. They acknowledged the findings.

1. Immediate Corrections: o All resident MARs have been reviewed and updated to ensure: ? PRN medications include resident-specific parameters and sequential instructions ? All medications and treatments have documented reasons for use ? Staff initials are documented in the EMR immediately after each medication or treatment is administered o Charts were corrected as needed to reflect accurate and complete instructions and documentation. 2. System Changes / Responsible Party Updates: o Community LPN charts all PRN parameters for residents. o ANDS RN reviews PRN parameters after completion by the LPN on a consistent basis to ensure accuracy and resident-specific instructions. o Community ED will review PRN documentation and MARs for compliance with facility policies. o On-site LPN/Wellness Director oversees medication administration by med techs and ensures MARs are accurately documented with initials and reasons for use. o All UAPs attended a Safety Medication Class on 12/22 and 12/30 to reinforce proper medication administration and documentation practices. 3. Monitoring: o Ongoing review of PRN parameters, reasons for use, and staff documentation is conducted to ensure continued compliance. o Any missing documentation or errors are corrected immediately. o Findings and corrections are documented and available for review to demonstrate compliance. Responsible Parties: Community LPN, ANDS RN, Community ED, and on-site LPN/Wellness Director

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

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

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 3 sampled residents (#s 1 and 2) who were prescribed PRN psychotropic medications. Findings include, but are not limited to: 1. Resident 1 was admitted to the MCC1 in 09/2023 with diagnoses including Alzheimer’s disease and adjustment disorder with mixed anxiety and depressed mood. S/he was subsequently admitted to hospice in 06/2025 with admitting diagnosis of Alzheimer’s disease. Review of Resident 1's clinical record indicated the following: * Resident 1 was prescribed lorazepam 0.5 mg as needed for agitation, anxiety, or restlessness; and * The MAR from 11/01/25 through 12/08/25 indicated staff administered two doses of PRN lorazepam. There was no documented evidence the staff attempted and documented non-pharmacological interventions with ineffective results prior to administering the medication. During an interview on 12/09/25 at 3:07 pm, Staff 22 (MT) confirmed non-pharmacological interventions were not attempted, and on 12/11/25 at 10:13 am, Staff 21 (MT) stated non-pharmacological interventions had been given in the past but were not documented. The need to ensure non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings. 2. Resident 2 moved into the MCC1 in 10/2025 with diagnoses including dementia. A review of the resident’s clinical record indicated the following: * Resident 2 was prescribed risperidone, 0.5 mg, as needed for agitation; and * MARs, dated 11/01/25 through 12/08/25, indicated staff administered 22 doses of PRN risperidone. There was no documented evidence the staff attempted and documented non-pharmacological interventions with ineffective results prior to administering the medication. On 12/11/25 at 12:07 pm, Staff 21 (MT) confirmed no non-pharmacological interventions had been documented as tried with ineffective results prior to the administration of the PRN psychotropic. The need to ensure non-pharmacological interventions had been tried with ineffective results prior to the administration of a PRN psychotropic medication was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 12:35 pm. They acknowledged the findings.

-Internal Service Plans will be put in place to provide and document non-pharmacutical interventions for PRN psychotropic Medications. - Resident specifc interventions will be properly care planned as well to help staff have options to try before giving medication.Behvioral training will be given as well. -Staff are to notify Wellness Director, ED, or Wellness coordinator when interventions have failed and medication needs admistered to ensure all non-pharmacutical efforts have been made and properly documented first. -This will be monitored as needed per resident need, and during morning wellness meetings. The Wellness Director, and Wellness Coordinator will be responsible to monitor and ensure follow through.

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was assessed by an RN, PT, or OT prior to use, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident’s service plan for 2 of 2 sampled residents (#1 and 6) who had side rails on their bed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility residential care unit in 11/2023 with diagnoses including heart failure and macular degeneration. Observations of the resident and the resident's room on 12/08/25 at 1:36 pm identified Resident 6 had side rails in the up position on each side of the bed. A current assessment for the side rail was requested on 12/09/25 and a copy of the initial assessment, completed on 10/28/25, was provided. Review of the side rail assessment identified the following: * The assessment had been completed by Staff 3 (Wellness Director/LPN) and lacked documented evidence it had been completed by an RN, PT or OT for the use of side rails; and * There was no documented evidence caregivers were instructed on the correct use of and precautions for the device. Additionally, review of the resident’s most recent service plan and temporary service plans lacked documented evidence of side rail instructions. The need to ensure an assessment was completed by an RN, PT, or OT and documentation requirements for side rail use was discussed with Staff 1 (ED) and Staff 3 on 12/11/25 at 2:40 pm. They acknowledged the findings. No additional documentation was provided. 2. Resident 1 was admitted to the MCC1 in 09/2023 with diagnoses including Alzheimer’s disease and adjustment disorder with mixed anxiety and depressed mood. S/he was subsequently admitted to hospice in 06/2025 with admitting diagnosis of Alzheimer’s disease. During the acuity interview on 12/08/25, Resident 1 was identified as having a side rail on his/her bed. Upon observation on 12/08/25, Resident 1's hospital bed was noted to have two half-length side rails in the up position. There was no documented evidence the facility registered nurse, a physical therapist, or an occupational therapist conducted a thorough assessment or other less restrictive alternatives were evaluated prior to the use of the device. During a phone interview on 12/11/25, Witness 1 (Family Member) confirmed the family was aware of the side rail use and had agreed to it as a measure for assistance with bedside mobility. The need to ensure the facility registered nurse, a physical therapist, or an occupational therapist had conducted a thorough assessment, and other less restrictive alternatives were evaluated, prior to the use of a supportive device with restraining qualities was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings.

plan is in place for RN delgation company ANDS to preform assesment of any supportive devices with restraining qualites, and to give clear instructions for staff. - Wellness Coordinator and/or Wellness Director will update care plan to reflect chagnes. Internal service plan will be intiated to give staff clear instructions on correct use and precautions. -This area will be evaluated as changes occur, during weekly RN consulting meeting, and morning clinical meeting. -This will be monitored by Wellness Corrdinator, Wellness Director, ED, and RN Consulting company ANDS.

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

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

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated and reviewed for each resident before they moved into the facility, whenever there was a significant change of condition, and updated no less than quarterly at the same time the resident’s service plan was updated for 3 of 6 sampled residents (#s 2, 4 and 6). Findings include, but are not limited to: During the acuity interview, at 9:43 am on 12/08/25, Staff 3 (Wellness Director/LPN), Staff 21 (MT), and Staff 11 (CG) confirmed the facility census was at 66 residents. The facility’s ABST data was reviewed on 12/08/25 and revealed the following: * There was no documented evidence Resident 2’s ABST data had been updated before the resident moved in; * There was no documented evidence Resident 4’s ABST data had been updated following a significant change of condition; and * There was no documented evidence Resident 6’s ABST data had been updated quarterly. The need to ensure residents’ ABST data was updated following a significant change of condition, no less than quarterly, and prior to move-in was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director/LPN) on 12/11/25 at 2:07 pm. They acknowledged the findings.

ABST will be updated berfore move in, any time signifgant changes occur, and quarterly. New residents will be added as soon as care plan is created, berfore move in. -Resident chages and quartley evaultions will be discussed in daily clinical meetings and will be updated as they occur. -This will be evaluated daily as need arrises. -The ED will be responsible for updates with assistance from Wellness Coordinator.

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.

The ABST will be reviewed weekly and as new move ins, care plan updates, and changes of conditon occur. This will be corrected by training the Wellness Coordinator and Wellness Director as well on updating. And weekly reviews to ensure all updates have been made. This will be evaluated weekly or as new move ins, care plans update, and changes in condition occur. The ED will be responsible for the contiued monitoring

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

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

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month and recorded according to Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: On 12/09/25 at 3:10 pm, six months of facility fire drill and fire and life safety records, from 06/2025 through 11/2025, were requested and reviewed with Staff 4 (Maintenance Director). The following was determined: 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 following required elements: * Location of the simulated fire origin; * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Staff members on duty and participating; and * Number of occupants evacuated. c. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills. The need to ensure fire drills were conducted per the OFC and staff were provided fire and life safety instruction on alternate months was discussed with Staff 1 (ED) on 12/11/25 at 4:05 pm. She acknowledged the findings.

Maintance Director has scheduled fire drills for the year. They will be documented for the required elements; Location, escape route, promlems that occurred, evacuation time/ reponse time, staff who participated, and residents. -The schedule will be set in the ED and Maintance directors calendars.This will be evaluated every other month. -The ED and Maintance director will be responsible to ensure these are completed.

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.

Fire Drills will be scheduled in advance by Maintance Director. Residents will be included by evacuating and re-located. Escape routes will be documented and problems that occurred, and number of residents/staff who participated will be documented as well. Drills will be scheduled and put on all management calanders. Documentation will be created to have a format that has all areas of concern to be filled out. This will need to be evaluated after each drill. The Maintance Director will be responsible for corrections and monitoring with ED to confirm completion each time.

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

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

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Facility fire and life safety records were provided by the facility and reviewed with Staff 4 (Maintenance Director) on 12/09/25 at 3:15 pm. There was no documented evidence residents were instructed in fire and life safety procedures within 24 hours of admission and re-instructed at least annually. The need to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission and to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the OFC, was discussed with Staff 1 (ED) on 12/11/25 at 4:15 pm. She acknowledged the findings.

-The fire life and safety overview will be completed on day of move in for all residents and annually with whole building. -To correct this the instruction will be part of the move in process so that is done on move in day. Annually it will be scheduled for all residents with a month time period and repeatded anuually going forward. -The will be evaulated weekly during Maintennace and ED meeting. -The Maintenance director is responsible to complete and monitor.

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.

All residents will be instructed on Fire life and safety procedures at move in. This will become part of the move in process. And then annually. The Fire life and safety procedures will be done as part of the move in process, and then scheduled in the maintance directors calandar to be done annually. This will be evaluated monthly to ensure everyone is up to date. The Marketing director will follow up with the Maintance Director on day of move in for initial instruction. The new move in and annual intstruction will be the Maintance Directors responsibility and monitored by the ED to ensure completion.

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

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

Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year in accordance with the Oregon Fire Code (OFC) and other applicable state and local codes as required. Findings include, but are not limited to: The facility was a two- story licensed residential care facility that included two memory care units. During an acuity interview on 12/08/25 and other staff interviews throughout the survey, the resident census was identified at 67, with 16 residents who required the assistance of two staff for transfers (eight on the second floor, including four residents who required a mechanical lift for transfers, and eight on the first floor, including five residents who required a mechanical lift for transfers). During an interview at 3:10 pm on 12/09/25, Staff 4 (Maintenance Director) stated the facility had not practiced a full evacuation that included the residents who required two-person transfer assistance. 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 12/11/25 at 2:14 pm. Staff 1 (ED) confirmed at the same time that the facility had not conducted 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 12/11/25. She acknowledged the findings, and no further information was provided.

Scheduled simulated drills will take place in June and Nov of each year to ensure it becomes a standard exercise. -This will be a scheduled drill in all manager calandars for participation. -This will be evaluated twice a year for completion and admendments on the procudure to update for even more sucessful drills in the future. -This will be the maintenance directors responsibility to complete and will be monitored by the Maintence director and ED.

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.

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

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: On 12/08/25, the interior of the facility was toured, and the following observations were made: * Walls, doors, windowsills, and handrails throughout the building on the first and second floors had scrapes, gouges, and chips in the paint, exposing drywall and wood, which created non-cleanable surfaces; * Multiple chairs and a sofa in the MMC1, common area, had excessive wear, including large tears and rips in the material coverings creating non-cleanable surfaces; and * Coffee and water tables in MMC1, MMC2, and the RCF were observed to have water damage, with rust. The environment was toured and the need to ensure all interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 12/11/25 at 10:02 am. They acknowledged the findings.

-Touch up to interior walls, doors, windowsills, hand rails, and walls will be patched repaired. -Plan is in place to replace furniture in MMC1 and MMC2. -Damaged or rusted drinking stations will be replaced. - updates are already in process of replacement. -This will be evaluated on daily walk throughs with Maintenance and Marketing departments. -Maintenance director will be responsible for completion and continued monitoring.

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.

The maintance director will paint areas with missing paint, front doors have already scheduled with vendor to repair- maintance will paint, courtyard doors will be painted, kitchen hallway will be patched and repainted,chair rails, hand rails will be patched and painted. Recliners are all being replaced- plan in place for all. Chairs that were seriously ripped were taken out. Bathroom walls will be cleaned and scuffs repaired. Resident doors and bathrooms needed painted will also be done. the system will be corrected by doing daily walk throughs and touching up areas as needed. The correction will be evaulated weekly to look for areas that are needing attention. The maintenance director will be responsible for corrections and monitoring.

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

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

Based on observation and record review, it was determined the facility failed to create an environment in which residents were treated with dignity and respect, were free from neglect, and received services in a manner that protected privacy for 3 of 6 sampled residents (#s 1, 2, 3, 5, and 6) and multiple unsampled residents. Findings include, but are not limited to: Refer to C200.

Please refer to C200 for plan of correction.

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

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

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C200, C231, C295, C363, C420, C422, C435, and C513.

Please refer to C200, C231, C295,C363, C420, C422, C435, and C513 for plan of correction.

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

Please refer to C231,C363,C420, C422, and C513 for plan of correction.

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

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

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff 18, 19 and 20 completed pre-service dementia training requirements prior to providing services to residents and demonstrated satisfactory performance in any duty they were assigned within 30-days of hire. Findings include but are not limited to: On 12/09/25, staff training records were reviewed and revealed the following: a. There was no documented evidence Staff 18 (MT), hired on 09/25/25, Staff 19 (CG), hired on 10/23/25, and Staff 20 (CG), hired on 10/23/25 had completed the following required dementia care trainings prior to providing care and working with residents independently: * Family support and the role the family may have in the care of the resident; * Behaviors that indicate change of condition; * Providing personal care to residents with dementia; * Orientation to service plans; and * Use of supportive devices with restraining qualities. b. There was no documented evidence Staff 19 and Staff 20 demonstrated satisfactory performance within 30-days of hire in the following areas: * Role of service plans; * Changes with normal aging; * Identification, documentation and reporting of change of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. c. Staff 18, had not successfully demonstrated satisfactory performance in the following areas: * Role of service plans; * Changes with normal aging; * Identification, documentation and reporting of change of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Medication administration. The need to ensure direct care staff completed pre-service dementia training requirements prior to providing services to residents independently and demonstrated satisfactory performance in any duty they were assigned within 30-days of hire was discussed with Staff 1 (ED) at 1:45 pm on 12/11/25. She acknowledged the findings.

-Staff in Memory Care will be assigned correct dementia specific trainings with a required completion date. -Staff who are missing the initial training classes will be assgined specific training with required completion date. -Caregiver and medication tech new hire checklists will be re-done to ensure satisfactory perfomance of required duties with a requried completion date. -This will be corrected and evaluation monthly. -The Business Office Manager and Wellness Coordinator will be responsible for completion and contiued montioring.

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

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

Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C303, C305, C310, C330, and C340.

Please refer to C252,C260, C303, C305,C310, C330, and C340 for plan of correction.

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

Please refer to tag C270 for plan of correction.

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations and individualized activity plans were completed for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 and 3’s service plans offered some information about residents' interests, but the facility had not fully evaluated the residents' activity needs in one or more of the following areas: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities which could be used as behavioral interventions, if necessary. There were no resident-specific activity plans developed from activity evaluations which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities. Observations made in MCC2 between 12/08/25 and 12/11/25 showed one group activity being led by facility staff on 12/09/25. The television was on in the unit, which played music or movies, and there were coloring pages, crayons, and colored pencils on a table. On 12/11/25 at 9:43 am, Staff 1 (ED) told a CG in the community about a painting activity starting at 10:00 am. She encouraged the CG to invite residents who were interested. No observations were made of the CG asking any residents if they wanted to join the activity, and no residents were taken to the activity at 10:00 am. The need to ensure activity evaluations were completed for all residents and individualized activity plans were developed and implemented was discussed with Staff 1 and Staff 3 (Wellness Director /LPN) on 12/11/25 at 12:35 pm. They acknowledged the findings.

-Activity profiles will be updated for current residents and done at move in for new residents. -Activity profiles will be givento wellness for appropriete updates to care plans, and a binder created for activites to keep and update as changes occur. -Activiy profiles will be addressed as changes in condition occur and at quartly evaluatons this will be initated by wellness management team to the activites department to assist in up to date accuracy. -This will be the responsibility of the activites department, Wellness Coordinator, and Wellness director to monitor and complete as changes or move ins occur.

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

Please refer to tag C270 for plan of correction.

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts for short-term changes of condition, for 1 of 1 sampled resident (# 11) who experienced a change of condition. Findings include, but are not limited to: Resident 11 was admitted to the Memory Care Community Two (MCC2) unit in 12/2025 with Alzheimer’s dementia. Resident 11’s progress notes indicated the following: * On 02/21/26 Resident 11 was placed on alert and staff noted, “During this shift [Resident 11] expressed suicidal comments to the care staff and was observed cleaning the butterknives while making comments about ending [his/her] life … went thru [sic] residents [sic] room to look for any sharp objects and took them out. Nurse was notified on this.” * Staff documented in progress notes from 02/22/26 through 02/24/26 that the resident was at baseline with his/her behaviors and no statements of suicidal ideations had been voiced. Observations were made on the MCC2 unit on 02/25/26. At 4:31 pm Resident 11 entered the dining room, approached an unsampled resident who was seated at the table, and asked if the resident had a knife so s/he could cut “right here in my throat” and motioned with his/her finger across his/her neck. Resident 11 leaned down again, muttered something unintelligible to the resident, stood up and made the same motion to his/her neck and stated, “I’d just like to go to heaven.” Resident 11 then pointed at the surveyor’s pen and sat down next to the surveyor. Resident 11’s hands were shaky, s/he displayed a worried look on his/her face, and s/he asked the surveyor if s/he had a knife “or the pen will do.” S/he repeated in that conversation, “I just want to go to heaven.” On 02/25/26 at 4:36 pm, the surveyor alerted Staff 5 (MT/CG) of the observation and interview with Resident 11. Staff 5 stated the facility was aware of his/her suicidal ideations from 02/21/26, a temporary service plan (TSP) was in place, and staff were monitoring the resident. On 02/25/26 at 5:03 pm, the surveyor shared the observations and interviews with Staff 3 (Director of Wellness/LPN) and he indicated he had not been aware of Resident 11’s suicidal ideation statements made on 02/21/26. A copy of the TSP related to suicidal ideations was requested. On 02/25/26 at 5:11 pm. Staff 3 and Staff 5 could not provide a TSP and acknowledged there was no documented evidence the facility had determined actions or interventions and communicated to staff to address Resident 11’s suicidal ideation on 02/21/26. Staff 3 immediately created a TSP that instructed staff to provide “frequent safety checks … avoid sharp objects like knife, pen, pencils.” Staff were also instructed to contact the physician or call 911 if s/he demonstrated any suicidal behavior. On 02/25/26 at 5:22 pm, the new TSP was provided. The surveyor then observed staff place a fork, spoon, and butterknife next to Resident 11 with dinner. The surveyor alerted Staff 3 and Staff 5 of this observation, and the fork and butterknife were immediately removed. Staff 3 stated he would ensure all staff on all shifts were made aware of the interventions identified in the TSP. An additional TSP was provided on 02/26/26, at 1:15 pm, that included how staff should respond to verbal comments of suicidal ideation, that they should check on the resident every hour, and what behaviors would warrant a call to 911. Staff working on the MCC2 unit were also trained in suicidal behaviors, and staff removed from the environment any devices that could possibly aid in a suicide attempt. The need to ensure the facility determined and documented resident-specific actions or interventions needed to address a resident’s condition and communicated the determined actions and interventions to staff was discussed with Staff 3 (Director of Wellness/LPN) on 02/25/26 at 5:03 pm and on 02/27/26 at 11:50 pm. He acknowledged the findings.

Short term change in conditions or residents put on alert for any reasons will have an immiediate tempary service plan put in place. This will be corrected by initiating the tempary service plan for all short term changes and residents on alert to include relevant information for each situation such as interventions, symptoms to look out for, instructions for new/changed care. This will be evaluated each day in wellness clinical meeting and each day as new changes of conditions and alerts happen. Temporay service plans will be initiated by Medication techs, Wellness Coordinator, Wellness Director, and ED. This will be monitored by the ED, Wellness Director, and Wellness Coordinator.

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

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

The

Copies of Plan of correction will be provided to all management members and each will be required to correct per plan by complaince date. Daily follow up to ensure corrections have been made, and manager discussion each morning on progress and completion in morning meeting. This will be evaluated each day till completed, and then on going evaluation it stays in compliance. Each department head and the ED will be responsible for conitued monitoring and compliance.

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

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

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 03/12/25 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas: * Wall behind spray hose in dishwashing area – build up of black matter; * Exterior doors on two and three door freezers – smears/spills/drips; * Interior of two and three door freezers – food debris on bottom shelves; * Hood vents above cooking equipment – dusty/greasy; and * Flooring under prep counters and ice maker – build up of black matter. Other areas of concern included: * Individual portioned food containers in refrigerator were not labeled or dated; * Garbage can next to handwashing sink full and not covered when not in use; * Colored cutting boards – worn finish, potentially uncleanable; and * Two kitchen staff not wearing hair restraints. The areas of concern were observed and discussed with Staff 1 (Dining Services Director) on 03/12/25. The findings were acknowledged.

Deep cleaning of full kitchen will be done to address cleaning violations.The kitchen cleaning system will be corrected by updated cleaning plans for daily, weekly, and monthly on schedule. Each area of concern will be addressed according to its scheduled cleaning and Dining Services Director and Executive Director will do walk throughs daily, weekly and monthly to ensure the complaince of new cleaning schedules. The following findings will be addressed as follows: *Wall behind dishpit and spray hose will be wiped daily and deep cleaned monthly *Exterior doors on freezers will be cleaned daily and deep cleaned monthly. *Interior freezer doors will be wiped daily, and food debris will be cleaned out daily. *Hood vents will be wiped down weekly and monthly deep cleaned by staff monthly. Quartley proffestional cleaning will contiue to be done as well. *individula portioned food contiaiers will be labeled a and dated as received. Any containers without labels will be desposed of. *Colored cutting boards will be replaced. *Hair restraints will be provided to all kitchen staff and put into use immiedietly.

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

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

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Refer to C240

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

Based on interview and record review, conducted during a site visit on 01/24/24 and 01/25/24, it was confirmed the facility failed to investigate and report an injury of unknown cause for 1 of 1 sampled resident (# 6). Findings include, but are not limited to: An incident report, dated 12/14/23, indicated Resident 6 had an unwitnessed fall with injury and was unable to tell staff what had happened. During an interview on 01/25/24, Staff 1 (Executive Director) stated the incident report "was recently found in the RN's desk" and the incident should have been reported to APS. The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (RN), Staff 3 (Wellness Coordinator), Staff 4 (Marketing and Sales Director), and Staff 5 (Regional Director of Operations) on 01/25/24. It was determined the facility failed to investigate and report an injury of unknown cause. Verbal plan of correction: All incidents will be reviewed by RN and ED at daily clinical meetings. Staff will be trained on 1/31/24 to complete incident reports timely. Facility was in the process of reporting the incident to APS on 01/25/23.

Based on interview and record review, conducted during a site visit on 01/24/24 and 01/25/24, it was confirmed the facility failed to ensure a resident receives regular bathing assistance for 1 of 1 sampled resident (# 4). Findings include, but are not limited to: During an interview on 01/24/24, Resident 4 s/he had to "beg for showers on scheduled shower days." Resident 4's service plan, dated 01/25/24, indicated "Staff will provide standby assist for showers twice a week." A review of the facility's "Caregiver Daily Assignment Sheet" and "Shower Review" sheets, dated 01/09/24 through 01/24/24, indicated Resident 4 had not received a shower from 01/14/24 through 01/23/24. The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (RN), Staff 3 (Wellness Coordinator), Staff 4 (Marketing and Sales Director), and Staff 5 (Regional Director of Operations) on 01/25/24. It was determined the facility failed to ensure a resident receives regular bathing assistance. Verbal plan of correction: Beginning 01/31/23, facility will be including shower sheets to clinical meeting.

Based on observation, interview, and record review, conducted during a site visit on 01/24/24 and 01/25/24, it was confirmed the facility failed to follow physician orders as prescribed for 2 of 2 sampled residents (#s 3 and 5). Findings include, but are not limited to: Resident 3's MAR, dated 10/01/23 through 10/31/23, indicated the following: *Atorvastatin 40mg (heart medication) and Losartan 100mg (hypertensive) were not administered 10/01/23 through 10/04/23. Notes indicated the facility was "waiting for medication from the pharmacy;" *Amlodipine 5mg (blood pressure) was not administered 10/14/23 through 10/17/23. Notes indicated the facility was "waiting for medication from the pharmacy;" and *Donepezil 5mg (dementia) was not administered 10/27/23 through 10/30/23. Notes indicated "meds unavailable." There was no documented evidence Resident 3's Atorvastatin, Losartan, Amlodipine, or Donepezil had been discontinued by a physician for any length of time in 10/2023. During an interview on 01/25/24, Resident 5 stated s/he was supposed to receive his/her Carbidopa/Levo 25-100mg (Parkinsons medication) late, and that if s/he did not receive it on time his/her body would begin to "lock up". Physicians order for Resident 5, dated 08/16/23, indicated s/he was to receive Carbidopa/Levo 25-100mg every two hours beginning at 8:00 am. On 01/25/24, Resident 5 was observed to have his/her 10:00 am dose of Carbidopa/Levo 25-100mg administered at approximately 10:37 am. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Wellness Coordinator), Staff 4 (Marketing and Sales Director), and Staff 5 (Regional Director of Operations) on 01/25/24. It was determined the facility failed to follow physician orders as prescribed.

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 02/01/22.  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 and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen, food storage areas, food preparation and food service on 11/14/23 revealed the following: * The outside of the juice machine had splatters present and was sticky to the touch; * The stand up fan was dusty; * The outside of the reach in freezer had drips visible, the handles were sticky to the touch, and the inside of the far right unit had food debris present; * A large canned food holder to the left of the stove had built up food debris on the racks; * The wall behind the large canned food holder had gouges and chipped paint present; * The industrial can opener had black matter present; * The double doors to the left of the dry storage had drips, scuffs, and brown matter present; * There were two 6.56 pound cans of pears that were very dented; * The area surrounding the dry food storage and walk in cooler had paint chipping present; * The flooring underneath the kitchen equipment had built-up black matter present; * The stand up mixer behind the kitchen door had dried, built up food matter throughout the machine; * The bread rack had food debris present; * Caulking around the hand washing sink was cracked and pulling away from the wall; * There was brown matter and drips observed on the wall where the hand washing sink was located from the automatic towel dispenser down to the floor; * The pipes under the hand washing sink had a layer of dust present; * There were two white unconnected pipes on the floor located to the left of the hand washing sink; * The lower section of the convection oven had built-up brown matter inside the lower portion of the equipment; * Inside of the right oven was in need of cleaning; * The back area of the stove, above the grill, had built up food debris present; * The fire safety inserts located in the hood above the stove had built up debris observed; * The lower shelving under the two compartment sink across from the stove had food debris present; * Cutting boards located in the kitchen and in the upstairs kitchenette had deep score marks observed; * The microwaves located in the kitchen and upstairs kitchenette had food build-up present on the inside and outside; * The upstairs kitchenette cupboards under the cereal buffet had food debris and splatters inside of them; * The food warmers located in the kitchenette had brown, built-up debris present; and * The drawers located in the upstairs kitchenette had food debris inside of them. The areas in need of cleaning and repair were reviewed with Staff 2 (Dining Services Manager) on 11/14/23. He acknowledged the findings.

1. The following actions will be taken to correct the rule violation for each example given: *The outside of the juice machine had splatters present and was sticky to the touch. - This has been cleaned and will be added to a daily cleaning list for future prevention. *The stand up fan was dusty.- Fan to be dusted and placed on to a weekly cleaning list. *The outside of the reach in freezer had drips visible, the handles were sticky to the touch, and the inside of the far right unit had food debris present- Freezer to be cleaned on the inside and outside and placed on to a daily and weekly cleaning list. Daily for outside of freezer and weekly for the inside. *A large canned food holder to the left of the stove had built up food debris on the racks- Food holder to be cleaned and placed on to a weekly cleaning list. *The wall behind the large canned food holder had gouges and chipped paint present- Wall to be repaired and painted. Wall to be placed on to a monthly inspection list. *The industrial can opener had black matter present- Black matter to be cleaned and can opener to be on a daily cleaning list. *The double doors to the left of the dry storage had drips, scuffs, and brown matter present.- Double doors to the left of the dry storage to be cleaned and placed on to a weekly cleaning list. *There were two 6.56 pound cans of pears that were very dented- These cans of pears were replaced and training to be provided to all cook staff not to accept dented cans from Sysco. *The area surrounding the dry food storage and walk in cooler had paint chipping present- Surrounding area to be repainted and placed on to a monthly inspection list. *The flooring underneath the kitchen equipment had built-up black matter present- Flooring underneath kitchen equipment to be pressure washed and placed on to a quarterly cleaning list.   *The stand up mixer behind the kitchen door had dried, built up food matter throughout the machine- Stand up mixer to be cleaned of any dried, built up food matter, education provided on cleaning equipment after each use to be provided, and mixer to be on a weekly list to ensure no dried up food matter. *The bread rack had food debris present- Bread rack to be cleaned of any food debris and bread rack to be placed on to a weekly cleaning list. *Caulking around the hand washing sink was cracked and pulling away from the wall- Caulking to be redone around the handwashing sink, sink caulking to be placed on to a monthly inspection list. *There was brown matter and drips observed on the wall where the hand washing sink was located from the automatic towel dispenser down to the floor- The brown matter and drips on the wall where the hand washing sink was located to be cleaned and placed on to a weekly cleaning list. *The pipes under the hand washing sink had a layer of dust present- The pipes under the hand washing sink to be dusted and placed on to a weekly cleaning list. *There were two white unconnected pipes on the floor located to the left of the hand washing sink- The two unconnected pipes on the floor were removed and education to be provided for no unknown items to be left laying around. *The lower section of the convection oven had built-up brown matter inside the lower portion of the equipment- The lower section of the convection oven to be cleaned up of any brown matter and/or food particles. The lower section of the convection oven to be placed on to a monthly cleaning list. *Inside of the right oven was in need of cleaning- Inside of the right oven to be cleaned and placed on to a weekly cleaning list. *The back area of the stove, above the grill, had built up food debris present- Back area of the stove, above the grill to be cleansed of any food debris, this area to be added to a daily cleaning list. * The firse safety inserts located in the hood above the stove had built up debris observed- The fire safety inserts to be cleansed of any debris, and these inserts to be placed on to a monthly cleaning list. *The lower shelving under the two compartment sink across from the stove had food debris present- The lower shelving has been cleansed of any food debris and this area has been placed on to a weekly cleaning list. *Cutting boards located in the kitchen and in the upstairs kitchenette had deep score marks observed- Cutting boards will be replaced and the cutting boards to be placed on a quarterly inspection list to ensure that they are replaced if too deep of scores. * The microwaves located in the kitchen and upstairs kitchenette had food build-up present on the inside and outside.- Microwaves to be cleansed of any food build-up and placed on to a weekly cleaning list. *The food warmers located in the kitchenette had brown, built-up debris present- The food warmers are to be cleansed of any brown built-up debris and placed on to a weekly cleaning list. * The drawers located in the upstairs kitchenette had food debris inside of them- The drawers to have any debris taken out and cleaned. The drawers to be placed on to a weekly cleaning list. 2. The system will be corrected so that this violation does not happen again by implementing a daily/weekly/monthly/quarterly inspection and cleaning list for kitchen staff to sign off on and turn in to the Dining Services Director. The Executive Director and Dining Services Director to conduct weekly walk throughs of all kitchen areas for cleanliness and upholding sanitation standards. Executive Director and/or designee to conduct a monthly kitchen audit to ensure compliance for the first 4 months and then quarterly thereafter if good compliance with expectations. 3. The Executive Director and Dining Services Director will conduct weekly walk throughs of all kitchen areas for cleanliness and upholding sanitation standards. Executive Director and Dining Services Director to also review all daily/weekly/monthly/quartely checklists for completion and thoroughness on a weekly basis. Executive Director and/or designee to conduct a monthly kitchen audit to ensure compliance for the first 4 months and then quarterly thereafter if good compliance with expectations. 4. The Executive Director and Dining Services Director to work cohesively to ensure that all corrections are completed and monitored as previously outlined.

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

See c 240

The findings of the kitchen inspection, conducted on 11/14/23, 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 revisit to the kitchen inspection of 11/14/23, conducted on 01/26/24, are documented in this report. The facility was found 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 licensee failed to ensure adequate administrative oversight of facility operations and supervision and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to: During the Change of Ownership survey, conducted 08/08/22 through 08/11/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations. 1. Situations were identified which constituted an immediate plan of correction to residents' health and safety in the following areas: Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area: OAR 411-054-0025 (1): Facility Administration: Operation; and OAR 411-054-0045 (1)(f)(B): RN Delegation and Teaching. The facility put immediate plans of correction in place during the survey and the situations were abated. 2. Refer to deficiencies in the report.

OAR 411-054-0025 - Facility Administration: Operation Please refer to all citations in this report

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving complaints. Findings include, but are not limited to: During the survey, multiple non-sampled residents expressed their concerns with the following: * Lack of structured activity program; * Call light times were long; * Food was served cold; * There was no resident forum (resident council/suggestion box); * Residents were not involved in care planning; and * There was a lack of staff on night shift. On 08/11/22, Staff 1 (ED) was interviewed about the facility's grievance resolution policy. She stated the facility had a grievance resolution policy, however, she had not yet implemented the system. She acknowledged the facility did not have a system of responding to and resolving resident complaints.

OAR 411-054-0025 (7) - Facility Administration: Policy & Procedure: The following resident concerns were noted in recent survey: 1.) Lack of structured activity program, 2.) Call-light times were long, 3.) Food was served cold, 4.) There was no resident forum (resident council/suggestion box),  5.) Residents were not involved in care planning, & 6.) There was a lack of staff on night shift. 1.) Facility has re-structured the resident grievance process, ensuring that grievance forms are available in conspicuous areas, easily accessible to residents and family members. Facility will take items 1-5 above and create grievance forms for each area of concern. Facility will follow the grievance process policy for all items listed above, until each area is resolved. 2.) a. Facility has provided training to all staff on the grievance process, b. Facility has moved grievance forms in common areas that are easily accessible,   c. Facility is sending out a memo via email to all residents' family members explaining how the grievance process works, & where to find grievance forms, d. Facility is putting the grievance process instructions on each resident's door to ensure they are aware of this process, & e. Facility has moved the barrier of having to get a grievance form from a staff member, and instead leaving them out in the common area, to ensure that each resident feels comfortable expressing concerns. 3.) a. Facility Administrator will review grievance binder daily during morning stand-up and ensure follow-up action happens timely. b. Facility administrator will bring grievance forms to monthly Quality Improvement meetings to discuss with the IDT and identify trending concerns. 4.) Facility Administrator will be responsible for reviewing grievances daily, and monitoring this system monthly during QI meetings.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to: During the survey, conducted 08/08/22 through 08/11/22, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective. On 08/10/22, Staff 1 (ED) was interviewed about the facility's quality improvement program. She stated the facility had a "Quality Improvement (QI) Program" policy, however, she had not yet implemented the QI program. She acknowledged the facility did not have a quality improvement plan in place. Refer to the deficiencies in the report.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement: 1.) Facility is actively working with the Vanda Consulting team to create the following: a. Daily/Weekly/Monthly audit(s)/form(s) for each         dept to utilize and collect applicable data &         to analyze any trends,     b. Clear written processes and expectations for the         Quality Improvement Program,     c. A Quality Improvement Binder with tabs for each         month of the year to store all data/trends         collected &,     d. Quality Improvement minutes/form for IDT to         document findings, staff members present, &         action plans created during each monthly         meeting. 2.)      a. Holi RDO & Vanda Consultant will provide          mandatory training with IDT to teach/train what a          Quality Improvement Program is, what each          dept. will be responsible for auditing, how to          create an action plan for negative          trends/outcomes, & why this          program is crucial to ensuring resident          satisfaction, safety, and positive outcomes.        b. Facility Administrator will be responsible for          ensuring that audits are completed timely &          submitted to her, once weekly. Facility          administrator will also ensure that monthly QI          meetings are scheduled & the IDT is present.      c. Facility administrator will send all Quality          Improvement meeting minutes to Holi RDO, &          will include any action plans created. 3.) The Quality Improvement Program will be evaluated weekly (ensuring audits are completed & turned in) and monthly, during QI meetings. 4.) Facility Administrator will be responsible for overseeing the Quality Improvement Program, with the help of the facility Director of Wellness who will assist in overseeing clinical audits, trends, and negative outcomes.

Based on observation, interview and record review, it was determined the facility failed to implement effective methods of infection control and to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to: 1. Observations and interviews with staff were conducted to determine adherence to universal precautions for infection control. On 08/08/22 at 11:15 am, the surveyor obtained permission and observed Staff 5 (CG) and Staff 12 (CG) provide incontinent care for Resident 3. During the observation, Staff 5 failed to change gloves after removing a soiled incontinent product and wiping feces and urine from Resident 3's perineum. Staff 5 applied barrier cream to the resident's bottom and touched the resident's clean blanket and clean incontinent brief while wearing the same soiled gloves. 2. On 08/09/22 at 12:20 pm, observations of the lunch meal being served in the memory care unit revealed direct care staff serving food to residents without the use of an apron or other material to act as a barrier between potentially soiled clothing and resident food. Care staff were observed holding trays of food against their clothing while distributing the meals. The need to ensure direct care staff consistently used universal precautions and used an apron while serving food was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22 and 08/11/22. They acknowledged the findings. 3. During an environmental tour of the facility on 08/08/22 through 08/11/22 multiple observations were made of residents and family members who brought dining room chairs outside to the interior secured courtyard. The dining room chairs were not of sufficient weight. When the chairs were no longer in use they were not brought back into the facility. Multiple residents were observed being able to lift or pull the chairs to different locations around the courtyard. The interior courtyard had a black metal gate with openings wide enough to secure a foothold, and with the use of the dining room chairs, had the potential to aid in elopement from the secured area. During the survey, multiple residents who resided in the MCC verbalized a desire to "get out of here". Due to the design of the gate and the lack of sufficiently weighted or secured seating in the courtyard, this posed a potential risk to the health and safety of residents. The above findings were discussed with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22 at 11:30 am and with Staff 15 (Director of Operations), and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0025 (4) Reasonable Precautions: 1.) The following actions have been taken to correct each violation, by example/resident: a. Universal Precautions secondary to           incontinence care - Facility leadership team           provided in-person hand-hygiene, & proper peri-           care infection precautions training to direct care           staff on 8/18/22.       b. Universal Precautions secondary to serving           food - Facility has ordered enough aprons for           each universal worker, as well as, provided           training related to dining service universal           precautions.       c. Universal Precautions secondary to a potential           risk to the health & safety of the residents due           to courtyard furniture not being weighted or           secured, creating a possible risk of elopement -           Facility has removed all furniture in the           courtyard that is not weighted or secured. 2.)    a. Universal Precautions secondary to            Incontinence care: Facility is enrolling each            direct care staff member in the following            trainings: Peri-Care Training through Relias,            Proper Hand-Hygiene Training through Relias            with a return demonstration training with facility            nurse, and 2hr Infection Control through            Oregon Care Partners. Facility admin will              ensure all new-hires are scheduled for new-              hire orientation, at which time each direct                care staff will be given a competency checklist              to bring with them during on-the-floor training.              This will ensure all new-hires complete return              demonstration of resident care tasks.          b. Universal Precautions secondary to universal              workers serving food: Facility is providing in-              person training to all universal workers on              the importance of infection/universal              precautions when working as a universal              worker. Facility will create policies &              procedures specific to universal workers,              to include appropriate uniform attire, hand-              hygiene, and on-going training. This policy will              be reviewed with current staff at mandatory              staff meeting, & will be given to all new-hires              during new-hire orientation. Facility will              ensure that all care staffs' food handlers cards              are current.          c. Universal Precautions secondary to the              potential risk of the health & safety of              residents - elopement risk: Facility will include              weighted &/or secured furniture in the              courtyard, away from gate exits, to ensure              appropriate seating for families, and in an              attempt to prevent further instances of family              or residents bringing inappropriate furniture              outside for visits. Facility admin will monitor              courtyard for unsafe furniture, during              environmental walk-throughs with              maintenance director. 3.) The above systems will be evaluated as follows:           a. Facility will maintain a training grid that is               reviewed at least once monthly during QI               meetings, to ensure all care staff are up to               date on annual infection control,               provisions of care topics, & hand hygiene               training. Facility Administrator will coordinate               with facility B.O.M at least once monthly to               ensure all new-hires are scheduled for new-               hire orientation. Facility admin will coordinate               with B.O.M at least once monthly to audit all               new direct care staff have completed               a competency checklist and return               demonstration of resident care.           b. Facility will monitor direct care staff food               handlers expiration dates, & annual trainings               via the training grid, at least once monthly.               Facility will ensure that all new direct-care               staff are given a copy of the 'Universal               Workers' policies & procedures, once monthly               during new-hire orientation.             c. Facility Administrator & Maintenance Director               will conduct once weekly environmental walk-               throughs. 4.) The facility Administrator, B.O.M, & Maintenance Director will be responsible for overseeing all areas related to reasonable precautions.

Based on observation, interview and record review, it was determined the facility failed to ensure investigations of incidents were thorough and complete in order to rule out neglect for 2 of 3 sampled residents (#s 1 and 3) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2014 with diagnoses including dementia. a. The resident experienced nine incidents between 05/12/22 and 08/05/22, including falls and sustaining skin injuries. While the documentation of the investigations did include sufficient evidence to rule out abuse, the investigations did not include documentation of whether current interventions were in place or other service planned directions were followed at the time of the incident in order to properly rule out neglect. b. Incident investigations did not include documentation of the Administrator review and signature. The need to ensure incident investigations included and documented a review of whether staff were following the provisions of the service plan in order to rule out neglect and include documentation of the Administrator's review was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings. Surveyor: An, Eun-Suk 2. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia and wrist and rib fractures. Resident 3 required a wheelchair for mobility. Observations of the resident from 08/08/22 to 08/11/22 revealed the resident required staff assistance with transfers and incontinent care. a. Clinical records reviewed from 05/08/22 to 08/08/22 noted the following: * The resident's 05/11/22 service plan indicated the resident required staff assistance with bladder and bowel management four times per shift as feasible; * On 05/25/22 staff documented the resident had a fall on 05/24/22. S/he was incontinent of bowel and was wearing only socks; and * On 06/20/22 staff documented the resident had a fall. The resident reported s/he wanted to use the bathroom. There was no documented evidence the facility conducted an investigation to reasonably conclude the above incidents were not the result neglect of care for not receiving timely bladder and bowel management, which constituted abuse. b. Incident investigations did not include documentation of the Administrator review and signature. The need to investigate incidents of suspected abuse and neglect and to report the incidents to the local APD when the facility's investigation was unable to rule out abuse was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations) on 08/09/22 and 08/10/22.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action: 1.) The following actions have been taken to correct each violation as listed in the S.O.D: a. Resident #1: Facility has reviewed &/or              updated resident's service plan/TSP to ensure              that all previous interventions are in place,              with the appropriate dates of each intervention              r/t the incident. Facility conducted a 2nd                     investigation for all falls from 5/12/22 - 8/5/22              to ensure that previous interventions were              being followed, as well as, service planning              items r/t the fall(s). During the 2nd investigation              process, the new facility Administrator              reviewed all above incident reports thoroughly,              & signed as the administrator on record.          b.  Resident #3: Facility has reviewed &               completed a 2nd investigation for incidents on               5/24/22 & 6/20/22 to ensure that bowel &               bladder care were provided as stated on               resident's current care plan. Facility has               added additional information to these incident               reports under the abuse & neglect section               ensuring that abuse & neglect can be r/o               as evidenced by; staff were providing               appropriate bowel & bladder care at time of               incident(s). As part of the 2nd review &               investigation, the new facility Administrator              signed above incident reports as the              administrator on record. 2.) Reporting & Investigating Abuse & Neglect System & procedures will be corrected as follows:            a. Vanda Consultant is providing a required                 training for all staff on: Incident report                 requirements, investigating incident reports,                 how to appropriately r/o abuse & neglect,                 implementing new interventions via TSPs,                 ensuring previous interventions & applicable                 service planning care were being followed to                 showcase r/o abuse & neglect secondary to                 'as evidenced by' & when to report to local                 APS. This training is taking place on 9/9/22.             b. Facility RDO/Regional team has updated                 the current incident report & investigation                 forms to include: What past interventions                 are were in place at time of incident, & were                 past interventions & current care plan being                 followed.             c. Facility will review incident reports each                 morning (during working days) to ensure                 that all incident reports are completed                 thoroughly, investigations including ruling                 out abuse & neglect are done timely, & that                 the administrator has reviewed & signed all                 incident reports & investigations. 3.) Reporting & investigating abuse & neglect system(s) will be monitored as follows:             a. Facility Administrator & Facility LN will                 coordinate with B.O.M at least once monthly                 during Quality Improvement meetings                 to ensure that all staff have completed the                 required pre-service & on-going training -                 'Abuse & Reporting Requirements.'             b. Facility Administrator & Clinical IDT will                 review all incident reports at least 5 days per                 week (during morning stand-up) & will bring                 all data/trends related to incident reports to                 once monthly Quality Improvement                 Meeting(s). 4.) The Facility Administrator, Facility LN, & Facility RCC will be responsible for overseeing all systems related to Reporting & Investigating Abuse/Neglect.

Based on observation, interview and record review, it was determined the facility failed to provide a social and recreational activity program based upon individual and group interests, physical, mental and psychosocial needs of the residents. Findings include, but are not limited to: On 08/08/22 at 9:30 am, during the entrance conference, the surveyor requested an activity calendar for the current month. At 4:25 pm, the same day, Staff 1 (ED) stated there was no facility activity calendar. The following observations were made from 08/08/22 to 08/10/22: * There was no posted activity calendar in the RCF or MCC unit; * There was no scheduled activity program; * Residents sat out in the common area for long periods of time watching movies or other TV shows, wandered the halls, or remained in their room; and * Staff did not provide any individual or group activities to residents in the MCC unit. During a group interview on 08/09/22, multiple non-sampled residents expressed there were no scheduled activities. On 08/09/22 and 08/10/22, the failure to provide an activity program based on individual and group needs was reviewed with Staff 1, Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings.

OAR 411-054-0030 (1) (c-d) Resident Services: Activities: 1.) The following actions have been taken to correct each violation per examples given on the S.O.D:             a. Facility was unable to provide monthly                 activity calendar: Facility has created a                 current activity calendar for both RCF &                 MCC, as well as an activity calendar                 template for on-going use.             b. Facility did not have a posted activity                 calendar: The activity calendar(s) have been                 posted for residents and family, in each                 POD.             c. Facility did not have a scheduled activity                 program: Facility has hired an activities                 coordinator who will provide activity program                 5 days per week. On AC's off days, facility                 staff will ensure that residents are engaged                 in individual and group activities. Facility is                 currently hiring/interviewing for the activity                 director position.             d. Residents sat out in the common area for                 long periods of time watching TV shows,                 wandered the halls, or remained in their                 room(s): Facility is auditing each resident's                 service plan(s) specifically the social/hobby                 interest section & interviewing residents to                 ensure that all resident's preferred activities                 & hobbies are up to date.                 Facility will reach out to family members for                 those residents in MCC and/or with cognitive                 deficits to obtain a reliable history of social                 interests and hobbies. As the facility obtains                 updated interests & hobbies, resident                 service plans/TSPs will be updated.             e. Staff did not provide any individual or group                 activities to residents in the MCC unit:                 Facility is working with the Vanda Consulting                 Team to write each MCC resident an                 individual activity plan via TSP, that will be                 entered into the resident's current care plan                 at next evaluation. Facility has hired an                 activity coordinator who will ensure that                 group activities are being offered to all MCC                 residents. Facility is enrolling Activity                 Coordinator in Relias training, titled:                 'Activities: Creating a Well-Rounded                 Program.'             f. Residents expressed that facility has no                 scheduled activities: Facility has posted a                 current monthly activities calendar in each                 pod. Facility will begin once monthly town-                 hall meetings with residents to get feedback                 on current activities and to suggest new                 activities. 2.) Resident Services: Activities, This system will be corrected as follows:              a. Facility Administrator will ensure that the                  monthly activity calendar is turned into her                  by the 25th of the month prior, for review.                  Activity calendar & resident feedback from                  monthly 'town-hall' meeting will be reviewed                  during monthly QI meeting.              b. Monthly activity calendar(s) will be posted                  no later than the 1st of each month, in all                  three pods.              c. Facility Administrator will ensure that there                  are meaningful, resident-centered activities                  each day. Facility Activities' Coordinator will                  review daily scheduled activities during                  morning stand-up with IDT, to ensure                  on-going activity program.              d. Facility will limit TV shows & movies as a                  scheduled activity and instead, ensure that                  residents are engaged & offered group &                  individual activities, that support their                  interests while keeping in mind mental,                  physical, & psychosocial needs &/or                  limitations. Facility will create opportunities                  for all residents to participate in daily                  activities. Facility Administrator & Facility                  Activities' Coordinator will ensure that each                  resident's Service Plan is up-to-date with                  hobbies & social interests.              e. Once all MCC residents have updated                  individual activity plans, facility will ensure                  that each activity plan is updated &                  reviewed in a timely manner & in                  accordance with required service planning                  schedule. Facility Activity Coordinator will                  complete on-going continuing education r/t                  activity program.               f. Facility is implementing a once monthly                  'town-hall' meeting for all residents to join,                  in an attempt to get honest feedback of                  current activities & to ensure that residents                  have a place to give suggestions for future                  activities. 'Town-hall' meeting notes will be                  reviewed during Quality Improvement                  meetings. 3.) Facility will evaluate Resident Services: Activities, system, as follows:              a. Facility Administrator will review monthly                  calendars at least once monthly, prior to                  calendar being posted. Facility Admin will                  ensure that all activity related topics will                  also be reviewed by the IDT, during monthly                  Quality Improvement Meetings.              b. Facility Administrator & Activity Coordinator                will ensure activity calendar(s) are posted in                each pod, no later than the 1st of each month                & Facility Admin will ensure that calendars                are posted, at least once weekly, when                conducting weekly environmental walk-                throughs.            c. Facility Activities Coordinator will be                responsible for bringing each days planned                activities to morning stand-up, to ensure that                all members of the IDT are aware of                important scheduled activities for that day, &                provide assistance as needed.            d. Facility Administrator & Activities Coordinator                will review the social interests & hobbies                sections of all residents' service plans as                follows: Pre-admission, Admission, 30 days                after admission, quarterly thereafter, & with                any significant change of condition. Activities                Coordinator will be required to be a part of                the service planning team to ensure                oversight & accuracy.            e. Facility Activities Coordinator & Facility                Admin will ensure all MCC residents have an                updated, accurate individual activities plan                during each service plan review, & in                accordance with required service planning                schedule: Pre-admission, Admission, 30-                days after admission, quarterly thereafter, &                with any significant change of condition.                Facility Administrator will ensure that AC                is scheduled on-going education r/t the                activity program, & will review this once                monthly.             f. Facility Administrator & Activities Coordinator                will ensure that the once monthly resident                'town-hall' is scheduled & on each months                activity calendar. Facility Administrator will                ensure that resident 'town-hall' is scheduled                every month when reviewing calendar, at                at least once monthly, prior to it being posted. 4.) The following staff will be responsible for overseeing the Resident Services: Activities, system: Facility Administrator, Facility Activities Coordinator, & Facility LN.

2. Resident 2 was admitted to the facility in 01/2022 with diagnoses including dementia and psoriasis. The resident's quarterly evaluation, dated 07/04/22, was reviewed and care staff were interviewed. The evaluation was incomplete or inaccurate in the following areas: * Skin condition (injuries, psoriasis); * Weight changes; and * Falls (history and interventions). The need for quarterly evaluations to be complete and accurate was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements, for 2 of 2 sampled residents (#s 4 and 5) and that quarterly evaluations were reflective for 1 of 3 sampled residents (#2). Findings include, but are not limited to: 1. Resident 4 was admitted to the facility on 07/28/22 and Resident 5 was admitted to the facility on 07/01/22. The new move-in evaluations were not signed or dated and lacked information regarding the following required elements: * Customary routines including eating and bathing preferences; * Spiritual and cultural preferences and traditions; * Mental health issues including depression, thought disorders or behavioral or mood problems including history of treatment and non-drug interventions; * Cognition, including memory, confusion and decision making; * Communication and sensory abilities including hearing,vision and speech; * Activities of daily living including toileting, bowel and bladder management, dressing, grooming, bathing, and personal hygiene; * Eating, dental status, and assistive devices; * Independent activities of daily living including ability to manage medications, use of call light and transportation; * Pain including pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Skin condition; * Nutrition habits, fluid preferences, and weight if indicated; * List of treatments: type, frequency, and level of assistance needed; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placements; and * Elopement risk or history. Additionally, Resident 4's evaluation lacked the following required elements: * Personality, including how the person copes with change or challenging situations; * Mobility: ambulation, transfers, and assistive devices; * Independent activities of daily living including ability to manage medications, housework, laundry and transportation; * Review of risk indicators including fall risk or history, emergency evacuation ability; * Complex medication regimen; * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting and room temperature. Additionally, Resident 5's evaluation lacked the following required elements: * List of current diagnosis; * List of medications and PRN use; * Vital signs if indicated by diagnosis, health problems or medications; and * Alcohol or drug use. The move-in evaluation and the need to complete all required components was reviewed with Staff 1 (ED), Staff 2 (Wellness Director), Staff 15 (Director of Operations), Staff 19 (VP of Operations) on 08/09/22 and 08/11/22. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-In & Eval: Resident Evaluation: 1.) The following actions are being taken for each violation, per examples given on the S.O.D:            a. Resident #s 4 & 5 lacked required                information on multiple areas of the                evaluation(s): Facility is                currently reviewing & updating above                  residents' evaluations to ensure all required                information is included. Facility RDO is                working with the Vanda Consultant to identify                areas of the current evaluation in EHR                system, Yardi, that are missing, structurally.                Once the missing required areas are                identified, Facility RDO will work with a Yardi                representative to restructure the current eval                to ensure compliance. Upon completion of                pre-admission, admission, 30-days after                admission, quarterly, and/or significant                change of condition evaluations, facility will                print, sign and date. All current evaluations                missing a signature & date, will be printed &                signed & dated by the employee who                completed them.            b. Resident #2's evaluation was inaccurate or                incomplete in the following areas: Skin                condition (injuries, psoriasis); Weight                weight changes; and falls (history &                interventions): Facility will complete a              thorough review of above inaccurate or              incomplete areas of this residents' evaluation              and will update with accurate information.              Facility Nurse will assess resident's skin &              weight to ensure proper oversight & accurate              documentation on the evaluation. 2.) Resident move-in & Eval: Resident Evaluation - Facility will correct this system to eliminate future violations, as follows:          a. Facility RDO is working with Vanda Consultant              to audit the current structure of the evaluation              in EHR system, Yardi, to identify missing              required elements. Facility RDO will then work              with a Yardi representative to have the eval              updated on the back-end to ensure              compliance. Facility IDT will receive training              on the required areas needed in each eval,              as well as, general training on how to & when              to complete (with date & signature)              evaluations.          b. Facility will review current policies and              processes around completing evaluations, to              ensure all evaluations are completed              thoroughly and accurately. Facility will ensure              that all TSPs from the last quarter are used as              a tool to build updated evaluation(s). Facility              will hold a once weekly IDT meeting to discuss              all evaluations/service plans coming due that              week, to ensure multiple staff members who              are familiar with resident care, can assist in              providing information for updated eval. Facility              will implement a 24hr audit system to ensure              that any resident w/ a short-term or significant              change of condition has appropriate              documentation, including TSPs, in an attempt              to ensure weights, skin events, falls, are              addressed & timely and made a part of              resident(s) care plans. Audit findings              will be brought to stand-up meetings to ensure              appropriate oversight & IDT collaboration. 3.) Resident move-in & Eval: Resident Evaluation - This system will be reviewed as followed:          a. Facility IDT will review evaluations coming due              at least once weekly during IDT meeting.              Facility administrator will review any upcoming              or overdue evaluations, each morning during              stand-up, with IDT. All evaluations will be              completed in accordance to current OARS:              Pre-admission, Admission, Within 30 days of              Admission, Quarterly Thereafter, & with any              significant change of condition.         b.  Facility will complete 24 hr audit daily on              Tuesday - Thursday & a 72hr audit on              Mondays to review with IDT daily during              stand-up. Facility Administrator will ensure              that any staff member completing evals will              have the proper training, and admin will              monitor this once monthly on training grid. 4.) Facility Administrator, RCC, Facility LN will be responsible for ensuring that evaluations are completed timely, accurately, and are resident-specific.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to caregiving staff regarding the delivery of services, and were followed for 3 of 5 sampled residents (#s 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia. Resident 3 was observed to utilize a wheel-chair for mobility and needed to be assisted for food intake during the breakfast and lunch meal. Observations of the resident, interviews with staff, review of the current 05/11/22 service plan and clinical records during the survey, revealed Resident 3's service plan was not reflective of the resident's status and did not provide specific directions to staff, and was not followed in the following areas: * Use of air mattress; * Denture care status; * Weight changes including plans; * Oral care status; * Skin status; and * Activity status. The need to ensure the service plan provided clear instruction to staff, was reflective of the resident's needs and was followed was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operation) on 08/09/22 and 08/10/22. They acknowledged the findings. 2. Resident 2 moved into the facility in 01/2022 with diagnoses including dementia. The most recent service plan available to staff, dated 01/01/22, was not followed or lacked clear instruction for staff in the following areas: * Obtain daily blood pressure; * Use of a knee brace; * The preference to keep room door locked; * Activity needs and preferences; * History of falls and current fall interventions; and * Skin conditions and treatment. The need to ensure the most current service plans were available to staff, reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 07/2022. The resident's current service plan, dated 08/03/22, temporary service plans (TSP), observations of the resident's apartment and interviews with staff were completed during the survey. a. The following care areas were not followed: * Weekly skin checks; * Weekly hydration monitoring for dehydration; * Daily blood pressure checks and PRN hypertension medication; * Two hour skin checks while wearing prosthetics; * Staff to order and administer PRN pain medications; * Weekly weights; * Apartment floor to be free of clutter; * Nursing needs including delegated tasks; * Use of "shrinker" on right amputation; * Daily HHPT exercises; and * Two-person transfers. A TSP was written on 07/26/22 to remind the resident to wear prosthetics after dinner and take them off prior to bed and to assist the resident with exercises. The information was added to the TAR and multiple staff had initialed the TAR, which indicated the treatment had been done. Observations during the survey from 08/08/22 through 08/11/22 showed the resident's prosthetics were placed at bedside. The resident was not observed to wear the prosthetics or "shrinker" during the survey. During an interview on 08/10/22, Staff 10 (MT), confirmed she doesn't assist with exercises, use of prosthetics or skin monitoring. During an interview on 08/10/22, Staff 12 (CG), reported "[s/he] doesn't wear the prosthetics, I don't give him reminders to put them on or help [him/her] do it. I don't help [him/her] with exercises." During an interview on 08/11/22, Staff 1 (ED), reported "I don't think I have ever seen [him/her] wear them [prosthetics]." b. The following care areas were not reflective and failed to provide clear direction to staff: * Urinal use and type of assistance needed; and * Incontinent care completed in bed. The need to ensure the service plan provided clear instructions, were reflective of the resident's needs and were followed was discussed with Staff 1 (ED), Staff 15 (Director of Operations), Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General: 1.) The following action has been taken for each violation, per examples given on S.O.D:            a. Resident #3's service plan was not reflective                of the resident's status and did not provide                specific directions to staff, and was not being                following in multiple areas - Facility is                conducting a thorough review & update of                resident #3's evaluation & service plan, & will                ensure that service plan is up to date &                reflective of residents current needs, with                specific instructions for staff. Due to resident                requiring nursing oversight, facility RN will                be a part of updating this resident's service                plan & will provide interventions needed.            b. Resident #2's service plan was not followed               or lacked clear instruction clear instruction for               staff in multiple areas - Facility is conducting               a thorough review & update to resident 3's               evaluation & service plan. Facility will ensure               that resident #3's current service plan is up-               to-date with resident's current needs, & has               clear instructions for staff to follow.             c. Resident #5's service plan was not followed               or lacked clear instruction in multiple areas -               Facility is conducting a thorough review of               resident #5's evaluation & service plan & will               ensure that resident's service plan is up-to-               date with resident's needs and has clear               instructions for staff to follow. Facility LN is               assessing resident #5 for current skin events,               risk for skin events, weight loss/gain, use of               prosthetics, & delegation needs. Facility RN               will be a part of this resident's service plan               update to ensure appropriate interventions               are in place, coordination of care with               resident's provider, and that staff have clear               instructions to follow. 2.) Service Plan: General, system: Facility will correct &  evaluate this system to eliminate future violations, as follows:           a.  Direct care staff are scheduled to receive the                following training(s): In-Person training on                short-term change of condition; creating &                following TSPs, importance of shift-to-shift                meeting, & when to notify LN for change of                condition.                Facility nurse will receive the following                training(s): Facility nurse will attend OHCA                'Role of the RN in Community Based Care' &                will receive training & training materials from                Vanda Consultant related to; Change of                condition oversight, service plan review                within 48hrs of significant change of                condition, resident specific interventions r/t                change of condition that are available to staff                on each shift. Facility will include all change                of condition(s) as part of the 24/72hr audit, to                ensure implementation of resident care                needs/interventions.            b. Service plans will be reviewed & updated in                accordance to current OARs: Prior to                admission, at admission, with updates at 30                days, quarterly thereafter, & with significant                change of condition. All other changes to                resident care needs that occur between                service plan updates will be written as a TSP                & will be reviewed by the IDT, as well as, all                direct care staff. Resident care needs that                are secondary to a significant change of                condition will have TSPs written by facility                RN & will include interventions & clear                instructions for staff to follow.            c. Facility Administrator will oversee & ensure                that all service plans are reflective of resident                needs as identified in the evaluation. Facility                Administrator will ensure that the clinical IDT                review all upcoming service plans for that                week, during stand-up. Any significant                change of condition(s) noted, will be                communicated with facility RN & added to                the significant change of condition log to                ensure appropriate service planning. 3.) Service Plan: General - This system will be evaluated as follows:            a. TSPs will be reviewed daily as part of the 24/                72 hr process,            b. Sig-Change log will be evaluated at least                once weekly by facility RN, with updates                made to the resident's service plan as                needed,            c. Service plans will be reviewed & updated                prior to admission, at time of admission,                within 30 days of admission, quarterly, &                with any significant change of condition,            d. Facility Administrator will ensure that all staff                have up-to-date training related to TSPs,                service plans, and resident care, & will                review the training grid at least monthly. 4.) The Facility Administrator, Facility RN, & Facility RCC will be responsible for ensuring all corrections to the residents' service plans are made, and overseeing this system as stated above.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated after a significant change of condition, were reflective of residents' needs, provided clear direction to caregiving staff regarding the delivery of services and were followed for 1 of 4 sampled residents (#8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia. Resident 8 was observed to utilize a wheel-chair for mobility, required 1-2 person assist for transfers, ambulation, bed mobility and needed assistance for food intake during breakfast and lunch meals from 02/21/23 through 02/22/23. Observations of the resident, interviews with staff, review of the current 01/07/23 service plan, temporary service plans and the clinical record revealed Resident 8's service plan was not updated after a significant change of condition, was not reflective of the resident's status, failed to provide specific directions to staff, and was not followed in the following areas: * Skin status, including treatments and intervention to float heels; * 1:1 meal assistance; * Weight loss intervention to provide preferred foods when meals were refused; * Hospice provided bathing; * One-to-two person assist with mobility, including ambulation, transfers and bed mobility; * Recent falls; * Toileting status; * Emergency evacuation status; and * Activity status. The need to ensure the service plans were updated following a significant change of condition, provided clear instruction to staff, were reflective of the resident's needs and was followed was discussed with Staff 2 (ED), Staff 8 (Wellness Coordinator) and Staff 22 (Director of Wellness, RN) on 02/22/23. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General 1.) Service Plan: The following actions will be taken to correct each violations per examples given on the SOD:       a) Resident 8 passed prior to SOD. No corrections to the                  service plan are able to be made at this time. 2.) Service Plan: General: This system is being corrected to eliminate future violations as follows:   a.) Facility Administrator, Wellness Coordinator, and Director of Wellness will discuss any changes of conditions and interventions or changes to care plan needed as part of the 24/72 hour process.   b.) One of the three members of the clinical team (ED, RCC, RN) will be decided on to complete the service plan in a timely manor.   c) Once completed, the service plan will be brought to the next daily clinical meeting where the clinical team members can sign off that it was completed thoroughly and accurately. 3.) Service Plan: General: This system will be evaluated as follows:   a) At each daily clinical meeting, the ED, RCC, and RN will review any identified changes of condition and ensure the RN has completed a note with interventions and/or changes to care plan. TSP(s) will also be immediately implemented.   b) Weekly, at each IDT, all TSPs related to the change of condition will be discussed and each department will have an opportunity to provide any further interventions and/or changes needed prior to finalizing the service plan. 4.) The Facility Administrator, Facility RN Director of Wellness, and Facility Wellness Coordinator will be responsible for overseeing the system as stated above.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5). Findings include, but are not limited to: Resident 1, 2, 3, 4 and 5's current service plans were reviewed during the survey. The service plans lacked evidence the residents or their legal representative's participated in the development of the service plans and that a Service Planning Team was used to develop the service plan. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 3 (Resident Care Coordinator) on 08/11/22. They acknowledged the findings.

OAR 411-054-0036 (5) Service Plan: Service Planning Team: 1.) The following actions have been taken for each violations, per examples listed on S.O.D:            a. Resident 1, 2, 3, 4, and 5's service plans                lacked evidence that the residents or their                legal representative's participated in the                development of the service plans & that a                service planning team was used to develop                the service plan - Facility is scheduling care-                conferences with residents 1, 2, 3, 4, & 5, &                will include applicable family/POA. Facility                IDT are reviewing these service plans & will                signing and dating after each respective                review. 2.) Service Plan: Service Planning Team - This system is being corrected to eliminate future violations, as follows:            a. Facility is currently working with Vanda                Consultant to establish policies & procedures                related to service planning/teams,            b. Facility IDT will receive training r/t the                service planning team, care conferences, &                who needs to be a part of the service plan                team,            c. Facility Administrator is actively scheduling                care conferences with residents and their                families/POAs.            d. Facility is developing a once-weekly IDT                meeting, wherein all completed evaluations &                service plans will be reviewed by each team                member, printed, signed and dated. 3.) Service Plan: Service Planning Team - This system will be evaluated as follows:            a. Upon completion of updated                policy/procedures, facility IDT will receive                training related to the requirements of a                service planning team - facility admin will                oversee on-going training for applicable staff                at least once monthly, per new-hires and/or                employee promotions.            b. Facility IDT will review all completed service                plans for that week, during once weekly IDT                meeting, and will print, sign, and date.            c. Facility Administrator will collaborate with the                Administrative assistant at least once                monthly, to review upcoming service plans &                to schedule care conferences for the                upcoming month. 4.) The facility Administrator will be responsible for overseeing and ensuring the correction of above violation(s).

2. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia and wrist and rib fractures. Resident 3 required a wheelchair for mobility. Observations of the resident from 08/08/22 to 08/11/22 revealed the resident required staff assistance with transfers and incontinent care. a. Resident 3's clinical record dated 05/08/22 through 08/08/22 were reviewed during the survey and revealed the following: * The resident's 05/11/22 service plan indicated the resident required staff assistance with bowel and bladder management four times per shift as feasible; * On 05/25/22 staff documented the resident had a fall on 05/24/22. S/he was incontinent of bowel and was wearing only socks; and * On 06/20/22 staff documented the resident had a fall. Staff further documented the resident wanted to use the bathroom. There was no documented evidence the facility thoroughly reviewed the incidents to determine if service planned interventions were followed in the area of bowel and bladder management and evaluated for effectiveness or new interventions determined and communicated to staff. On 08/09/22 and 08/10/22, the above findings were reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged findings. b. Clinical records reviewed from 05/08/22 to 08/08/22 and staff interview noted the following: * 05/04/22 - Returned from the hospital; * 05//18/22 - "blister/diaper rash on the hip"; and * 06/08/22 - Small red area on coccyx. There was no documented evidence that the resident's short-term changes of condition were consistently monitored, at least weekly, to resolution. On 08/09/22 and 08/10/22, the above findings were reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, necessary actions/interventions were determined, documented, and communicated to staff, and the residents' conditions, including the effectiveness of interventions, were monitored weekly through resolution for 4 of 5 sampled residents (#s 1, 2, 3 and 5) who had documented changes of condition. Resident 1 had repeated falls with injuries. Findings include, but are not limited to: 1. Resident 1 was admitted to the memory care unit in 09/2021 with diagnoses including encephalopathy and dementia. During the survey, s/he was identified as having a history of and recent falls. Observations of Resident 1 throughout the survey confirmed the resident was often unsteady on his/her feet, had poor safety awareness and was dependent on staff for most ADLs. Clinical records, including the service plan, temporary service plans (TSP's), incident reports and investigations, provider notes and charting notes were reviewed. The clinical record provided the following information: a. Resident 1 experienced nine falls between 05/12/22 and 08/05/22 as follows: * 05/12/22 in common area; * 05/16/22 in common area resulting in skin tear and bruising; * 05/18/22 in common area resulting in pain and bruising; * 05/21/22 in outside courtyard resulting in abrasion; * 05/25/22 in common area; * 06/09/22 in room, bruising and swollen lip observed the following day; * 07/07/22 in common area; * 07/13/22 in common area, skin tears to head, bruising visible several days later; and * 08/04/22 in common area. The records documented information on the falls, how the injuries occurred, treatment provided and that the resident was placed on alert monitoring. Incident investigations provided, from 05/12/22 through 08/05/22, were reviewed and documented new fall interventions including: * 05/16/22 staff to assist [the resident] when looking to sit down; * 05/18/22 guide resident to a chair to sit, re-direct to an activity and ensure resident is wearing non-skid socks or shoes; * 05/21/22 staff to assist resident when outside for walks, re-direct back inside when outside for walks; and *07/07/22 present the resident with an activity to keep occupied, re-direct as feasible, keep dining room chairs pushed in. While the follow-up investigations included documentation of new interventions identified to prevent further falls/injury, the record did not include documented evidence the new interventions were communicated to staff and there was no evidence the interventions were implemented and monitored for effectiveness.   The failure of the facility to ensure interventions were communicated to staff, added to the service plan, were implemented and monitored for effectiveness to prevent future falls or injuries placed the resident at risk and the resident continued to experience falls and/or injuries. b. Resident 1 sustained multiple skin injuries (as listed above) and included the following: * 05/26/22 sustained redness and bruising to nose while ambulating in common area; * 06/20/22 hit chin on a shelf, bruising to chin; * 06/27/22 hit head on handrail, sustained a cut to the head; * 08/05/22 bleeding to head, bruising visible two days later. The skin injuries represented short term changes of condition. The injuries were identified and documented in the alert monitoring charting notes by medication technicians. While the facility licensed nurse discontinued the alert monitoring of the skin injuries and noted the status of the injury at the time of ending the alert monitoring, there was no documented evidence interventions were developed if needed and staff was monitoring the skin issues, at least weekly, until the injury was resolved. The monitoring process and need to ensure interventions related to changes of condition were communicated to staff and the conditions were monitored at least weekly until resolved was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.   2. Resident 2 was admitted to the memory care unit in 01/2022 with diagnoses including dementia and chronic kidney disease. Clinical records, including the service plan, dated 01/01/22, temporary service plans (TSP's), provider visit notes and charting notes were reviewed. The clinical record provided the following information: Resident 2 had the following skin injuries identified during the review period from 05/09/22 through 08/01/22: * 05/19/22 abrasions to left knee and head, skin tear to right hand; * 05/21/22 bruising to left eye; * 06/17/22 skin rash to neck, forehead and top of head; * 06/25/22 bruise to right hand; and * 07/22/22 open area on neck with drainage. Resident 2's skin injuries represented short term changes of condition. The clinical record revealed the following: The skin injuries were identified and documented in the alert monitoring charting notes by medication technicians. While the facility licensed nurse discontinued the alert monitoring of the skin injuries and noted the status of the injury at the time of ending the alert monitoring, there was no documented evidence the injuries were evaluated at onset, interventions developed, if needed, and the skin issues were being monitored, at least weekly, until the injuries were resolved. The need to ensure changes of condition were evaluated at onset, interventions developed as needed and monitored, at least weekly, until resolved was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 07/2022 with diagnosis of diabetes, CVA (cerebrovascular accident) and hypertension. a. Review of the clinical record, including progress notes indicated the following short-term changes of condition were not monitored through resolution and monitoring instructions were not communicated to staff: * On 07/03/22, missed insulin dose at 2:00 pm; * On 07/16/22, ER visit 07/16/22 and return to facility on 07/17/22 with diagnosis of hyperglycemia; * On 07/28/22, vomiting and elevated BP 188/81 at 9:14 am, PRN Clonidine was given and BP rechecked at 12:20 pm. Blood pressure (BP) remained elevated at 166/75. No further BP monitoring was completed. b. Resident 5's new move-in evaluation dated 07/01/22 and physician orders indicated the following evaluated care needs that required monitoring: * Dehydration monitoring, related to diabetes; * Weekly skin monitoring; and * Blood pressure monitoring due to history of CVA and hypertension. There was no documented evidence the facility monitored the resident per evaluated care needs. c. A review of the current service plan, dated 08/03/22, temporary service plans (TSP's) and progress notes from 07/02/22 through 08/08/22 noted the following service planned fall risk interventions: * Two-person transfers; * Monitor every two hours; * Provide verbal cues during transfers; * Keep apartment free of clutter on the floor; and * Home health PT. On 07/16/22, staff documented the resident had a witnessed fall in his/her apartment. There was a TSP written for staff to monitor for latent injuries and bruises, however; the facility failed to review the service planned interventions for effectiveness and new interventions determined and communicated to staff. On 08/05/22, staff documented the resident had an unwitnessed fall in his/her apartment. There was no documented evidence the service planned fall interventions were reviewed for effectiveness and there was no documented evidence monitoring instructions were communicated to staff. Resident 5 was alert and oriented and able to explain how both falls occurred. The need to ensure the facility monitored service planned fall interventions for effectiveness, monitor and document on the resident's condition until resolved and communicate changes of condition to staff was discussed with Staff 1 (ED), Staff 15 (Director of Operations), Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring: 1.) The following actions will be taken for each violation, per the examples written on the S.O.D:            a. Resident #1 - Facility failed to ensure that the                monitoring process and need to ensure                interventions related to change of condition                were communicated to staff, and that the                conditions were monitored at least once                weekly - Facility is reviewing all falls within                the last 90 days & ensuring all appropriate                interventions are in place and communicated                to staff via TSPs. Facility nurse is                assessing current skin events and the risk                for skin events, & will document findings, &                interventions via TSPs. All current skin                events will be monitored by facility LN at                at least once weekly, until resolved.            b. Resident #2 - Facility failed to ensure that                changes of condition were evaluated at                onset, interventions developed as needed &                monitored, at least weekly, until resolved -                Facility LN is assessing resident for any                current skin events and the risk for skin                events. All findings will be documented via                TSPs, and will include interventions for staff.                All current skin events will be monitored by                LN, at least once weekly, until resolved.            c. Resident #3 - Facility failed to ensure:                 fall interventions were in place, being               followed, and were effective, new fall               interventions were communicated with staff, &               that short-term changes of condition were               monitored at least weekly, until resolution -               Facility is reviewing the last 90 days of falls               to ensure that appropriate fall interventions               are in place, effective, and communicated               with staff via TSPs. Facility will review               resident records/chart to ensure that any               recent short-term change of condition is being               monitored, at least once weekly, until               resolved.           d. Resident #5 - Facility failed to ensure fall               interventions were effective, monitor &               document on the resident's condition until               resolved, and communicate changes of               condition to staff - Facility is reviewing all               resident falls within the last 90 days to               ensure that 1.) Current fall interventions are               effective, 2.) New fall interventions are in               place and communicated to staff via TSP.               Facility LN will review resident's chart/record,               and ensure that any short-term changes of               condition are being monitored at least once               weekly until resolved, and communicated to               staff, via TSP. 2.) Change of Condition - This system is being corrected to eliminate future violations, as follows:           a. Facility is implementing a 24/72hr audit to               ensure that all resident changes of condition               are evaluated at onset, that appropriate               interventions are put in place via TSP, & that               all changes of condition are monitored until               resolution,           b. Facility is requiring updated training to               applicable IDT & direct care staff, that will               focus on change of condition documentation,               monitoring, and interventions.           c. Per mandate, facility staff will also receive               training and training material related to               incident reports, investigation of incident               reports, previous & new interventions, when               to notify the nurse, and ensuring all               interventions are made a part of the resident               record & communicated with staff via TSP.           d. Facility is implementing a skin log as part of               the 24hr process, to ensure appropriate               oversight, interventions, and communication               to staff.           e. Facility nurse will review skin log, & resident               alerts, and will ensure that new skin events               and/or treatments are entered into the               residents' TAR to ensure monitoring & tx               interventions, until resolved.            f. Facility will receive training from Vanda               Consultant related to the service planning               process, secondary to changes of condition. 3.) Change of Condition & Monitoring - This system is will be evaluated, as follows:           a. The clinical IDT will review and complete the               24/72 hr audit as follows: The 24hr               report/audit will be completed daily five days,               and the 72 hr report/audit will be completed               once weekly, or upon return from two days               off.           b. Facility LN will review skin log & resident               alerts r/t new skin events, daily (5 days a               week) and will review a 72 hr look back upon               return from 2 days off.           c. Facility LN will ensure once weekly oversight               and documentation on residents with active               skin events and/or nursing needs, until               resolved.           d. Facility will include incident report reviews               during daily stand-up to ensure appropriate               interventions are in place, communicated with               staff, and are effective.           e. Facility will ensure that all TSPs (Temporary              Service Plans) are made a part of the              resident's service plan when completing              service plans/evaluations as they are updated              per scheduling requirements: Initial, within 30-              days of admission, quarterly thereafter, & with              significant change of condition.           f. Facility Administrator will ensure that all              applicable staff (those writing, reviewing, &              updating TSPs/Service plans will have the              appropriate training - This system will be              monitored & reviewed once monthly, via              the training grid, and upon new-hire              orientation. 4.) Facility administrator, Facility Licensed Nurse, & Facility RN will ensure that all above corrections are made.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, interventions developed based on the condition of the resident and updated the service plan for 2 of 2 sampled residents (#s 2 and 3) who experienced a significant change of condition in weight status. Resident 3 continued to have weight loss. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia. Observations of the resident on 08/08/22 and 08/09/22 revealed the resident required hands-on assistance to eat meal and nectar thickened liquids to drink. Resident 3's weight record was reviewed during the survey and revealed the following: * 04/2022 - 137. 2 pounds; * 05/2022 - 127.1 pounds; and * 08/2022 - 116.3 pounds. From 04/2022 to 05/2022, Resident 3 had weight loss of 10.1 pounds or 7.36 % of his/her body weight, which represented a significant change of condition. Weights documented after 05/2022 revealed the resident experienced another significant weight loss of 8.49 % in three months from 05/2022 to 08/2022. There were no weights recorded in 06/2022 and 07/2022 to review. There was no documented evidence the RN completed an assessment of the resident's condition which included that the weight loss had been evaluated, actions or interventions had been determined to address the weight loss. During the survey on 08/09/22 the following was observed: * From 9:05 am to 9:40 am, the resident was not observed in common area or in the dining room, the resident was in his/her bed; * At 10:25 am, Staff 5 (CG) was observed in Resident 5's room to assist the resident with fluid intake. Staff 5 stated s/he complained of being thirsty and offered a cup of thickened orange juice; * At 12:00 pm, the resident was in the dining room for lunch. S/he was holding a sandwich and s/he ate the sandwich independently with staff cueing. The resident consumed 80 % of lunch.   The failure to complete a RN assessment at the time of the significant weight loss and failure to initiate interventions resulted in further weight loss. On 08/09/22 and 08/10/22, the above findings and lack of an RN assessment was shared with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2022 with diagnoses including dementia. a. Observations of the resident from 08/08/22 to 08/10/22 revealed the resident required hands-on assistance to eat meals. Direct care staff reported the resident ate well with staff assistance and the resident would be unable to eat unless staff assisted. The resident was observed to be able to drink his/her thickened liquids with minimal assistance from staff. Resident 2's weight record was reviewed during the survey and revealed the following: * 03/2022 - 156.5 pounds; * 04/2022 - 160.7 pounds; * 05/2022 - 174.7 pounds; and * 08/2022 - 178.4 pounds. From 03/2022 to 08/2022, Resident 2 had weight gain of 21.9 pounds or 13.09 % of his/her body weight, which represented a significant change of condition. There were no weights recorded on 06/2022 or 07/2022. On 07/28/22, the facility RN instructed staff to "please take weight monthly" to determine weight changes. The next weight was obtained on 08/04/22 of 178.4 pounds. There was no documented evidence the RN completed an assessment of the resident's condition, which included whether the weight gain had been evaluated and any actions or interventions determined to address the weight gain. b. On 07/22/22, charting notes documented the resident had an open wound on his/her neck and a family member cleaned and placed a dressing on the wound. The wound was described as having drainage and a "hole" was visible. Direct care staff documented cleaning and dressing the wound daily from 07/22/22 through 08/01/22. On 07/28/22, the resident was seen by the facility RN and the assessment described the wound and provided instruction for staff to leave the wound open, monitor and allow it to heal. The RN assessment, conducted on 07/28/22, was not completed timely for the open wound which represented a significant change of condition. The need to ensure changes of condition were evaluated and referred to the RN, on a timely basis, for assessment and interventions was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services: 1.) The following actions will be taken to correct each violation, per examples written on S.O.D:            a. Resident #3 - Facility failed to ensure the RN                performed an assessment, interventions                developed based on condition of the                resident, and updated the service plan                related to significant weight loss: Facility                is implementing weekly weights for resident                #3 to ensure oversight on weight status.                Facility RN will assess resident and begin                weekly significant change of condition                assessments, with interventions in place                via the RN assessment and TSPs. Facility                RN will coordinate with resident's provider as                well, to ensure coordination of care.            b. Resident #2 - Facility failed to ensure that                changes of condition were evaluated &                referred to the RN, on a timely basis for                RN assessment - Facility will implement bi-                weekly weights for resident #2, to ensure                appropriate oversight and action for weight                gain. Facility RN will assess resident #2 to                identify any concerns r/t weight gain, & r/o                other symptoms that might be contributing to                weight gain. Facility RN will add resident #2                to weekly significant change of condition                assessments, and will include appropriate                 interventions, as needed, on the                 weekly assessment, as well as, TSPs.                 Facility RN will assess resident #2's wound                 and document once weekly via significant                 change of condition, until resolved. RN will                 add interventions in weekly assessment(s)                 as well as, on TSPs for staff to review.                 Facility RN will add an order for monitoring                 on the TAR of resident #2, and any                 additional treatments needed, until resolved. 2.) Resident Health Service - This system is being corrected to eliminate future violations, as follows:             a. Facility is implementing a 24/72 hr process                 & audit. As part of this process,                 facility will update the 24hr binder with the                 following: An updated significant change of                 condition log, weekly skin logs, and when to                 notify the nurse. Facility RCC will run the                 24/72 hour audit each morning (on work                 days, 5 days a week, & 72hr audit after                 2 days off) to identify any changes of                 condition noted. This audit will be ran in                 EHR system, QuickMAR, & will allow RCC                 to have a 24/72 hr look back at everything                 that has been happened with that 24-72hr                 timeframe. This audit will ensure that all                 notable changes in a resident's condition is                 identified in a timely manner, & that all                 interventions & assessments are initiated                 and then maintained until resolution. This                 audit will be brought to morning stand-up to                 be reviewed by IDT, and skin log(s),                 significant change of condition log(s), and                 TSPs will be updated as appropriate.            b. Facility is reviewing & updating weight                tracking system to ensure appropriate                oversight & timely assessment. This will be                done in the EHR system, QuickMAR. Facility                RN will run the weight(s) report at least once                weekly, to identify significant weight                loss/gain.            c. Facility Administrator will review assessment                logs at least once weekly to ensure all                changes of condition, & nursing assessments                are done timely, thoroughly, and with the                required components. 3.) Resident Health Services - This system will be evaluated as follows:             a. The 24/72 hour process/audit will be                 completed daily (5 days a week, on work                 days), & a 72 hour process/audit will be                 completed once weekly (after RCC returns                 from 2 days off.) Skin logs & change of                 condition log will be reviewed at least once                 per week. Alert charting log & TSPs will                 reviewed daily, during Clinical                 stand-up meeting.             b. Weight tracking report will be ran at least                 once weekly, in an attempt to identify any                 significant weight gain/loss.             c. To ensure on-going compliance with                 oversight and resident assessments', Facility                 Administrator will review all active                 assessments, at least once weekly. 4.) Facility Administrator, & Facility RN will be responsible for ensuring completion and monitoring of this system.

2. Resident 7's July and August MARs were reviewed, included an order to obtain CBG's twice monthly, and notify the physician for CBG readings above 300. In an interview on 08/10/22, Staff 9 (MT) stated the facility LPN provided instruction, initially, on how to obtain and record the CBG but there were no written instructions available for how to obtain the resident's CBG's for staff to refer to when performing the task. The need to have written instructions available for staff to follow when performing a taught task was reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the teaching, delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 2 of 2 sampled residents (#s 5 and 7) who were being assisted with insulin injections or CBG readings by unlicensed facility staff. Resident 5 was at risk for harm related to potential medical complications from the lack of an RN assessment of the resident's condition, unlicensed staff training and supervision to ensure safety and accuracy of insulin administration. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility with diagnoses including diabetes and bilateral below the knee amputation. Review of Resident 5's clinical record and staff interviews identified the following: * Blood sugars were documented on the MAR ranging from 102 to 377; * The resident would take his/her own CBG's, inform the MT who would then advise the resident on how much insulin, including any additional sliding scale dose that was needed; * The resident would then administer their own insulin injection; and * The MT's would then initial on the MAR that they had administered the insulin, including documentation of the sliding scale dose administered. A review of the 07/01/22 through 08/08/22 MAR indicated Staff 7 (MT), Staff 10 (MT), Staff 14 (MT), Staff 20 (MT) and Staff 21 (MT) initialed the MAR for insulin administration. There was no documented evidence an RN delegation had been completed which included the following: * RN assessment to determine Resident 5's condition was stable and predictable; * Determination of frequency resident should be reassessed, including rationale; * Rationale why the task could be safely delegated; * Skills, abilities and willingness of unlicensed staff to complete the task; * Unlicensed staff were taught the task was client specific and not transferable; * Determination of frequency the unlicensed staff should be supervised and re-evaluated, including rationale; and * Written instructions available including risks, side effects, response, risk factors, and whom to report the same; * RN takes responsibility for delegating task and ensures supervision will occur for as long as RN was supervising performance. In an interview on 08/09/22, Staff 2 (Wellness Director) explained the resident and his/her spouse received teaching and education at another facility prior to moving in. She further stated she was unaware that CBG's and advising on sliding scale insulin dose was a delegated or taught task. Staff 2 confirmed there were no unlicensed staff that had been delegated nor had there been an assessment of the resident's condition. A review of the 07/01/22 through 08/08/22 MAR indicated 31 occasions where the sliding scale insulin dose was incorrectly documented. On 08/09/22, Staff 10 (MT) stated she documented insulin administration on the MAR and was confused on how to document the sliding scale dose. A review of the progress notes dated 07/02/22 through 08/08/22 indicated the following: * On 07/16/22, Resident 5 went to the ER and returned with a diagnosis of hyperglycemia and a recommendation to increase daily scheduled insulin dose; and * On 07/28/22 the MAR indicated Resident 5's CBG was 123 at 5:00 pm and should have been administered 0 units sliding scale dose however, the MAR indicated the resident was administered 6 units. Later in the evening on 07/28/22, Resident 5 called for assistance due to vomiting. The lack of an RN assessment of the resident's condition, lack of unlicensed staff delegation and supervision to ensure safety and accuracy of insulin administration put Resident 5 at risk for harm related to potential medical complications and an ER visit. On 08/09/22, the need to ensure all staff who administered insulin injections or performed delegated, taught tasks were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED) and Staff 2. They acknowledged the above findings. The Surveyor requested an immediate plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules. On 08/09/22 at 4:25 pm, a plan to address the delegation issue was submitted and the situation was abated.

OAR 411-054-0045 (1)(f)(B): RN Delegation and Teaching: 1.) The following actions will be taken for each violation, per examples written on the S.O.D:             a. Facility failed to ensure that teaching,                 delegation, and supervision of special tasks                 of nursing care was completed in                 accordance with the OSBN rules: Facility                 is now administering all insulin for resident                 #5, & obtaining CBGs. Resident has been                 assessed & deemed stable & predictable.                 Facility RN has delegated all medication-                 aides who are required to administer insulin.                 Vanda RN Consultant is working with facility                 RN for further training and training material,                 related to delegations.             b. Facility failed to ensure that written                 instructions were available for staff to                 follow when performing a taught task:                 Facility has updated the 24hr binder to                 include written instructions for CBGs. All                 applicable staff who are responsible for                 obtaining CBGs were given additional                 training on how to obtain and record CBGs.                 All orders pertaining to blood glucose                 testing will be in EHR system QuickMAR,                 with records recorded as ordered. 2.) RN Delegation and Teaching: This system is being corrected to eliminate future violations, as follows:             a. Facility RN will implement a delegation                 spreadsheet with all residents requiring                 delegations, and all staff members who will                 be administering insulin. This document will                 have date of initial delegation for each staff                 member, to ensure re-delegation at                 appropriate dates.             b. Facility RN will be taking the 'Role of The                 RN' through OHCA, at the next training,                 10/11/22.             c. Facility Administrator will review/audit all                 delegation requirements, to ensure thorough                 and timely assessment. 3.) RN Delegation and Teaching: This system will be evaluated as follows:             a. Facility RN will review delegation task sheet                 at least bi-weekly, to ensure appropriate                 oversight and assessment.             b. Facility Administrator will review/audit                 delegations at least once monthly to ensure                 appropriate requirements are in place &                 being followed per the regulations &                 division 47. 4.) Facility Administrator and Facility RN will be responsible for ensuring compliance.

Based on observation, interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers and ensure outside service providers left written information in the facility that addressed the on-site service being provided, for 2 of 4 sampled residents (#s 3 and 5) who received outside services. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 07/2022 with diagnoses of bilateral below the knee amputation and diabetes. a. The record indicated Resident 5 began receiving HH PT services on 07/07/22. The HH PT service provider had consistently left written information regarding the service provided and the following recommendations: * On 07/07/22, "needs caregiver assist for all transfers and assist with maintaining hygiene and skin checks"; * On 07/13/22, "please provide assistance with hygiene and skin checks and caregiver assist with all mobility tasks at this time"; * On 07/20/22, "remind pt [patient] to wear "shrinker" on RBK (right below knee) amputation, do [his/her] exercises and to call CG to assist with transfers"; * On 07/21/22, "please monitor for any increase in [his/her] pain and neuropathy"; and * On 08/01/22, "continue to assist [name] with transfers and home exercise program. Please monitor skin for bruise, wounds." There was no documented evidence the facility implemented the above recommendations. b. 07/16/22 ER visit noted a diagnosis of hyperglycemia. Review of the after visit summary indicated the following recommendations were made: * Increase existing Lantus insulin from 25 units to 30 units; * New medication, PRN Hydrocodone every four hours; * New medication, Protonix 40 mg tablet, once daily; and * Follow up with "PCP" [primary care provider] within two days. The ER after visit summary was reviewed and signed by three facility staff, however there was no documented evidence the facility followed up to ensure the medication recommendations were implemented and follow up appointment with PCP was scheduled. The need to ensure the facility had a system for coordinating on-site services with outside providers was discussed with Staff 1 (ED), Staff 15 (Director of Operations) and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia. Resident 3's clinical record, dated 05/08/22 through 08/08/22, was reviewed during the survey and revealed the following: * 05/06/22 a hospital discharge report, indicated not to use a straw for fluid intake; and * 06/02/22 a hospice visit note indicated frequent oral care was to be provided to the resident. Observations of the resident on 08/08/22 revealed the resident was provided thickened liquids with a straw. There was no documented evidence the recommendations were communicated to staff or implemented. 3. A pharmacy audit was conducted on 05/11/22 through 05/13/22 of multiple non-sampled residents and recommendations were made. There was no documented evidence the recommendations were communicated to staff or implemented. On 08/09/22 and 08/10/22, the need to ensure on-going coordination of care was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings.

OAR 411-054-0045 (2) Resident Health Services: On and Off-Site Health Services: 1.) Resident Health Services: The following actions have been taken to correct each violation per example written in S.O.D:             a. Facility failed to have a system for                 coordinating on-site services with outside-                 providers: Facility has updated resident #5's                 care plan with all interventions written by                 HHPT (all current and applicable). Facility                 LN has reviewed ER after visit summary                 from 7/16/22 to ensure all orders are in                 place appropriately, and is coordinating any                 further care needed with provider.             b. Facility failed to ensure recommendations                 were communicated to staff: Facility LN has                 is reviewing resident # 3's clinical record to                 ensure all recommendations are in place,                 via TSP for staff to review.             c. Facility failed to ensure on-going                 coordination of care, related to pharmacy                 audit: Facility requested another pharmacy                 audit, which was completed on 8/18/22.                 Facility has followed all recommendations                 & sent out all physician notes from                 Pharmacist. 2.) Resident Health Services: This system is being corrected to eliminate future violations, as follows:            a. Facility has updated Outside Provider                Procedure, including creating an outside                provider binder. All Outside Provider Notes                will go through the triple check process, with                the facility LN being the last check. All                Outside Provider Notes will be processed as                'orders' to ensure that staff are made aware                of any new interventions or recommendation,                that the care plan is adjusted when                necessary. This process includes writing a                TSP and placing resident on alert when                applicable.            b. All pharmacist audit results &                recommendations will now be sent to new                facility administrator, who will coordinate                with facility nurse and RCC to ensure a                timely follow for recommendations & notes                to providers. Facility will document all                changes made secondary to pharmacy                recommendations in the EHR system. 3.) Resident Health Services: This system will be evaluated as follows:           a. Med-Techs will check Outside Provider               Binder at least once per shift, and process               all Outside Provider notes prior to their shift               ending.           b. Facility LN will review triple checks at least               once daily, to ensure appropriate follow-up,               coordination of care, and implementation of               recommendations and/or interventions.           c. Facility administrator will review all pharmacy               audits and recommendations as they are               sent to the facility, at least quarterly. 4.) Facility Administrator and Facility LN will oversee on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure a safe medication administration system was in place for all residents and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to: 1.  During the survey, conducted 08/08/22 through 08/11/22, administrative oversight of the medication and treatment administration system was found to be ineffective based on deficiencies in the following areas: * C 282: RN Delegation and Teaching; * C 302: Tracking Control Substances; * C 303: Medication and Treatment Orders; * C 310: Medication Administration; * C 315: Treatment Administration; and * C 325: Self-Administration of medications. The need to ensure the facility had a safe medication administration system and the overall medication and treatment administration system was reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Operation of Director) on 08/09/22 and 08/10/22. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 07/2022 with diagnoses of diabetes, hypertension and pain. a. A review of the progress notes dated 07/02/22 through 08/08/22 identified the following: On 07/15/22, Staff 2 (Director of Wellness) received a verbal phone order to "hold Clonidine (for hypertension) PRN, every 6 hours when SBP (systolic blood pressure) was over 155 and PRN Bismuth every 6 hours (for indigestion), due to possible drug interaction with Clopidogrel (blood thinner)" until the physician completed a medication review. The PRN Bismuth and PRN Clonidine were held from 07/16/22 through 07/22/22. The medication review had not been completed, the facility failed to follow up with the physician and the medications were placed back on the MAR, resulting in the medications being available to administer to the resident. On 07/28/22, the PRN Clonidine was administered. b. A review of Resident 5's signed physician orders upon move-in indicated the resident was prescribed Oxycodone PRN, every eight hours for pain. The Oxycodone was transcribed onto the July and August 2022 MAR. During observation and interview on 08/08/22 with Staff 7 (MT) there was no PRN Oxycodone in the medication cart and there was no page for the Oxycodone in the narcotic disposition log for Resident 5. Staff 7 stated she "doesn't believe [she] had ever administered Oxycodone to the resident" and "believed the facility never received the Oxycodone from the pharmacy." The need to ensure the facility had a safe medication administration system was reviewed with Staff 1 (ED), Staff 2, Staff 15 (Director of Operations) and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments: Please reference C302, C303, C310, & C315 for plan of correction

2. Resident 1 was admitted in 09/2021 and had diagnoses including dementia and anxiety. Resident 2 had a physician's order for Lorazepam 0.5 mg, one tablet PRN for severe anxiety. The Controlled Substance Disposition Log revealed the Lorazepam was administered on 08/01/22, however, the MAR (reviewed from 08/01/22 through 08/08/22) lacked documentation that the resident received the medication. The inconsistency between the MAR and Controlled Substance Disposition log was reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They reviewed the documentation and acknowledged the discrepancies.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 3 sampled residents (#s 1 and 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: 1. Resident 4 was admitted in 2022 and had diagnoses which included hip replacement. Resident 4 had an order for oxycodone, one - two tablets (5 - 10 mg) every four hours PRN pain (1 tab for pain 1-5 and 2 tabs for pain 6 - 10). Resident 4's Controlled Substance Disposition Logs and MARs, reviewed from 8/1/22- 8/10/22, revealed two occasions when staff signed on the drug disposition log that the oxycodone was given. However, the MAR lacked documentation that the resident received the medication. Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/11/22. They reviewed the documentation and acknowledged the discrepancies.

OAR 411-054-0055 (1)(e.) Systems: Tracking Controlled Substances: 1.) Tracking Controlled Substances: The following action will be taken to correct each violation, per example written on the S.O.D:               a. Facility has corrected hole(s) in the MAR                   for resident #4, who received PRN pain                   medication per the narcotic log.               b. Facility has corrected hole(s) in resident #                   2's MAR, who received PRN for anxiety                   per the narcotic book. 2.) Tracking Controlled Substances: This system is being corrected to eliminate further violations, as follows:               a. Facility RCC is now completing a narcotic                   audit to: ensure appropriate documentation                   of PRN & Scheduled Narcotics, ensure                   consistency between narcotic book and                   MAR, to ensure all narcotics are destroyed                   per policy, and to identify any trends in                   narcotic administration. 3.) Tracking Controlled Substance: This system will be evaluated as follows:               a. Facility RCC will complete a narcotic                   audit at least once weekly,               b. Facility RCC will bring all narcotic audits to                   once monthly quality improvement                 meetings,             c. Facility Administrator will review all narcotic                 audits at least once monthly to ensure                 completion. 4.) Facility Administrator and Facility RCC will ensure on-going compliance.

2. Resident 6 was admitted to the facility in 03/2021 with high blood pressure, congestive heart failure and asthma. a. Resident 6 had a physician's order, dated 03/11/21, to administer Furosemide (for high blood pressure) 60 mg two times daily. The resident's 08/01/22 through 08/09/22 MAR revealed staff documented 40 mg of the medication was administered to the resident, not 60 mg as prescribed. b. Resident 6 had a physician's order, dated 03/11/21, to administer lactose, 300 units with meal, for digestion, Symbicort inhaler for asthma two times daily and Systane ultra-solution eye drops daily. The resident's 08/01/22 through 08/09/22 MAR revealed there was no indication those orders were transcribed to the MAR. c. Resident 6 had a physician's order, dated 03/11/21, to administer Famotidine, 40 mg with dinner, for indigestion. The resident's 08/01/22 through 08/09/22 MAR revealed staff documented 40 mg of the medication was administered at 8:00 am in the morning, not with dinner as prescribed. d. The resident's 08/01/22 through 08/09/22 MAR revealed staff documented Calcium 500 mg was administered two times daily and Breo Elli 100-25 mcg inhaler (for chronic obstructive pulmonary disease) daily was administered to the resident. There was no signed physician order to administer those medications. On 08/11/22, the physician orders and the MARs were reviewed with Staff 1 (ED) and Staff 15 (Director of Operations). They acknowledged the findings. 3. Resident 1 was admitted to the facility in 09/2021 with diagnoses including dementia and anxiety. Resident 1 had physician's orders to administer Lorazepam 0.5 mg, every eight hours, PRN for severe anxiety and Risperdone 0.5 mg, three times daily, PRN for physical aggression. Parameters prescribed by the physician included to administer the Risperidone "if not improved with use of PRN Lorazepam first". The 07/01/22 through 08/08/22 MARs revealed the resident was administered the Risperdone on 07/21/22, however, the Lorazepam had not been administered first and deemed ineffective, as the order instructed. The need to ensure medications were administered as ordered, including following parameters, was reviewed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to carry out orders as prescribed for 3 of 6 sampled residents (#s 1, 5 and 6) whose orders and MAR/TAR's were reviewed. Resident 5 was not administered blood pressure medications as prescribed which put the resident at risk. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 07/2022 with diagnoses including diabetes, stroke and hypertension. Resident 5's current signed physician orders and 07/01/22 through 08/08/22 MAR/TAR's were reviewed during the survey. a. The following was ordered by the physician: * Hydration monitoring every day and notify MD weekly, every Friday for signs and symptoms of dehydration; * Weekly skin audits every Tuesday during showers; * Weekly weights; and * Two hour skin checks when wearing prosthetics. There was no documented evidence the above orders were carried out as prescribed. b. The following medications were not carried out as prescribed: * Carvedilol tablet 6.25 mg, give 1 tablet by mouth 2 times per day with meals and hold for SBP (systolic blood pressure) less than 100 and HR (heart rate) less than 55. The MAR's indicated the resident was administered the medication at 8:00 am and 8:00 pm. The 8:00 pm dose was not given with meals and there was no documentation the SBP and HR were taken prior to administering the medication. * PRN Clonidine (for hypertension) every six hours, as needed, when SBP was over 155. The MARs and progress notes reviewed had some recorded blood pressure readings, intermittently, related to alert charting instructions. Resident 5's blood pressure was documented over the SBP of 155 on the following dates: * 07/02/22 (173/72); * 07/05/22 (166/84); * 07/09/22 (173/79); * 07/16/22 (165/69); * 07/28/22 (188/81); and * 08/05/22 (159/68). On 07/16/22, a progress note at 10:21 pm documented "systolic [blood pressure] number was very high of 165/69. Will recheck in 15 minutes. 183/80 complains of severe numbness and tingling in fingers and does not feel like [him/her] self. The PRN Clonidine was not administered. The resident was sent to the hospital at 11:36 pm. On 07/28/22 at 9:14 am, a progress note documented the resident's BP was elevated 188/81. The PRN Clonidine was administered. The resident's BP was rechecked at 12:20 pm and was recorded as 166/75. There was no further BP taken at the 6th hour to determine if the SBP was still over 155 which would require another dose of the PRN Clonidine. The failure to monitor Resident 5's SBP and administer the PRN Clonidine when systolic blood pressure was elevated above 155, as prescribed, put the resident at serious risk of potential harm. The need to ensure orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 15 (Director of Operations) and Staff 19 (VP of Operations). They acknowledged the deficiencies.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders: 1.) Treatment Orders: The following action will be taken to correct each violation per examples given on S.O.D:                a. Resident #s 1, 5 and 6 medication &                    treatment orders will be reconciled to                    ensure all orders are accurate & being                    administered as prescribed.                b. All medication aides responsible for                    administering medications will receive                    updated training related to medication                    administration with parameters.                c. Facility LN will audit all parameters                    on medications and treatments to ensure                    clear instructions for staff to follow.                d. Facility will implement parameter audits to                    ensure medications are being                    administered per set parameters, &                    identify any medications errors secondary                    to parameters, to ensure appropriate                    follow-up & monitoring. 2.) Treatment Orders: This system will be corrected to eliminate future violations, as follows:                a. All residents medications and treatments                    will be reconciled to ensure accurate &                    clear orders, via P.O.s at least quarterly.                b. Facility will complete a parameter audit                    at least bi-weekly to ensure accurate                  administration and to identify med-errors.              c. Facility LN will review triple checks (orders)                  at least once daily, and will ensure                  appropriate and clear parameters are in                  place. 4.) Facility Administrator, and Facility Nurse will ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 4 sampled residents (# 11) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 11 was admitted to the facility in 04/2021 with diagnoses including presenile dementia. Resident 11's MAR dated 02/01/23 through 02/21/23 and corresponding progress notes were reviewed and revealed the following: * Resident 11 had a prescriber's order to provide 237 mL of Vanilla Ensure three times a day with meals as a nutritional supplement; and * The resident's MAR was blank from 02/01/23 through the 8:00 am administration of Ensure on 02/07/23. On 02/22/23 at 3:10 pm, the surveyor and Staff 10 (MT) observed and checked the resident's MAR. Staff 10 was unable to confirm whether the supplement had been administered as prescribed. The need to ensure orders were carried out as prescribed was discussed with Staff 2 (ED), Staff 22 (Director of Wellness/RN), Staff 8 (Wellness Coordinator) and Staff 33 (Consultant) on 02/22/23. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders 1.) The following action has been taken to correct the rule violation for each example given on S.O.D:   a.) Wellness Coordinator documented in Resident #11's chart detailing the reason for having holes in the MAR, secondary to the Ensure (Supplement) Order.   b.) Current Ensure (Supplement) PRN order has been verified with PCP. 2.) Systems: Treatment Orders: Facility will correct this volation to prevent it from happening again as follows:   a.) Facility Administrator, RN Director of Wellness, and Wellness Coordinator will review holes daily and investigate to correct and ensure proper documentation is completed on a timely basis.   b.) RN Director of Wellness and Wellness Coordinator will provide training to medication technicians on how to correctly input, correct, and verify orders into the EMAR system. 3.) Systems: Treatment Orders: The system will be evaluated as follows:   a.) The Missed Meds Report will be audited daily as part of the 24/72 hour process   b.) Facility Administrator will audit all resident MARs weekly for any holes and ensure it is investigated and the follow-up is documented and/or corrected in the EMAR 4.) The Facility Administrator, Facility RN Director of Wellness, and Facility Wellness Coordinator will be responsible for ensuring all corrections to the resident's chart is made, and overseeing this system as stated above.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included clear parameters for administration of prescribed medications for 3 of 5 sampled residents (#s 1, 3 and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 11/2020 with diagnoses including dementia. Review of the 08/01/22 through 08/08/22 MARs noted the following as needed medication: * Tylenol 325 mg tablet, take 2 tablets every 4- 6 hours as needed for pain or fever. There were no resident-specific parameters regarding whether to administer the medication in 4 hours frame verses a 6 hour time frame. The resident did not receive the medication. On 08/09/22 and 08/10/22, the above findings were reviewed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations). They acknowledged the findings 2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including dementia and anxiety. Review of the physician's order, dated 03/15/22, and the 08/01/22 through 08/08/22 MAR noted the following discrepancy: * The resident had a physician's order for Lorazepam 0.5 mg by mouth every 8 hours PRN for severe anxiety; * Physician's order for Risperdone 0.5 mg by mouth three times daily as needed for physical aggression, paranoid delusional behavior. It included instructions to administer the Risperdone if agitation was not improved with the administration of Lorazepam first; * 08/01/22  MAR stated to give Risperdone 0.5 mg by mouth three times daily as needed for agitation. The resident-specific parameters were not transcribed as ordered for the Risperdone. In addition, the parameters did not provide clear instruction to staff regarding which medication to administer when the resident displayed either agitation, anxiety or aggression. The resident had received the Risperdone on 08/01/22. The need to ensure clear parameters were reviewed and provided for PRN medications was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. They acknowledged the findings 3. Resident 5 was admitted to the facility in 07/2022 with a diagnosis of diabetes. A review of the MAR/TAR from 07/01/22 - 08/08/22 identified the following deficiencies: * There were blanks on the MAR for Tylenol and Gabapentin on 07/06/22 at 2:00 pm; and * Documentation of the sliding scale dosage administered was inaccurately recorded on 31 occasions. The need to ensure accurate MAR/TAR's were kept was discussed with Staff 1 (ED), Staff 15 (Director of Operations), and Staff 19 (VP of Operations). They acknowledged the deficiencies.

OAR 411-054-0055 (2) Systems: Medication Administration: 1.) Medication Administration: The following action will be taken to correct each violation per examples given on S.O.D:            a. Resident #s 1, 3, and 5 medications &                treatments will be reconciled by facility                nurse to ensure appropriate parameters                and non-pharm interventions are in place                and clear, for non-licensed staff to follow.            b. Facility request Consonus Pharmacy Audit                1x for the next 3 months to ensure increased                oversight for medications; systems.            c. Vanda Consulting team is providing facility                with a 3-way cart audit to identify areas                including: parameters, non-pharm                interventions, updated P.O's w/ MD                signature.            d. Facility is correcting all holes to the MAR to                ensure appropriate documentation. 2.) Medication Administration: The system is being corrected to eliminate future violations as follows:           a. Facility will ensure that all resident's               medications & treatments are reconciled,           b. Facility RCC will complete a daily missed               medications report to ensure that med-techs               fix any holes noted, in a timely manner.           c. All medication-aides will receive updated             training on the 7 rights of medication             administration. 3.) Medication Administration: The system will be evaluated as follows:         a. Facility will complete P.O.s and reconciliation             at least, quarterly.         b. Missed medication report will be ran, at least             daily,         c. Facility administrator will review all medication             audits, at least once monthly 4.) Facility Administrator and Facility LN will ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure resident specific parameters and instructions for insulin were followed for 1 of 4 sampled resident (# 13) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 13 moved into the facility on 01/06/23 with diagnoses which included Diabetes and Alzheimer's disease. Physician orders and MARs for Resident 13, reviewed from 02/01/23 - 02/21/23, revealed the following: * A physician's order for Novolog (insulin) 100 units/ml to be injected three times a day with meals; and * The MAR included "HOLD IF CBG IS <200." On the following days Novolog was given even though the CBG was less than 200: * 02/09/23 - 5 pm CBG 145; * 02/10/23 - 12 pm CBG 69; * 02/11/23 - 8 am CBG 111; * 02/11/23 - 5 pm CBG 161; * 02/12/23 - 5 pm CBG 185; * 02/16/23 - 5 pm CBG 160; * 02/19/23 - 5 pm CBG 191; and * 02/21/23 - 8 am CBG 158. There was no documented negative outcome to Resident 13. The need to ensure resident specific parameters were followed was reviewed with Staff 2 (ED) 02/22/23 at 11:00 am. She reviewed the MARs with the surveyor and acknowledged the findings. She stated the MTs would receive additional training on medication administration and documentation. No further information was provided.

OAR 411-054-0055 (2) Systems: Medication Administration 1.) The following action has been taken to correct the rule violation for each example given on S.O.D:   a.) Director of Wellness provided one-on-one education to the medication technicians who have been identified as having medication errors secondary to insulin administration parameters, on medication administration and documentation.   b.) Resident #13's Primary Care Provider was faxed of the medication administration errors and that there were no ill effects. 2.) Systems: Medication Administration: Facility will correct this volation to prevent it from happening again as follows:   a.) Director of Wellness and Wellness Coordinator provided additional training with all medication technicians involving medication administration and documentation in general.   b.) Specific QuickMAR training will be given by Director of Wellness and Wellness Coordinator to medication technicians and will be required of any newly hired medication technicians. This will include focused training on medication parameters, where to find them in the order & when to notify the community RN. 3.) Systems: Medication Administration: The system will be evaluated as follows:   a.) Medications with parameters will be audited daily by the clinical team as part of the 24/72 hour process.  b.) Facility Administrator will audit all resident MARS weekly for any discrepancies involving medications with parameters. 4.) Facility Administrator, RN Director of Wellness, and Wellness Coordinator will be responsible for ensuring all education provided and overseeing this system as stated above.

3. Observations of Resident 3 during the survey and review of his/her records between 06/08/22 and 08/08/22 indicated that facility staff administered treatments, including barrier cream, on bottom area for redness. The facility failed to document on Resident 3's TAR that the treatment was administered. The need to ensure all treatments administered by the facility were documented on the TAR was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. Staff acknowledged treatments administered by the facility were not being documented on resident TARs.

Based on interview and record review, it was determined the facility failed to keep an accurate treatment record of all treatments ordered by a legally-recognized practitioner and administered by the facility, for 3 of 4 sampled residents (#s 1, 2 and 3) whose TARs were reviewed. Findings include, but are not limited to: 1. Resident 1's records indicated that between 05/10/22 and 08/08/22, facility staff administered treatments, including first aid and wound care, for the following conditions: * A cut to the forearm; * A wound to the elbow; * A skin tear to the wrist; * A cut to the top of the head; and * Skin tears to the forehead. 2. Resident 2's records indicated that between 05/19/22 and 08/08/22, facility staff administered treatments, including wound care, for the following conditions: * A skin tear to the hand; * An abrasion to the knee; * A dry, flaky rash to the top of head, neck and forehead; and * An open and draining wound to the neck. The facility failed to document any of the treatments it administered on Resident 1 or Resident 2's TARs. The need to ensure all treatments administered by the facility were documented on the TAR was discussed with Staff 1 (ED) and Staff 2 (Director of Wellness) on 08/10/22. Staff 2 acknowledged treatments administered by the facility were not being documented on resident TARs.

OAR 411-054-0055 (3) Systems: Treatment Administration: 1.) Treatment Administrations: This system is being corrected for each violation per examples given on S.O.D:             a. Residents' #1, 2 & 3 will be assessed                 by LN for any current skin event(s) and                 orders for treatment or monitoring will be                 added to the TAR for staff to follow,             b. Facility has implemented a skin-log sheet                 that will be kept in the 24hr binder, to ensure                 that all active skin events have oversight &                 current interventions and orders for staff to                 follow,             c. Facility medication-aides will receive further                 training on the change of condition process,                 including placing resident(s) on alert w/skin                 events, writing a TSP, and adding resident                 to the skin log in the 24hr binder. 2.) Treatment Administrations: This system is being corrected to eliminate future violations as follows:             a. Facility has implemented a skin-log to the                 24hr binder, that facility LN will review                 daily to ensure appropriate oversight,                 interventions, and treatment orders,             b. Vanda Consultant is working with facility                 LN on the short-term change of condition                 process, related to skin events. This will               include the process of reviewing alerts daily,               assessing residents with new skin events               discontinuing short-term alert &               implementing interventions via TSP, as well               as, creating an order in the TAR for tx and/or               monitoring skin event,               ensuring staff completed an incident               report, and adding resident to weekly skin               assessments, until resolved.           c. IDT will review 24hr binder/audit, daily during               clinical drill down, to ensure oversight &               timely follow-up. 3.) Treatment Administrations: This system will be evaluated as follows:           a. Skin log and resident alert log will be               reviewed daily by facility LN (work-days),           b. Skin logs will be reviewed once monthly by               facility LN to identify trends/concerns, & IDT               will review during monthly QI meeting.           c. Facility RCC will review all skin-events noted               when completing 24/72hr audit, to ensure               skin event is on skin log, resident is on alert,               incident report is completed, and facility LN               is aware of change(s) of condition. 4.) Facility LN, Facility Administrator, and Facility RCC will ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure a resident who self administered a subcutaneous medication monthly and a resident who had daily insulin injections were evaluated initially and at least quarterly to assure the ability to self administer medications for 2 of 2 sampled resident (#s 4 and 5). Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in July 2022 with diagnoses including arthropathic psoriasis. A review of Resident 4' clinical information revealed the following: * Resident 4 was self-administering his/her Taltz subcutaneous solution for psoriasis; * There was no documented evidence a complete evaluation of the residents' ability to self administer Taltz subcutaneous solution for psoriasis  was completed; and * There was no documented evidence the facility obtained a written physician order authorizing the resident to self-administer the Taltz subcutaneous solution for psoriasis. In an interview on 08/08/22 at 2:00 pm, Staff 2 (Director of Wellness) confirmed she was aware the resident required an order to self-administer her/his injection and had not yet completed an evaluation of the resident's ability to self administer medications. The need to complete evaluations of a resident's ability to self administer medications initially and at least quarterly was discussed with Staff 1 (ED) and Staff 2 on 08/11/22. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 07/2022 with diagnosis including diabetes. A review of Resident 5's clinical record identified the following: * Resident 5 was self-administering his/her scheduled insulin, including taking CBG's prior to administering sliding scale dose; * There was no documented evidence a complete evaluation of the residents' ability to self administer insulin was completed; and * There was no documented evidence the facility obtained a written physician order authorizing the resident to self-administer the insulin. During an interview with Staff 2 (Director of Wellness) on 08/08/22 at 2:00 PM, she confirmed there wasn't a physician order that authorized the resident to self-administer insulin. The need to complete evaluations of a resident's ability to self administer medications and have a signed, written doctor's order for the resident to self-administer medications was discussed with Staff 1 (ED), Staff 15 (Director of Operations), and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0055 (5) Systems: Self-Administration of Medications: 1.) Self-Administration: This system is being corrected for each violation per examples given on S.O.D:                a. Resident 4: Facility will obtain a written                    physician's order for resident to self-                    administer medication. Facility will                    complete a self-medication evaluation to                    ensure resident's ability to self-administer                    medications/subcutaneous injection,                b. Resident 5: Facility now administers                    resident's insulin, and all staff have been                    delegated. 2.) Self-Administration of Medications: This system is being corrected to eliminate future violations, as follows:                a. Facility is working with Vanda Consultant                    to create a self-medication policy that                    meets Oregon regulations, as well as,                    an updated self-medication evaluation                    form,                b. Facility LN and RCC will be trained on                    updated self-medication evaluation policy,                c. Facility LN and RCC are completing an                    audit to identify any residents who self-                    administer medications, and will ensure                    that facility has a written order from MD for                    that resident to self-administer                    medications, and will complete a self-                    medication evaluation. 3.) Self-Medication Administration: This system will be evaluated as follows:                 a. Upon Admission - Facility LN and Facility                     administrator will identify the desire or                     request for a resident to self-administer                     their own medications, as part of the initial                     evaluation,                 b. Facility will review P.O's at least quarterly,                     and will ensure that any resident with                     on-going self-administration of medication                     is listed on P.O. and sent to provider,                 c. Facility will complete self-medication                     evaluations, quarterly as required. 4.) Facility LN, and Facility Administrator will oversee and ensure on-going compliance

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed for assistive devices with potentially restraining qualities for 2 of 2 sampled residents (#s 4 and 5) who had a supportive device. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 07/2022 with diagnoses including hip replacement. During the entrance conference on 08/08/22, Resident 4 was not identified as having bilateral siderails on his/her bed. An order for a hospital bed with side rails was in Resident 4's chart. Observations of the resident and the resident's room showed the siderails were on the bed and in the up position. The side rails were not in Resident 4's current service plan. Review of Resident 4's record revealed there was no documented evidence an assessment of the siderails had been completed by an RN, PT or OT. In an interview on 08/09/22 at 11:35 am, Staff 2 (Director of Wellness) stated no assessment had been completed for Resident 4's siderails. The lack of an assessment for the resident's siderails was discussed with Staff 1 (ED) and Staff 2 on 08/11/22. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 07/2022 with diagnoses including bilateral below the knee amputation. During the entrance conference on 08/08/22, Resident 5 was identified as having bilateral siderails on his/her bed. Observations of the resident and the resident's room on 08/09/22 showed ¼ length bilateral siderails were installed at the head of the hospital bed and were in the up position while the resident was laying in the bed. The side rails appeared intact and in good repair. During an interview with the resident on 08/09/22, s/he reported the preference to use the siderails for self transferring while using a slideboard and pulling him/herself across the slideboard. The resident further reported s/he used them to assist the caregivers during care that was completed in bed. Review of Resident 5's record revealed there was no documented evidence an assessment of the siderails had been completed by an RN, PT or OT. In an interview on 08/09/22 at 2:00 pm, Staff 2 (Director of Wellness) stated there was no assessment completed for Resident 5's siderails. The need to ensure the supportive devices with potentially restraining qualities were assessed by an RN, PT or OT was discussed with Staff 1 (ED), Staff 15 (Director of Operations), and Staff 19 (VP of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices: 1.) Restraints and Supportive Devices: The following actions are being taken to correct each violation per examples given on S.O.D:              a. Resident 4: Facility RN will complete                  a supportive device assessment to address                  bilateral side-rails, and facility RN will                  update resident's service plan to include                  the use of supportive devices, via TSP.              b. Resident 5: Facility RN will complete a                  supportive device assessment to address                  1/4 length bilateral side-rails. Facility RN                  will ensure that resident has an updated                  order for side rails, and will ensure that                  that resident's service plan is reflective of                  the use of supportive device(s). 2.) Restraints and Supportive Devices: This system is being corrected to eliminate future violations, as follows:              a. Facility has conducted a facility walk-                  through to identify all supportive devices in                  use.              b. Facility RN will ensure that all current                  support devices have a valid written order                  from the provider, are part of the resident                  service plan, and an assessment that                  includes the following: (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.                 (e) Documentation of the use of supportive                 devices with restraining qualities must be                 included in the resident service plan and                 evaluated on a quarterly basis or with a                 significant change of condition.              c. Facility RN will keep a log of all supportive                  supportive devices, to ensure that timely                  assessments are completed, on schedule.              d. Facility RN will provide training via in-                  service on proper use of bed-rails &                  supportive devices. 3.) Restraints and Supportive Devices: This system will be evaluated as follows:              a. With each new admission, as applicable,              b. Quarterly,              c. With significant change of condition. 4.) Facility RN and Facility Administrator will ensure oversight and on-going compliance.

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident during the night shift. Findings include, but are not limited to: 1. During the entrance conference and acuity interview on 08/08/22 the following was identified: * The facility consisted of two floors with resident rooms located on the first floor, in two separate units, for memory care residents and second floor for assisted living residents; * The facility had 50 residents; * One resident on the first floor required two-person assistance with transfers; and * One resident on the second floor required two-person assistance with transfers. 2. The facility's staffing plan for 08/2022 was as follows: * During the night shift, there was one caregiver assigned to the second floor and on multiple days, there were no staff assigned to the second floor. 3. On 08/08/22, at 9:30 am, at the entrance conference, the surveyor requested the facility staffing tool used to determine the number of caregiving staff needed to provide scheduled and unscheduled needs of the residents. Staff 1 (ED) stated she was aware of the requirement to have an acuity-based staffing tool, but the facility had not implemented it. 4. During the group interview, conducted on 08/09/22 at 11:00 am, multiple alert and oriented non-sampled residents stated the following: * Residents had made complaints to management related to delayed call light response times, especially on the night shift. 5. On 08/10/22, the survey team requested the call response logs from Staff 1. She stated she was not able to generate the call response logs. 6. During an interview on 08/10/11, Witness 1 stated several residents "on the assisted living unit expressed concern with the lack of staff available on the night shift", long wait times when a call light was initiated and a lack of any activity staff. Witness 1 verified they had previously expressed these concerns to Staff 1. The failure to ensure adequate staff to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 and Staff 2 (Wellness Director) on 08/09/22 and 08/10/22. They acknowledged the findings.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing: 1.) Staffing Requirements and Training: This following action is being taken to correct each violation per examples given on S.O.D:              a. Facility has increased staffing for NOC shift                  as follows: 3 Caregivers (1 for each POD)                  & 2 med-techs,              b. Facility is currently staffing to staffing                  requirement as outlined in conditions:                  Dayshift: 4 caregivers & 3 med-techs,                  Evening Shift: 4 caregivers & 3 med-techs,                  NOC shift: 3 caregivers & 2 med-techs,              c. Facility has completed the required acuity                  based staffing tool, on The Departments'                  site,              d. Facility will identify how to run the report for                  staff call lights and will review call light                  times, each morning during stand-up. 2.) Staffing Requirement and Training: This system is being corrected to eliminate future violations, as follows:              a. Until otherwise directed, facility will maintain                  staffing requirements set forth in conditions,              b. Upon removal of staffing requirements,                  facility will maintain staffing based on the                  most current ABST,              c. Facility maintenance director will audit &                pull all call-times from the last 24hrs and will                bring results to morning stand-up for IDT to                review,            d. Facility Administrator will update the ABST at                each evaluation (Initial, 30 day, quarterly) &                with significant change of condition, to                ensure adequate staff to meet the scheduled                & unscheduled needs of the residents. 3.) Staffing Requirement and Training: This system will be evaluated as follows:             a. Facility administrator will update the ABST                 with each resident evaluation completed                 (initial, 30-day, quarterly) and with significant                 change of condition,             b. Facility administrator will review the staff                 schedule at least once monthly to ensure                 the schedule is reflective of the staffing                 requirements as based on the ABST,             c. The facility maintenance director will run &                 review resident call times at least daily (on                 work days) and will bring this report to daily                 stand-up. 4.) The Facility Administrator and Facility Maintenance Director will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose records were reviewed. Findings include, but are not limited to: There was no documented evidence the facility was using an ABST which would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents. On 08/08/22, Staff 1 (ED) reported the facility had not implemented an ABST. The need to implement an ABST was discussed with Staff 1 and Staff 2 (Wellness Director). They acknowledged the findings.

OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool: 1.) Acuity-Based Staffing Tool: The following action is being taken to correct each violation per examples given on the S.O.D:               a. Facility has completed the Acuity-Based                   Staffing Tool on The Department's Site,               b. Facility RCC will receive training related to                   ABST requirements, to ensure the                   staffing schedule meets requirements. 2.) Acuity-Based Staffing Tool: This system is being corrected to eliminate future violations, as follows:              a. Facility is working with Vanda Consultant                  to create policies & procedures related to                  the ABST,              b. Facility IDT will receive training related to                  the requirements of the Acuity-Based                  Staffing Tool,              c. Facility will maintain ABST and update                  resident care needs in the ABST at time                  of each resident evaluation &/or with any                  significant change of condition              d. Facility Administrator will review staffing                  schedule to ensure that the schedule is                  reflective of staffing requirements based on                  the ABST. 3.) Acuity-Based Staffing Tools: This system will be evaluated as follows:              a. Facility will update the ABST with each                  resident evaluation: initial, 30-days,                  quarterly, and with significant change of                  condition,              b. Facility Administrator will review monthly                  staffing schedule to ensure that schedule                  is reflective of staffing needed per the ABST                  at least once monthly. 4.) Facility Administrator and Facility RCC will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics was completed and documented for 4 of 4 sampled staff (#s 3, 4, 5 and 6). Findings include, but are not limited to: Facility training records were reviewed on 08/08/22 and 08/09/22. Staff 3 (CG) hired 06/2022, Staff 4 (MT) hired 05/2022, Staff 5 (CG) hired 06/2022 and Staff 6 (Housekeeper) hired 06/2022, lacked documented evidence of completing the following required elements of the pre-service orientation: * Staff 3, 5 and 6 lacked documentation of resident rights and values of CBC care; and * Staff 3, 4, 5 and 6 lacked evidence of standard precautions for infection control. The need for new staff to complete the required pre-service orientation training before working with residents was reviewed with Staff 1 (ED) on 08/09/22. No additional information was received.

OAR 411-054-0070 (3-4) Staffing Requirements and Training: Caregiver Requirements: 1.) Caregiver Requirements: The following action is being taken to correct each violation per example given on the S.O.D:              a. Staff members 3, 4, 5, & 6 will complete all                  pre-service training as required, with                  documented evidence of training in                  their respective training files. 2.) Caregiver Requirements; Training: The following corrections are being made to eliminate future violations:              a. Facility B.O.M has created an updated                  training grid, with all required Pre-service,                  within 30 days, and annual on-going                  training.              b. Facility is updating new-hire orientation to                  include pre-service trainings: Resident                  Rights, & Values of CBC Care,              c. Facility is completing an audit on staff                  staff training, and will ensure each staff                  member has required training and                  documents. 3.) Caregiver Requirements; Training: This system will be evaluated as follows:              a. Facility B.O.M will review training grid at                  least once monthly,             b. Facility Administrator will review all new-hire                 orientation and training, at least once                 monthly, to ensure compliance,             c. Facility B.O.M will bring staff training grid to                 Quality Improvement meetings to review                 with IDT, at least once monthly.             d. Facility will schedule new-hire orientation at                 least once monthly, to ensure all pre-service                 training is completed. 4.) Facility Administrator and Facility B.O.M will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 3, 4 and 5) had demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 08/08/22 and 08/09/22. There was no documented evidence Staff 3 (CG), Staff 4 (MT), and Staff 5 (CG), hired 06/17/22, 05/13/22, and 06/17/22, respectively, demonstrated competency in all assigned job duties within 30 days of hire in the following areas: * Role of service plans in providing individualized care: * Providing assistance with ADLS; * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; and * Conditions that require assessment, treatment, observation, and reporting. The need to ensure newly-hired direct care staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (ED) on 08/09/22. No further documentation was provided.

OAR 411-054-0070 (6)(9) Training within 30-days: Direct Care Staff: 1.) Training within 30-days: The following actions are being take to correct future violations per examples given on S.O.D:              a. Facility will complete med-tech and Care-                  giver competency with staff, #s 3, 4, & 5.                  Each staff member will show return                  demonstration with trainer. 2.) Training within 30-days: The following corrections are being made to eliminate future violations:              a. Facility B.O.M has created an updated                  training grid, to be reflective of required                  staff trainings,              b. Facility has created 2 competency                  checklists: One for caregivers & one for                  med-techs,              c. Facility will ensure that all current staff have                  appropriate competency checklists,                  including return demonstration,              d. All new-hires will be scheduled for new-hire                  orientation to ensure that all applicable                  training - including competency checklists,                  are scheduled and handed out. 3.) Training within 30-days: This system will be evaluated as follows:             a. B.O.M will review and update training grid               at least once monthly, with new-hire               orientation,            b. All direct-staff will have competency                checklists with return demonstration                completed within 30 days of hire,            c. Facility Administrator and Facility B.O.M                will review staff training grid, at least once                monthly during Quality Improvement                meetings. 4.) The Facility Administrator and Facility B.O.M will ensure oversight and on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 26 and 28) had verification of demonstrated competency in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 02/21/23. 1. There was no documented evidence Staff 26 (MT), hired 12/27/22, demonstrated competency in the topic of changes associated with normal aging. 2. There was no documented evidence Staff 28 (MT), hired 01/10/23, had demonstrated satisfactory performance in all assigned duties, including: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. There was no documented evidence the facility had observed and evaluated Staff 28's ability to perform safe medication and treatment administration, unsupervised. The surveyor requested the facility remove Staff 28 from medication and treatment administration until demonstrated competency was documented in all assigned job duties. The facility expressed compliance with the request. The need to ensure newly-hired direct care staff had verification of demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 2 (ED) and Staff 31 (Business Office Manager) on 02/21/23. They acknowledged the findings.

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff 1.) The following actions will be taken to correct each violation, per examples written on S.O.D:   a.) Staff 26 was provided training and demonstrated competency with the completion of a new skills checklist including the topic of changes associated with normal aging.   b.) Staff 28 was pulled off of the floor and has completed their demonstrated competency skills checklist and has provided documentation of all necessary training prior to returning to the medication cart, including: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; *Changes associated with normal aging; *Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; *Conditions that require assessment, treatment, observation and reporting; and *General food safety, serving, and sanitation 2.) Training within 30 days: Direct Care Staff: This system is being corrected to eliminate future violations, as follows:   a.) All newly hired staff will be given their skills checklists and manuals at orientation. Newly hired staff will be educated on how to complete the checklists, who needs to observe & sign the checklist and where they shall be kept in the community.   b.) These checklists are to be left here at the community in the hanging file folder near the B.O.M office after each shift and turned in once completed to the same hanging file folder to ensure it is accurately and thoroughly completed.   c.) Staff will not be able to work independently beyond their 30 days without the competency checklist verified and turned into the Business Office Manager and/or Facility Administrator. If found working on the floor they will be pulled from the schedule until their skills checklist is completed. 3.) Training within 30 days: Direct Care Staff: This system will be evaluated as follows:   a.) Business Manager and Facility Administrator will check the designated areas for the status of any checklists in the process of completion and/or completed and turned in competency checklists, once daily.   b.) Business Manager and Facility Administrator will review weekly the upcoming week's schedule to ensure that all staff beyond their 30 days that is working on the floor have a completed skills checklist.     c.) Business Office Manager and Facility Administrator will audit monthly that all staff have the necessary trainings needed. 4.) Facility Administrator and Facility Business Office Manager will be responsible for ensuring completion and monitoring of this system as stated above.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. Findings include, but are not limited to: On 08/09/22, fire drill and fire and life safety records were reviewed from February 2022 through July 2022. The following deficiencies were identified: 1. There was no documented evidence the facility was providing fire and life safety training on alternating months for staff; and 2. The evacuation/drill documentation did not contain information on: * The escape route used; * Evidence of alternate escape routes used; * Residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * The number of occupants evacuated. The need to meet all requirements for fire drills and fire and life safety instruction was reviewed with Staff 1 (ED) on 08/09/22. She acknowledged the findings.

OAR 411-054-0090 (1-2) Fire & Life Safety: Safety 1.) Fire & Life Safety: The following actions are being taken to correct each violations per examples given on S.O.D:              a. Facility is providing an in-service for all                  staff members to receive fire & life safety                  training. This training will be documented as                  required,              b. Facility is working with Vanda Consultant to                  create an updated fire drill form, to include                  the following required information:                  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                  g) Number of occupants evacuated 2.) Fire & Life Safety: This system is being corrected to eliminate future violations, as follows:              a. Facility Maintenance director is receiving                  updated training on the requirements for                  Fire & Life Safety; Fire Drills & on-going                  training,              b. Facility Maintenance director will conduct                  all fire drills and on-going training as                  required by regulations,              c. All documentation related to fire-drills &                  fire & life instructions/trainings, will be filed                  in the 'Fire Drill/Fire & Life Safety binder,                  and will be filed by month,              d. Facility Maintenance director will be                  required to turn in all fire drills and on-going                  fire and life safety training, each month                  during QI meeting.              e. Facility administrator will review & audit Fire                  & Life Safety Binder, to ensure compliance. 3.) Fire & Life Safety: This system will be evaluated as follows:              a. All fire drills and fire & life safety training                  will be reviewed on a monthly basis. 4.) The Facility Maintenance Director & Facility Administrator will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. This is a repeat citation. Findings include, but are not limited to: On 02/21/23, fire drill and fire and life safety records were reviewed from 11/2022 through 02/2023. The following were identified: 1. There was no documented evidence the facility provided fire and life safety training on alternating months of the fire drills for staff. 2. Written fire drill records did not include information on: * Location of simulated fire origin; * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. 3. Staff did not evacuate or relocate residents during all fire drills. 4. The fire alarm system was not activated during each fire drill. The need to ensure staff received fire and life safety instruction on alternate months and the requirements regarding fire drills were discussed with Staff 2 (ED) and Staff 18 (Director of Maintenance) on 02/21/23 at 2:40 pm. They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety 1.) Fire and Life Safety: Safety: The following action is being taken to correct each violation per examples given on S.O.D.:   a.) Facility will now be implementing a Fire and Life Safety Binder to include all 12 months and ensure that in each month there is documented evidence of either a fire drill conducted or resources used for Fire and Life Safety training.   b.) Facility Maintenance Director will be utilizing a fire drill form that has all necessary information, including: * Location of simulated fire origin; *The escape route used; *Problems encountered and comments relating to           residents who resisted or failed to participate in the drills; *Evacuation time period needed; and * Number of occupants evacuated.     c.) Facility Administrator and Maintenance Director will verify and ensure that on each fire drill, residents are either evacuated and/or located and ensure it is documented on the new fire drill form.   d.) Facility Administrator and Maintenance Director will verify and ensure that on each fire drill, the fire alarm system was activated during each shift and it is documented on the fire drill form. 2.) Fire and Life Safety: Safety: This system is being corrected to eliminate future violations as follows:   a.) A new fire drill form is being utilized with all of the required documentation needed.   b.) Facility will be using a Fire and Life Safety binder to show evidence of compliance each month. 3.) Fire and Life Safety: Safety: This system will be evaluated as follows:   a.) Facility Maintenance Director and Administrator will review monthly the Fire and Life Safety binder to ensure all components of the requirement are met and plan accordingly.   b.) Fire and Life Safety binder to be audited during each QA monthly meeting and discussed by leadership team on future planning for drills and/or educational topics for the following month. 4.) Facility Administrator and Facility Maintenance Director will be responsible for implementing all new documentation and continued monitoring of this system as stated above.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements for residents were met. Findings include, but are not limited to: Fire drill records from 02/2022 through 07/2022 were reviewed on 08/09/22 with Staff 1 (ED). The facility lacked documentation of the following required elements: * Evidence residents were being instructed on fire and life safety procedures, including designated meeting places inside or outside of the building in the event of an actual fire, within 24 hours of admission. The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (ED) 08/09/22. She acknowledged the findings.

OAR 411-054-0090 (5) Fire & Life Safety: Training for Residents: 1.) Fire & Life Safety Training for Residents: The following actions are being taken to correct each violation per examples given on the S.O.D:               a. All residents will be instructed on 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, and re-                   instructed annually. Residents who do not                   have the mental capability to understand                   fire & life instructions and/or training, will                   have clear evacuation instructions in                   their service plans, for staff to reference. 2.) Fire & Life Safety Training for Residents: This system is being corrected to eliminate future violations as follows:              a. All new residents will be instructed of fire &                  life safety, within 24hrs of move-in, and                  reinstructed annually thereafter.              b. All resident fire and life safety                  documentation will be filed and kept on-site,              c. Facility Maintenance Director will keep an                  on-going spreadsheet of residents'                  admission dates, and dates of re-instruction              d. Facility Maintenance director will bring all               fire & life safety training for residents, to               Quality Improvement Meetings for review. 3.) Fire & Life Safety Training for Residents: This system will be evaluated as follows:            a. Within 24hrs of a new resident admission, &            b. Annually thereafter,            c. Facility administrator will review fire & life                safety for residents, at least once monthly                to ensure compliance. 4.) Facility Maintenance Director and Facility Administrator will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not have drop-offs and the facility grounds were kept orderly and free from refuse. Findings include, but are not limited to: 1. Observations of the exterior of the facility and interior courtyard on 08/08/22 showed drop-offs along pathway edges in the interior courtyard in excess of 3 inches in multiple areas. 2. An exterior corridor between the buildings had discarded and broken furniture, mobility devices and broken office chairs. The need to ensure pathways in the resident courtyard did not have drop-offs and the exterior of the facility was kept free of refuse was discussed with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22 at 11:30 am. They acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior: 1.) General Building Exterior: The following actions are being take to correct each violation, per the examples given in the S.O.D:              a. Facility has received a BID for landscaping                  to fill drop-off areas along the pathway                  edges, in the courtyard.              b. All broken furniture, mobility devices, &                  broken office chairs have been removed                  from the exterior corridor. 2.) General Building Exterior: The following corrections are being made to eliminate future violations:              a. Facility has implemented a building walk-                  through, which will include facility                  administrator & facility maintenance director                  to identify any environmental concerns. 3.) General Building Exterior: This system will be evaluated as follows:               a. Facility Maintenance Director & Facility                   Administrator will conduct once weekly                   walk-throughs, using the environmental                   checklist sheet,               b. Facility Maintenance director will bring all                   documents pertaining to environmental                   concerns or findings, to Quality                   Improvement meeting, once monthly. 4.) Facility Maintenance Director & Facility Administrator will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to ensure the interior environment was kept clean and in good repair. Findings include, but are not limited to: A tour of the facility was conducted on 08/08/22 through 08/11/22. The facility was comprised of an RCF upstairs and an endorsed memory care downstairs. The MCC units were split into two separate units that were titled MC1 (Memory Care One) and MC2 (Memory Care Two). a. MC1 required cleaning and repair in the following areas: * Multiple recliners in common areas were torn, rendering the surface uncleanable; * Toilet riser in the common use bathroom was rusted, rendering the surface uncleanable; * Gouges and peeling paint on common use bathroom door, room 128, 134, 135, and 139; * Splintered and peeling paint on handrail between rooms 124 and 126, and near rooms 129, 135, 138, 141 and 145; * Multiple wall corners in the dining room and hallway corridors were gouged with exposed sheetrock and metal underneath; and * Wall gouged and peeling paint (underneath handrail) between fire door and room 135 and around the air return vent (near med room). b. MC2 required cleaning and repair in the following areas: * Multiple recliners in common areas were torn, rendering the surface uncleanable; * Splintered and peeling paint on handrail near room 156; * Wall gouged with peeling paint approximately 10 feet above couch and drink station in the dining room; * Multiple wall corners in the dining room, hallway corridors and the wall (with windows) behind the dining room tables were gouged with peeling paint and exposed sheetrock underneath; * Wall gouged with peeling paint (underneath handrail) near electrical panel labeled 1A and 1B, rooms 102, 106, 115 and 123; and * Multiple resident room doors had gouged and peeling paint. c. RCF (upstairs) required cleaning and repair in the following areas: * Splintered handrail near room 207; and * Gouged doors on rooms 203, 207, 208 and 234. The above areas were toured and discussed with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22 at 11:30 am. They acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors: 1.) Facility Doors, Walls, Elevators, & Odors: The following action is being taken to correct each violation per examples given on S.O.D:             a. Facility Maintenance Director is working on                 all environmental deficiencies in MC1, MC2,                 & RCF.             b. Maintenance Director is working down the                 list of environmental deficiencies in order                 order of priority. 2.) Facility Doors, Walls, Elevators, & Odors: This system is being corrected to eliminate future violations as follows:             a. Facility has created new procedures                 for environmental walk-throughs, in an                 attempt to identify areas that need                 immediate attention.             b. Facility Maintenance Director & Facility                 Administrator will document findings on                 weekly environmental checklist. This                 document will have an area for goal of                 completion.             c. Facility environmental walk-through checklist                 will be filed each week, and then brought to                 Quality Improvement meeting to review                 areas that have not been fixed/corrected. 3.) Facility Doors, Elevators, & Odors: This system will be evaluated as follows:               a. Facility Maintenance Director & Admin                   will conduct environmental walk-throughs                   at least once weekly,               b. Environmental walk-through checklist will                   reviewed at least once monthly by IDT to                   ensure follow-up. 4.) Facility Administrator & Facility Maintenance Director will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to: The facility laundry room was observed on 08/08/22 with Staff 18 (Maintenance Director). The washing machines were a residential type with no indicator for the water temperature. The detergent the facility used did not include a disinfecting agent. The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (ED) and Staff 18 on 08/09/22 at 11:30 am. They acknowledged the findings.

OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry: 1.) Housekeeping and Laundry: The following actions are being taken to correct each violation per example given on S.O.D:               a. Facility is working with Eco-Labs to obtain                   the best chemical disinfectant for laundry, 2.) Housekeeping and Laundry: This system is being corrected to eliminate future violations as follows:               a. Facility Maintenance Director will ensure                   that all washing machines have approved                   chemical sanitizer, in stock and in use. 3.) Housekeeping and Laundry: This system will be evaluated as follows:               a. While conducting environmental                   walk-throughs, facility maintenance                   director will ensure that all washers are                   using chemical sanitizer, & that chemical                   sanitizer is in stock. Environmental                   walk-throughs will be conducted weekly. 4.) Facility Maintenance Director and Facility Administrator will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to: During a tour of the facility with Staff 1 (ED) and Staff 18 (Maintenance Director) on 08/09/22, the following observations were made: * Wall heaters with surface temperatures of 136 - 158 degrees Fahrenheit, were installed under the paper towel dispensers between the sink and toilet in common use bathrooms where residents could potentially come into incidental contact. Staff 1 and Staff 18 acknowledged the need to ensure wall heater covers did not exceed 120 degrees Fahrenheit. Staff 18 stated the wall heater knobs would be removed which would disable the use of the wall heaters. On 08/11/22, a random check of the common use bathrooms identified the wall heaters were inoperable.

OAR 411-054-0200 (8) Heating and Ventilation: 1.) Heating and Ventilation: The following actions are being taken to correct each violation, per examples given on S.O.D:                a. Wall Heaters in common area bathrooms                    have been disabled.                b. Facility Maintenance director is working                    to identify the temperature malfunction                    in the heaters in the common bathroom. 2.) Heating and Ventilation: This system is being corrected to eliminate future violations, as follows:                a. Facility Maintenance director will keep                    a spreadsheet of all temperatures, to                    ensure compliance,                b. Facility Maintenance Director will check                    the temperatures of all common area                    wall heaters, to ensure temps below                    120 degrees F.                c. Facility Maintenance Director will keep a                    log of all temperature checks and bring it                    to monthly Quality Improvement meetings                    to discuss any concerns or follow-up                    needed.                d. Facility Administrator will review temp-logs                    at least once monthly to ensure                    all temperatures are within required                    parameters, as well as, conducting                    random spot-checks for temps.

Based on observation and interview, it was determined the facility failed to ensure exit door alarms were functioning to alert staff when residents exited the RCF. Findings include, but are not limited to: The facility was toured on 08/09/22 with Staff 1 (ED) and Staff 18 (Maintenance Director) and the following was identified: * There were two exit doors in the MCC units that opened into the secured courtyard. The doors had alarms installed but the alarms had been manually disabled and the doors were locked. The need to ensure the facility had operable exit door alarms was discussed with Staff 1 and Staff 18. They acknowledged the findings and Staff 18 activated the door alarms during the facility tour. Refer to Z 168.

OAR 411-054-0200 (11-13) Call System, Exit Door Alarms, Phones, TV, or Cable: 1.) Exit Door Alarms: The following action is being taken to correct each violation per examples given on S.O.D:              a. Facility has had MCC door alarms fixed as                  of 8/10/22 - By Davis Lock & Safe Co. MCC                  Exit doors now have a visual and audible                  alarm when opened. 2.) Exit Doors: The following corrections have been made to eliminate future violations:               a. MCC staff to have in-person training                   related to exit doors in MCC, how the alarm                   system works, and when to notify facility                   maintenance director if not working                   correctly,               b. Facility Maintenance director will check                   MCC exit doors to courtyard, when                   conducting environmental walk-throughs. 3.) Exit Doors: This system will be evaluated as follows:               a. Maintenance Director will check exit doors                   in MCC, at least once weekly during                   environmental walk-through. 4.) Facility Maintenance Director and Facility Administrator will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units per their evaluated needs. Findings include, but are not limited to: Review of records for Residents 1, 2, and 3 revealed no documented evidence the residents had been evaluated for the ability to manage keys to their rooms. On 08/09/22 at 12:25 pm, in an interview with Staff 2 (Wellness Director/LPN), she confirmed there was no documented evidence the residents' ability to manage keys was evaluated and serviced plan if the residents were not able to manage their keys. On 08/09/22 and 08/10/22, the need to ensure all residents were evaluated for the ability to manage keys to their units and provided keys, based on those evaluations, was discussed with Staff 1 (ED) and Staff 2. They acknowledged the findings.

OAR 411-004-0020(2)(e.) Individual Door Locks: Key Access: 1.) Individual Door Locks: The following actions are being taken to correct each violation per example given on S.O.D:                  a. Resident #s 1, 2, and 3 will be evaluated                      for the ability to manage keys to their room.                  b. Facility is conducting an audit to identify                      all residents who need Lock & Evaluation 2.) Individual Door Locks: The system is being corrected to eliminate future violations, as follows:                 a. Facility is working with Vanda Consultant                     to create policies and procedures for                     individual door locks,                 b. Facility is working with Vanda Consultant                     to create a Lock and Key Evaluation.                 c. IDT will receive training related to                     evaluating resident(s) for ability to use                     a lock and key. 3.) Individual Door Locks: This system will be evaluated as follows:                 a. All new admissions will be evaluated for                     ability to manage keys, within 24hrs of                     admission,                 b. Lock and Key evaluations will be                     completed during quarterly evaluations                     thereafter. 4.) Facility Administrator and Facility Maintenance Director will oversee and ensure on-going compliance.

Based on observation and interview, the facility failed to ensure residents who lived in the facility had the freedom and support to have access to food at any time.  Findings include, but are not limited to: Observations of the RCF between 08/08/22 and 08/11/22 showed no snacks were provided to residents and two large glass drink dispensers in the RCF dining area were not filled with any beverages for the resident's consumption.  The residents did not have refrigerators or kitchenettes in their rooms. In an interview on 08/09/22, an unsampled resident stated sometimes the facility provided snacks if they were requested by residents but sometimes there were none available. The need to ensure all residents had access to food at any time was discussed with Staff 1 (ED), Staff 2 (Director of Wellness) and Staff 15 (Director of Operations) on 08/11/22. They acknowledged the findings.

OAR 411-004-0020 (2)(j) Individual Freedom: Access to Food Any Time: 1.) Access to Food: The following actions will be taken to correct each violation per example given on S.O.D:                a.) Facility has created a hydration and                     nutrition station in each POD that                     includes snacks and drinks for the                     residents at any time.                b.) Facility will ensure that sandwiches and                     fruit are available at all times as well. 2.) Access to Food: The system is being corrected to eliminate future violations, as follows:                 a.) Facility Activities Coordinator will ensure                      that nutrition and hydration stations are                      fully stocked, each morning.                 b.) Facility administrator is speaking with all                      residents and staff to let them know that                      sandwiches, fruit, deserts, etc ...are                      available anytime of the day. 3.) Access to Food: This System will be evaluated each morning by either activities director, or direct care staff, by ensuring all nutrition and hydration carts are fully stocked. 4.) Facility Administrator will oversee and ensure on-going compliance.

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 150, C 154, C 156, C 160, C 231, C 242, C 360, C 361, C 370, C 372, C 420, C 422, C 510, C 513, C 530, C 540 and C 555.

OAR 411-057-0140 (2) Administration Compliance: Please reference C150, C154, C156, C160, C231, C242, C360, C361, C370, C372, C420, C422, C510, C513, C530, C540, and C55 for Plan of Correction.

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 C372 and C420.

OAR 411-057-0140(2) Administration Compliance Please reference C372 and C420 for plan of correction.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities.  Findings include, but are not limited to: Refer to C 252, C 260, C 262, C 270, C 280, C 282, C 290, C 300, C 302, C303, C 310, C 315, C 325 and C 340.

OAR 411-057-0160 (2b) Compliance with Rules Healthcare: Please reference C252, C260, C262, C270, C280, C282, C290, C300, C302, C303, C310, C315, C325, and C340 for plan of correction.

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 and C303.

OAR 411-057-0160(2b) Compliance with Rules Health Care Please reference C260 and C303 for plan of correction.

3. Resident 3 resided on the memory care unit. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs. Observations performed during the survey at meal times revealed the resident required hands-on assistance to eat meals, was provided regular texture foods and nectar thickened liquids to drink. The resident ate some of his/her meals with staff assistance. The resident was not observed to be provided with snacks or fluids between the morning and noon meals, during observations on 08/08/22 and 08/09/22. The resident had experienced a significant weight decline over the past five months and was dependent on staff to meet nutrition and hydration needs. The service plan did not address hydration needs and lacked information on interventions to monitor weight loss. The lack of an individualized nutritional plan was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 08/10/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutritional plans for each resident were developed and included in service plans for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to: 1. Resident 1 resided on the memory care unit and had been identified, in the entrance conference interview, to require meal assistance. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs. Observations performed during the survey at meal times revealed the resident required frequent cueing and hands-on assistance to eat meals. The resident was able to eat most of his/her meals with staff assistance. During observations on 08/08/22 and 08/10/22, the resident was not provided with snacks or fluids between the morning and noon meals. The resident had experienced slow weight decline over the past six months and was dependent on staff to meet nutrition and hydration needs. The service plan did not address hydration needs and lacked information on interventions to monitor weight changes. 2. Resident 2 resided on the memory care unit and had been identified, in the entrance conference interview, to require meal assistance. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs. Observations performed during the survey at meal times revealed the resident required hands-on assistance to eat meals, was provided regular textured foods and was able to use a cup to drink nectar thickened liquids independently. The resident ate most of his/her meals with staff assistance. During observations on 08/08/22 and 08/09/22, the resident was not provided with snacks or fluids between the morning and noon meals. The resident had experienced significant weight increase over the past five months and was dependent on staff to meet nutrition and hydration needs. The service plan did not address hydration needs, the provider recommendation to provide a mechanical soft diet and lacked information on interventions to monitor the weight increase. The lack of an individualized nutritional plan was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 08/10/22. They acknowledged the findings.

OAR 411-057-0160 (2)(c.)(A)(B) Nutrition and Hydration: 1.) Nutrition and Hydration: The following action will be taken to correct each violation per example given on S.O.D:              a. Facility will write individualized nutrition &                  hydration plans for resident #s 1, 2, and 3.                  Individualized nutrition and hydration plans                  will be written via TSP, and be entered into                  resident's Service Plan. 2.) Nutrition and Hydration: The following corrections will be made to eliminate future violations:              a. Facility is working with Vanda Consultant to                  create a policy and process around                  Nutrition and Hydration plans,              b. Facility is conducting an audit to identify any                  residents who are lacking a nutrition and                  hydration plan. Facility will ensure all MCC                  residents have an individualized nutrition &                  hydration plan.              c. All direct-care staff will have access to each                  resident's nutrition and hydration plan, via                  TSP. 3.) Nutrition and Hydration: This system will be evaluated as follows:              a. Facility Administrator, LN, and/or RCC will                  review MCC nutrition and hydration plans                  during each resident evaluation/SP:                  Initial, 30-days, quarterly thereafter, and with significant change of condition. 4.) Facility Administrator, Facility LN, and RCC will oversee and ensure ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: Residents 1, 2 and 3's service plans offered some information relating to the resident's past interests; however, the facility had not thoroughly evaluated the resident's: * Current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. Observations of the residents from 08/08/22 through 08/10/22 revealed the lack of activity programs that included the residents in one to one or group interaction. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with individualized activities. The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 08/10/22. They acknowledged the findings.

OAR 411-057-0160 (2d) Activities: 1.) Activities: The following action is being taken to correct each violation per example given on the S.O.D:              a. Facility is completing individual activity                  plans for resident #s 1, 2, and 3.              b. Activity plans will be documented on TSPs,                  for all staff to review. 2.) Activites: The system is being corrected to eliminate future violations, as follows:              a. Facility has hired an activities coordinator,                  who will work 5 days a week,              b. Facility is conducting interviews with family                  members, and residents, to get a thorough                  background on each residents' hobbies and                  preferences,              c. Facility will audit all MCC residents to                  identify any residents who do not have an                  active activity plan.              d. Facility will obtain important social interests,                  hobbies, backgrounds, religion preferences,                  etc ...during admissions.              e. Activity Plans will reviewed and updated                  with each evaluation/SP update. 3.) Activities: This system will be evaluated as follows:             a. All activity preferences will be obtained                 prior to admission,             b. All activity plans will be reviewed & updated                with each evaluation/SP update: Pre-                admission, initial, within 30 days, quarterly                thereafter, and with changes of condition.            c. Activity coordinator will review all upcoming                nutrition plans that need to be reviewed, at                at least once weekly during morning stand-up. 4.) Facility Activities Coordinator and Facility Administrator will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to: The RCF included an endorsed memory care unit on the main level that was split into two units titled Memory Care One (MC1) and Memory Care Two (MC2). Observations during the survey between 08/08/22 through 08/11/22 of MC1 and MC2, showed the doors to the interior courtyard were locked and did not allow residents to exit and return without staff assistance. On 08/09/22, Staff 18 (Maintenance Director) was able to disengage the keypad lock to the MC2 door that lead to the courtyard, however, was unable to disengage the lock to the MC1 courtyard door. During a tour of the building on 08/09/22 at 11:30 am, Staff 1 (ED) and Staff 18 acknowledged the courtyard doors were locked.

OAR 411-057-0160 (g) Outside Area: 1.) Outside Area: The following action will be taken to correct each violation per examples given on S.O.D:              a. Facility has fixed all MCC door locks and                  are now open for residents to use the                  courtyard. 2.) Outside Area: The following corrections are being made to eliminate future violations:               a. All MCC employees are receiving training                   related to providing access to residents                   to a secure outside area,               b. Facility Maintenance Director will conduct                   spot-checks to ensure MCC doors to                   the courtyard remain unlocked. 3.) Outside Area: This system will be evaluated at least once weekly, when facility administrator and maintenance director are completing environmental walk-throughs. 4.) The facility Administrator and Facility Maintenance Director will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. Findings include, but are not limited to: The RCF included an endorsed memory care unit on the main level that was split into two units titled Memory Care One (MC1) and Memory Care Two (MC2). During the survey, the doors to the MCC unit interior courtyard were observed to be locked during daylight hours with sunny and warm weather on 08/08/22 and 08/09/22. On 08/09/22, Staff 1 (ED) confirmed the facility did not have a written policy for when the courtyard doors would be locked. On 08/09/22 at 11:30 am, Staff 1 and Staff 18 acknowledged the above findings.

OAR 411-057-0170(6) Secure Outdoor Recreation Area: 1.) Secure Outdoor Recreation Area: The following action is being taken to correct each violation per examples given on S.O.D:                  a. Facility is working with Vanda Consultant                      to create policies & procedures related                      to secured outdoor area and when to                      lock/unlock doors. 2.) Secure Outdoor Recreation Area: This system is being corrected to eliminate future violations as follows:                  a. Upon creation of policy and procedure                      for secured outdoor area, all staff will                      receive training on updated policies.                  b. Facility will ensure that Secure Outdoor                      Area Policy is being implemented by                      facility maintenance director conducting                      random spot-checks, at least once                      monthly. 3.) Secure Outdoor Recreation Area: This system will be evaluated as follows:                    a. Facility Maintenance director will do                        random spot checks at least once                        monthly. 4.) Facility Administrator and Facility Maintenance Director will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C260, C303, C372 and C420.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval Please reference C260, C303, C372, and C420 for plan of correction.

The findings of the Change of Ownership survey conducted 08/08/22 through 08/11/22 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 Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area: OAR 411-054-0025 (1): Facility Administration: Operation; and OAR 411-054-0045 (1)(f)(B): RN Delegation and Teaching. The facility put immediate plans of correction in place during the survey and the situations were abated.

The findings of the first revisit to the Change of Ownership survey of 08/11/22, conducted 02/21/23 through 02/22/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 08/11/22 conducted 05/01/23 through 05/02/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.