Iuditas' Memory Care

Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main facility kitchen and food storage areas on 10/18/24 from 10:45 am thru 2:15 pm revealed the following deficient practices.

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Floor under/behind and between major equipment;
* Floor under and around ware washing area;
* Kitchen drains near/around ware washing area;
* Clean area of dish washing area with visible food debris;
* Wire spice rack;
* Industrial Mixer;
* Reach in freezer;
* Ceiling vents and sprinkler heads;
* Floor in dry storage room;
* Shelving in dry storage;
* Window ledges and screens around kitchen,
* Stainless steel counter top where steam wells stored;
* Can opener/housing; and
* Interior of microwave.

b. The following areas needed repair:

* Holes by electrical conduit by stove hood.

c. Multiple dishwashing racks observed stored on the floor.

d. Multiple dietary employees were handling clean dishes, serving residents food, and/or preparing food without facial hair restraints.

e. Multiple potentially hazardous food items were observed in cold food storage areas without open dates and/or without use by dates.

f. Reach in refrigerator in dry storage observed without thermometer to accurately monitor cold food storage temperature. Staff 2 (Kitchen Manager) verified food stored in that fridge was for resident consumption.

g. Facility did not have test strips to check surface sanitizer solution concentration to ensure sanitizer dispensing at correct parts per million (PPM).

h. Dry food storage was located in same location as activity supply storage causing potential cross contamination of food items. Single service cups/utensils stored open to potential contamination.

i. Pureed food items were left uncovered during extended time frames during preparation and staff did not ensure those products were held hot until served. Process to mechanicalize/puree food products took an extended amount of time (greater than 30 minutes). Staff 2 acknowledged extended service times for mechanical soft and puree items and always waited to the end of service for these residents. Facility had 3 residents with puree texture and 1 small capacity food processor. Surveyor observed need to puree multiple batches of all food items in order to produce the 3 servings extending the preparation time. Staff 2 and other dietary staff were unsure of appropriate texture for puree stating not much education/training was provided. Surveyor ensured pureed items were at correct texture prior to service to residents and provided staff with spoon flick and fork test procedures per IDDSI guidelines for future use.

j. Staff 2 was not able to adequately demonstrate appropriate knowledge of food worker illnesses for exclusion, proper reheat temperatures, nor correct cooling processes. Staff 2 did not have access to Oregon food sanitation rules.

k. Menu items for lunch was Baked fish, baked potato, and mixed vegetables. Alternate item was Swedish meatballs. Several servings of alternate were served to residents with solely a bowl of meatballs. No starch or vegetable was offered with alternative for a complete meal.

Staff 2 (Kitchen manager) toured with surveyor and acknowledged areas in need of cleaning and attention. In a phone interview on 10/21/24 at 11:15 am, Staff 1 (Executive director) was informed of concerns found and acknowledged areas needing correction.

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).

This Rule is not met as evidenced by:

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

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to provide 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 relicensure survey, conducted 10/01/24 through 10/04/24, oversight to ensure resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.



Refer to deficiencies in the report.

OAR 411-054-0025 (1) Facility Administration: Operation

(1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to develop and implement written policies and procedures to respond to and resolve resident complaints. Findings include, but are not limited to:



During the entrance conference on 10/01/24 the survey team requested resident council meeting minutes. The resident council minutes for 07/2024, 08/2024 and 09/2024 included multiple resident complaints including but not limited to:



* Residents not receiving their packages and mail;

* Taking too long to have laundry returned;

* Blind needing replaced; and

* Lock on restroom door broken.



There was no documentation of follow up or resolution.



A grievance binder located in the charting room included a grievance note dated 09/24/24 which did not include any documented evidence of review.



During an interview on 10/04/24, Staff 1 (Executive Director) acknowledged an effective method of responding to and resolving resident complaints had not been implemented.



The need to ensure the facility developed and implemented written policies and procedures for responding to and resolving resident complaints was discussed with Staff 1 (Executive Director) on 10/04/24. She acknowledged the findings.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure

(7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement:
(a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living.
(b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship.
(c) Effective methods of responding to and resolving resident complaints.
(d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management).
(e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking.
(f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident.
(g) A policy on facility employees not receiving gifts or money from residents.
(h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).”
(j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes and resident satisfaction. Findings include, but are not limited to:



During the survey, conducted 10/01/24 through10/04/24, a quality improvement program developed to ensure adequate resident care, services and satisfaction was found to be ineffective.



Refer to the deficiencies in the report.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

(9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure residents received services in a manner that protected privacy and dignity in a safe and homelike environment for multiple unsampled residents, and medical records were kept confidential for one unsampled resident. Findings include, but are not limited to:



a. Resident 1 observations notes indicated the following:



* 09/7/24 “This morning resident went into other residents [sic] room [sic] and taking personal stuff that did not belong to [him/her]. residents asked for there [sic] rooms to be locked.”



* 09/25/24 “This morning resident was going in to every residents [sic] rooms witch [sic] got some of the residents agitated.”



Staff 4 (Life Enrichment Director) reported in an interview on 10/02/24 at 5:00 pm that “we can’t give residents keys to their rooms to keep other residents out because one key opens all the resident doors.”



b. On 10/02/24 at 12:30 a CG was observed standing over a resident, providing one to one feeding assistance.



c. On 10/03/24 at 5:05 pm an open laptop with a resident MAR in view was observed on top of an unattended medication cart in a common area. A CG called for Staff 7 (MT) who came immediately and closed the resident record.



d. During an interview with Staff 1 (Executive Director) on 10/04/24, she reported there were multiple resident shared bathrooms that did not have a locking mechanism to provide privacy for the residents when using the bathroom.



The need to ensure all residents received services in a manner that protected their privacy and dignity in a safe and homelike environment, and medical records were kept confidential, was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 3:05 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure resident-to-resident physical altercations were immediately reported to the local Seniors and People with Disabilities (SPD) office, and/or injuries of unknown cause were reported to the local SPD office, or the local Area Agency on Aging (AAA), as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse for 3 of 3 sampled residents (#s 1, 2, and 3) whose incidents were reviewed. Findings include, but are not limited to:



1. Resident 3 moved into the facility in 12/2023 with diagnoses including Parkinson’s disease and dementia.



Resident 3’s service plan available to staff dated 01/04/24, observation notes dated 07/01/24 through 09/30/24, and corresponding Interim Service Plans (ISPs) and incident reports were reviewed. The following incidents were identified:



* 08/17/24 – Fall resulting in left knee redness and bruising of the face and chest; and

* 09/26/24 – Left knee bruising.



There was no documented evidence the bruises or the unwitnessed fall with injuries had been investigated to rule out abuse or suspected abuse, nor evidence the local Seniors and People with Disabilities (SPD) office was immediately notified of the incidents.



During an interview on 10/03/24 at 3:10 pm, Staff 1 (Executive Director) confirmed the incidents were not promptly investigated to rule out abuse or neglect and were not reported to the SPD office.



The facility was requested to notify the SPD office of the incidents. Confirmation of the reporting was received on 10/03/24 at 4:06 pm.



The need to immediately investigate injuries of unknown cause and unwitnessed falls with injury to rule out abuse or suspected abuse and to notify the local SPD if abuse could not be ruled out was discussed with Staff 1 and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 2:50 pm. They acknowledged the findings.





2. Resident 1 moved into the facility in 04/2021 with diagnoses including dementia and depression.



Review of the resident's observation notes and Incident Reporting Forms from 07/02/24 through 09/28/24 indicated the following:



On 09/05/24 at 9:55 pm Resident 1 was discovered to have bruising to the top of both hands, on both shins, and above her knees.



There was no documented evidence these injuries were investigated to rule out abuse.



On 10/02/24 Staff 1 (Executive Director) was asked to report the injuries to the local SPD office. Confirmation of the report was provided on 10/02/24 at 4:51 pm.



The need to investigate injuries of unknown cause to rule out abuse and report to the local SPD office as required was discussed with Staff 1 on 10/04/24 at 3:05 pm. She acknowledged the findings.





3. Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia with agitation.



A review of the resident's 12/19/23 service plan, progress notes dated 07/01/24 through 10/01/24, incident reports, and interim service plans (ISPs) was completed, and interviews were conducted. The following was identified:



* 08/05/24 – “This resident slapped another resident while waiting for lunch to be served.”



* 09/10/24 – Resident 2 was standing up from a chair, holding another resident’s arm when the other resident tried to move away. Resident 2 then scratched the other resident’s arm leaving scratch marks.



* 09/27/24 – Resident 2 was attempting to talk to another resident who became agitated and yelled “don’t come near me”. Resident 2 grabbed the other resident’s arm and shook it, leaving red marks.



There was no documented evidence these incidents were immediately reported to the local SPD as suspected abuse or promptly investigated.



On 10/01/24, the facility was asked to report the resident-to-resident altercations to the local SPD office. Confirmation of the reports were received on 10/02/24.



The need to immediately report all suspected abuse to the local SPD office and to promptly investigate all resident incidents was discussed with Staff 1 (Executive Director). She acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 4) and failed to complete 30-day evaluations for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to:



1. Resident 4 was admitted to the facility in 09/2024.



The move-in evaluation failed to address the following:



* Personality: including how the person copes with change or challenging situations;

* Elopement risk or history; and

* Environmental factors that impact the resident’s behavior including, but not limited to noise, lighting, and room temperature.



The failure to address all required areas in the move-in evaluation was discussed with Staff 1 (Executive Director) on 10/03/24. She acknowledged the findings.



2. On 10/01/24 a review of Resident 2’s clinical record was completed and revealed there were no evaluations performed at least quarterly with corresponding quarterly service plan updates after 04/08/24.



The need to ensure evaluations were performed at least quarterly, to correspond with the quarterly service plan updates was discussed with Staff 1 (Executive Director) on 10/03/24. She acknowledged the findings.





3. Resident 3 was admitted to the facility in 12/2023 with diagnoses including cancer and Parkinson’s disease.



A review of the resident's record identified there were no evaluations performed at least quarterly or corresponding quarterly service plan updates between 01/03/24 and 09/04/24. The lack of evaluations and service plan updates was confirmed by Staff 1 (Executive Director) on 10/04/24 at 11:10 am.



The need to ensure resident quarterly evaluations and corresponding service plan updates were completed was discussed with Staff 1 and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 3:15 pm. They acknowledged the findings.

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ care needs, readily available to staff, provided clear direction to staff, and/or services were implemented for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:



1. Resident 1 moved into the facility in 04/2021 with diagnoses including dementia and depression. The resident’s service plan available to staff dated 10/23/23, and Interim Service Plans (ISPs) dated 07/03/24 to 09/25/24, were reviewed, observations were made, and interviews were conducted.



a. The resident's service plan was not implemented in the following area:



* Finger foods.



b. The resident's service plan was not reflective in the following areas:



* Bathing;

* Dressing;

* Infection control;

* Toileting;

* Transfer assistance; and

* Laundry.



c. During the entrance interview on 10/01/24, facility staff reported service plans were stored in the service plan binder for direct care staff to review. Upon observation of the binder stored in the unit chart room at 3:30 pm on 10/01/24, the service plan for Resident 1 was dated 10/12/23. A service plan dated 09/05/24 was provided by the facility at 1:30 pm on 10/01/24, but this was not available to staff at the time of survey entrance.



The need to ensure current service plans were reflective, available to staff, and implemented was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 3:05 pm. They acknowledged the findings.





2. Resident 2 moved into the facility in 12/2023 and had diagnoses including dementia with agitation and macular degeneration.



Observations of the resident, interviews with staff, review of the service plan dated 12/19/23, interim service plans, progress notes, and incident reports from 07/01/24 through 10/01/24 showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:



* Disruptive behaviors to include resistive to cares, yelling, aggression and combativeness, and multiple physical altercations;

* Use of eye glasses;

* Use of hearing aids;

* Catheter;

* Use of walker or cane; and

* Two-person assistance with toileting, dressing, showers.



The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Executive Director) on 10/03/24. She acknowledged the findings.



3. Resident 3 was admitted to the facility in 12/2023 with diagnoses including cancer and Parkinson’s disease.



The resident's service plan available to staff, dated 01/03/24, and interim service plans were reviewed, observations were made, and interviews with caregivers were conducted between 10/01/24 and 10/04/24:



a. The resident's service plan was not implemented in the following area:



* Mechanical soft diet.



b. The resident's service plan was not reflective and/or did not provide clear direction to staff in the following areas:



* Languages spoken;

* Ambulation assistance;

* CG and MT strategies to increase the resident’s acceptance of ADL assistance and medications;

* Dressing and hygiene assistance; and

* Hospice, including services provided and instruction on when and how to contact the provider.



The need to ensure current service plans were reflective of the identified needs of the resident, implemented, and provided clear direction regarding the delivery of services was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 3:15 pm. They acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure resident-specific actions and interventions were determined, documented, made part of the resident record, and communicated to staff on each shift with weekly progress noted to resolution for short-term changes of condition, and failed to ensure significant changes of condition were referred to the facility nurse for 3 of 3 residents (#s 1, 2, and 3) whose experienced changes of condition. Findings include, but are not limited to:



1. Resident 3 moved into the facility in 12/2023 with diagnoses including Parkinson’s disease and dementia.



Resident 3’s service plan available to staff dated 01/04/24, observation notes dated 07/01/24 through 09/30/24, and corresponding Interim Service Plans (ISPs) and incident reports were reviewed. Interviews with staff were completed between 10/01/24 and 10/04/24.



The facility failed to determine and document the resident-specific action or intervention needed, communicate the resident-specific action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:



* 07/01/24 – Non-injury fall;

* 07/04/24 – Increased agitation and combativeness with caregivers;

* 07/22/24 – Medication refusals;

* 07/24/24 – Non-injury fall;

* 07/26/24 – Non-injury fall;

* 07/29/24 – Cannabis use with non-injury fall;

* 07/31/24 – Non-injury fall;

* 08/07/24 – Non-injury fall;

* 08/09/24 – Non-injury fall;

* 08/12/24 – Visit to emergency department;

* 08/12/24 – Fall with pain;

* 08/17/24 – Bruising to chest and face;

* 08/18/24 – Non-injury fall;

* 08/22/24 – Vaccines administered;

* 08/22/24 – Admit to hospice;

* 09/01/24 – Non-injury fall;

* 09/03/24 – Non-injury fall;

* 09/08/24 – Medication refusals;

* 09/15/24 – Non-injury fall;

* 09/15/24 – “Out of medication”;

* 09/23/24 – Non-injury fall; and

* 09/23/24 – Non-injury fall.



The need to ensure the facility determined and documented what resident-specific action or interventions were needed for changes of condition, communicated the resident-specific interventions to staff on all shifts, and monitored the changes of condition, at least weekly, through resolution was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 2:50 pm. They acknowledged the findings, and no additional documentation was provided.



2. Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia with agitation.



The resident's clinical record, including progress notes, dated 07/01/24 through 10/01/24, and incident reports were reviewed, and interviews with staff were conducted.



The facility failed to determine and document the resident-specific actions or interventions needed, communicate the resident-specific action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:



* 07/11/24 - Chronic bilateral lower extremity edema with weeping blisters, and recurrent open wounds;

* 07/31/24 - Medication dose change for atorvastatin for high cholesterol;

* 08/05/24 - Slapped another resident in the face;

* 09/10/24 - Scratched another resident’s arm; and

* 09/27/24 - Grabbed and shook another resident’s arm leaving red marks.



The need to determine and document the resident specific actions or interventions needed, communicate the resident-specific action to staff on each shift, and/or document weekly progress through resolution was discussed with Staff 1 (Executive Director) on 10/03/24. She acknowledged the findings.



3. Resident 1 moved into the facility in 04/2021 with diagnoses including dementia and depression.



Resident 1’s clinical record was reviewed, including the service plan available to staff dated 10/12/23, observation notes dated 07/02/24 through 09/30/24, and corresponding Interim Service Plans (ISPs), Temporary Service Plans (TSPs), and outside provider notes.



a. There was no documented evidence the facility determined resident-specific action or intervention needed for the following changes of condition, communicated the interventions to staff on each shift, or documented weekly progress until the conditions resolved.



* 07/10/24 – “Complete abdomen is red with raised bumps,” and

* 07/19/24 – Bleeding right big toe.



b. There was no documented evidence the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed for the following significant changes of condition.



* 7/26/24 – a stage III wound on the right foot; and

* 9/11/24 – a severe weight gain of 8.4% in three weeks.



The need to ensure the facility determined and documented what resident-specific action or interventions were needed for changes of condition, communicated the resident-specific interventions to staff on all shifts, and monitored the changes of condition, at least weekly, through resolution, as well as evaluated significant changes of condition and referred to the facility RN for assessment was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24. They acknowledged the findings, and no additional documentation was provided.



See C 280, example 2.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed including documented findings, resident status, and interventions made as a result of the assessment for 2 of 3 sampled residents (#s 1 and 2) who experienced significant changes of condition. Findings include, but are not limited to:



1. Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia with agitation and macular degeneration.



During the acuity interview on 10/01/24 Resident 2 was identified as having a change of condition related to increased ADL assistance needed.



Review of the resident’s record to include the service plan available to staff dated 12/19/23, 09/01/24 – 09/30/24 MAR/TARs, incident reports, interim service plans and progress notes dated 07/01/24 through 10/01/24 was completed. Observations of the resident and interviews with staff were conducted.



Resident 2’s service plan indicated s/he needed set up assistance with minimal cues for dressing, grooming, toileting, and bathing, had an indwelling catheter, and required set up assist for hygiene tasks, although at times would need assistance after toileting. The resident was independent with eating and ambulation using a walker. The service plan indicted s/he was never resistant to care and did not have any combative or aggressive behavior.



Observations during survey found the resident did not have an indwelling catheter, walked independently without a walker and received two-person assistance to use the bathroom.



The progress notes and MAR/TARs revealed the resident refused medications and treatments at times, had multiple physical altercations with other residents, was resistive to cares, and was closely monitored, needing assist from staff to prevent urination and defecation on floors.



During an interview with Staff 11 (CG) on 10/02/24 at 8:45 am, it was reported that Resident 2 was frequently incontinent of bladder and was toileted every two hours. Two-person assist was needed for toileting, bathing and dressing related to combative behaviors. One-person full assist was needed for grooming and hygiene, and Staff 11 confirmed the resident no longer had a catheter. Staff 11 reported Resident 2 had increased behaviors to include yelling, hitting, and attempting to instigate trouble with other residents by whistling, staring and name calling.



Resident 2 had a significant change of condition after removal of the indwelling catheter in February 2024. The resident had another significant change of condition related to increased behaviors and increased assistance with ADLs needed. There was no documented RN assessment to include documented findings, resident status, and interventions made as a result.



The need to ensure an RN assessment was completed for significant changes of condition which included documented findings, resident status, and interventions made as a result was discussed with Staff 1 (Executive Director) and Staff 20 (RN) on 10/02/24. Staff 20 acknowledged the lack of RN assessment documentation and on 10/02/24 completed an RN assessment for the significant changes of condition and added interventions on an interim service plan. Staff 1 acknowledged the findings.



2. Resident 1 moved into the facility in 04/2021 with diagnoses including dementia and depression.



a. A review of the resident's weight record was completed, and staff were interviewed. The following was identified:



* 08/21/24 – 108.9 pounds;

* 09/02/24 – 116.1 pounds;

* 09/04/24 – 116.1 pounds; and

* 09/11/24 – 118.0 pounds.



Between 08/21/24 and 09/11/24 the resident experienced a weight gain of 9.1 pounds, or 8.4% of his/her total body weight in three weeks. This was considered a severe weight gain and a significant change of condition.



There was no documented evidence an RN assessment was completed for the resident's weight gain.



In an interview on 10/01/24 at 2:00 pm Staff 20 (RN) reported he had been notified by the facility about the weight gain on 10/01/24.



b. A hospice Visit Note Report dated 08/27/24 documented the resolution of a stage III wound on Resident 1’s left foot. The report stated the onset date of the wound was 07/26/24.

There was no documented evidence an RN assessment was completed as required for a stage III wound identified on 07/26/24.

In a telephone interview on 10/04/24 at 12:04 pm Staff 20 (RN) reported that he was not aware of the stage III wound and had not completed an assessment.

The need to ensure the facility RN conducted an assessment when a resident experienced a significant change of condition was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 3:05 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols. Findings include, but are not limited to:



1. Observations completed 10/01/24 through 10/04/24 identified the following:



a. During meal service in the dining room throughout the survey the following was observed:



* Direct care staff served food and beverages without wearing protective aprons; and



* No hand hygiene was performed between dirty and clean tasks.



b. During lunch service in the dining room on 10/01/24, the following was observed:



* An unsampled resident used their silverware to feed another unsampled resident from the first resident’s own half-eaten plate. A CG feeding another unsampled resident at the same table observed this and did not intervene.



The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager on 10/04/24. They acknowledged the findings.

2. On 10/01/24 during lunch service, Staff 12 (CG) was observed to be using a three-tiered cart to transport lunch trays to individual resident rooms. At 12:44 pm, the cart was wheeled into an unsampled resident’s room with multiple plates of food, uncovered silverware, and Styrofoam cups. The door closed behind the CG, and then Staff 12 opened the door and exited the room with the cart. At 12:47 pm, Staff 12 proceeded to wheel the same cart with two remaining plates of food into another resident’s room. The door closed behind the CG. Staff 12 then exited the room with one remaining plate of food and unused silverware.



The facility failed to minimize the risk of cross-contamination of food items and to ensure effective infection prevention protocols during the delivery of meals to individual rooms.



The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 2:22 pm. They acknowledged the findings.

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to:



During the re-licensure survey, conducted 10/01/24 through 10/4/24, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:



* C 303 - Medication and Treatment Orders;

* C 304 – Medication and Treatment Review;

* C 305 - Resident Right to Refuse;

* C 310 - Medication Administration; and

* C 330 – Psychotropic Medications.



The need to ensure a safe medication and treatment system was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 4:30 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

(1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 3 sampled residents (# 3) whose orders were reviewed. Findings include, but are not limited to:



DB - Resident 3 was admitted to the facility in 12/2023 with diagnoses including cancer and Parkinson’s disease.



Resident 3's MAR, dated 09/01/24 through 09/30/24, prescriber orders, and corresponding progress notes were reviewed and revealed the following:



a. The resident had a prescriber order dated 08/23/24 to discontinue multiple medications. The facility failed to carry out prescriber orders as written and continued to administer the following discontinued medications through 09/04/24 (unless otherwise stated):



* Acalabrutinb 100 mg by mouth every 12 hours for lymphoma;

* Atorvastatin 10 mg by mouth every evening for cholesterol was administered through 09/03/24;

* Finasteride 5 mg by mouth daily for prostate;

* Myrbetriq ER 25 mg by mouth daily for bladder control; and

* Vitamin D 1000 units by mouth daily (supplement).



b. Resident 3 had an order dated 08/23/24 to receive five mg of oxybutynin by mouth daily at bedtime for overactive bladder. The facility failed to administer the order as prescribed until 09/04/24, or 12 days after the original order was written.



c. Resident 3 had a physician’s order dated 08/23/24 for a mechanical soft diet.



Observations on 10/01/24 and 10/02/24 revealed staff provided the resident regular textured foods and failed to provide the prescriber ordered diet of mechanical soft textures.



On 10/01/24 at 2:50 pm Staff 3 (Culinary Director) stated he was unaware the resident had a mechanical soft diet ordered.



The need to ensure all medications and treatments were carried out as prescribed was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 3:15 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure a registered pharmacist or registered nurse reviewed all medications and treatments administered by the facility to a resident at least every 90 days with documentation of recommendations made by the reviewer. Findings include, but are not limited to:



In an interview on 10/04/24 at approximately 2:00 pm, Staff 1 (Executive Director) reported an RN or pharmacist came to the facility in August 2024, although was unable to find documentation that all medications and treatments administered by the facility to residents in the last 90 days had been reviewed.



The need to ensure all medications and treatments administered by the facility were reviewed by a registered pharmacist or RN at least every 90 days with documentation of recommendations made by the reviewer was discussed with Staff 1 on 10/04/24. She acknowledged the findings.

OAR 411-054-0055 (1)(i) Systems: Medication and Treatment Review

(i) A registered pharmacist or registered nurse must review all medications and treatments administered by the facility to a resident at least every 90 days. The facility must provide documentation related to the recommendations made by the reviewer.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 3 of 3 sampled residents (#s 1, 2, and 3), who had documented medication and treatment refusals. Findings include, but are not limited to:



1. Resident 3 was admitted to the facility in 12/2023 with diagnoses including cancer and Parkinson’s disease.



The resident's MAR dated 09/01/24 through 09/30/24 was reviewed and revealed facility staff documented Resident 3 refused the following orders:



* Acalabrutinib (for lymphoma) on one occasion;

* Carbidopa/Levodopa (for Parkinson’s disease) on 20 occasions;

* Finasteride (for prostate) on one occasion;

* Melatonin (for insomnia) on ten occasions;

* Myrbetriq (for bladder control) on one occasion;

* Omeprazole (for gastroesophageal reflux disease) on three occasions;

* Oxybutynin (for overactive bladder) on 16 occasions;

* Quetiapine (for behavioral symptoms of dementia) on 29 occasions;

* Rivastigmine (for dementia) on one occasion;

* Senna (for constipation) on three occasions;

* Tamsulosin (for urinary retention) on 19 occasions;

* Valproic Acid (for behavioral symptoms of dementia) on ten occasions; and

* Vitamin D3 (for supplement) on one occasion.



There was no documented evidence the facility notified Resident 3's physician of the refusals.



The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 3:15 pm. They acknowledged the findings, and no additional documentation was provided.





2. Resident 1 moved into the facility in 04/2021 with diagnoses including dementia and depression.



Review of the resident's 09/01/24 through 09/30/24 MAR identified Resident 1 refused the following scheduled medications and treatments on multiple occasions:



* Lorazepam 0.5mg BID for anxiety, agitation and restlessness;

* C-ABH cream 1 ml (four clicks of device) topically to abdomen, inner wrist or back of neck every six hours for anxiety and agitation;

* Dressing check with PRN treatment to right foot second toe; and

* Clotrimazole Cream for fungal rash.



There was no documented evidence the physician or other practitioner had been notified of the refusals.



The need to notify the physician or other practitioner of resident medication and treatment refusals was discussed with Staff 1 (Executive Director) on 10/03/24 at 2:25 pm. She acknowledged the findings.



3. Resident 2's MAR/TARs from 09/01/24 through 09/30/24 and corresponding progress notes were reviewed. The resident's records showed the following medications and treatment refusals:



* Furosemide 40 mg (for edema);

* I-Vite Tablet (for supplement);

* Losartan 50 mg (for blood pressure);

* Metoprolol 50 mg (for blood pressure);

* Potassium Chlor 10 meq (for supplement);

* Quetiapine 50 mg (for behaviors); and

* Tamsulosin Hcl 0.4 mg (for bladder) were all refused on 09/04/24; and

* Donning and doffing of compression stockings were refused on multiple occasions.



There was no documented evidence the facility notified the physician or other practitioner each time the resident refused consent to the orders.



The need to ensure the facility notified the physician or other practitioner of medication and treatment refusals was reviewed with Staff 1 (Executive Director) on 10/03/24. She acknowledged the findings. No further information was provided.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure MARs included resident-specific parameters and instructions for PRN medications and reasons for use for 3 of 3 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:



1. Resident 3 moved into the facility in 12/2023 with diagnoses including cancer and Parkinson’s disease.



A review of Resident 3’s 09/01/24 through 09/30/24 MAR identified the following medications lacked a reason for use:



*Quetiapine;

*Rivastigmine patch;

*Tamsulosin;

*Valproic Acid; and

*Vitamin D.



On 10/03/24 at 11:10 am, Staff 6 (MT) confirmed the electronic MAR did not include a reason for use for these medications.



The need to ensure medications included a reason for use was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 3:15 pm. They acknowledged the findings.



2. Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia with agitation and macular degeneration.



A review of Resident 2's 09/01/24 through 09/30/24 MAR identified the following medications lacked reasons for use:



* Atorvastatin;

* Furosemide;

* I-Vit;

* Potassium Chloride;

* Quetiapine; and

* Tamsulosin HCL.



The need to ensure MARs included reason for use for all medications was discussed with Staff 1 (Executive Director) on 10/03/24. No additional information was provided.



3. Resident 1 moved into the facility in 04/2021 with diagnoses including dementia and depression.



Resident 1's 09/01/24 through 09/30/24 MAR and physician orders were reviewed and identified the following:



a. Multiple PRN behavior medications lacked parameters for order of administration.



b. The following medications lacked reason for use:



* Ondansetron;

* Morphine solution; and

* Clotrimazole topical.



The need to ensure the MAR included clear instruction for PRN administration, and provided reason for use for all medications and treatments was discussed with Staff 1 (Executive Director), on 10/03/24 at 2:25 pm. She acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure PRN medications that were given to treat a resident’s behavior had resident-specific parameters and non-pharmacological interventions were attempted and documented as ineffective prior to their administration for 3 of 3 sampled residents (#s 1, 2, and 3) who were prescribed psychotropic medications. Findings include, but are not limited to:



1. Resident 3 was admitted to the facility in 12/2023 with diagnoses including cancer and Parkinson’s disease.



Review of Resident 3’s MAR, dated 09/01/24 through 09/30/24, prescriber orders, and medical records revealed the following:



* Resident 3 had a physician order to receive lorazepam 1 mg tab - one tablet by mouth every four hours as needed for anxiety, agitation.



* Lorazepam was documented as administered to the resident on five occasions between 09/10/24 and 09/18/24.



The facility lacked documented evidence of resident-specific parameters regarding when unlicensed staff were to administer lorazepam, non-pharmacological interventions were attempted and were ineffective prior to administration of the lorazepam, and information on which non-pharmacological interventions to attempt.



On 10/04/24 at 1:30 pm, Staff 7 (MT) confirmed the electronic MAR did not have resident-specific parameters for PRN psychotropics, non-pharmacological interventions listed for staff to attempt prior to administering the PRN medication, and there were no non-pharmacological interventions documented in the electronic MAR for the five administrations of the PRN psychotropic.



The need to ensure medications that treat a resident’s behaviors had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to administration of PRN psychotropic medications was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 3:15 pm. They acknowledged the findings.







2. Resident 2 was admitted to the facility in 12/2023 with diagnoses including dementia with agitation.



A review of the resident's 09/01/24 through 09/30/24 MAR and current physician orders showed the following prn psychotropic medications:



*Olanzapine 5 mg every four hours as needed for agitation or hallucinations; and



*Lorazepam 0.5 mg every 12 hours as needed for anxiety, insomnia or other (anxiety, restlessness).



The MAR did not contain resident-specific parameters for staff describing how the resident expressed agitation or delirium, and there was no documented evidence of non-pharmacological interventions to attempt first with ineffective results prior to administration of the prn psychotropic medications.



The need to ensure medications given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions to be attempted and documented as ineffective prior to the administration for psychotropic medications was discussed with Staff 1 (Executive Director) on 10/03/24. She acknowledged the findings.





3. Resident 1 moved into the facility in 04/2021 with diagnoses including dementia and depression.



Review of Resident 1’s MAR, dated 09/01/24 through 09/30/24, and prescriber orders identified the following:



a. Resident 1 had the following orders:



* Haloperidol 2mg every four hours PRN for nausea, vomiting, agitation, and hallucinations; and



* Lorazepam 0.5mg every two hours PRN for anxiety, agitation or restlessness.



The MAR did not include a description of how the resident exhibits agitation, anxiety, restlessness, or hallucinations.



b. Lorazepam was documented as administered to the resident on five occasions between 09/01/24 and 09/30/24.



The facility lacked documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the lorazepam.



The need to ensure medications that treat a resident’s behaviors had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to administration of PRN psychotropic medications was discussed with Staff 1 (Executive Director) on 10/03/24 at 2:25 pm. She acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed, failed to document other less restrictive alternatives evaluated prior to the use of the device, failed to instruct caregivers on the correct use and precautions related to the use of the device, and failed to include the use of the device in the resident service plan for 1 of 1 sampled resident (#3) who had side rails. Findings include, but are not limited to:



Resident 3 was admitted to the facility in 12/2023 with diagnoses including cancer, Parkinson’s disease, and dementia.



Observations during the survey between 10/01/24 and 10/04/24 revealed Resident 3 had bilateral side rails on the bed in the up position and used the rails for transfers.



Interviews were completed and the resident’s medical chart was reviewed during the survey, including RN assessments and observation notes dated 07/01/24 through 09/30/24. It was revealed the resident had a history of unsafe use of adaptive equipment, overestimating his/her physical abilities, making unsafe choices, and frequent falls. Due to the resident’s history, the side rails were identified as devices that had potentially restraining qualities.



There was no documented evidence the following required elements were completed:



* Assessment by an RN, PT or OT;
* Documentation of less restrictive alternatives evaluated prior to use of the device;
* Instruction provided to staff on the correct use and precautions related to the device; and

* Documentation of side rails in the resident's service plan.



The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, staff were instructed on the correct use and precautions, and was included in the resident's service plan was discussed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 3:15 pm. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to use the Acuity-Based Staffing Tool (ABST) to determine appropriate staffing levels and to update the ABST for each resident at least quarterly. Findings include, but are not limited to:



In an interview with Staff 1 (Executive Director) on 10/03/24 at 1:10 pm, she reported that the ABST was not fully updated. She stated that approximately two weeks prior the facility changed from two 12-hour shifts to three 8-hour shifts and that she had not yet converted the times on the facility ABST to reflect this. Staff 1 reported that she was staffing at, or above, the level mandated by the recent ABST condition, but she was unable to state what the facility’s ABST was currently to indicate what staffing levels should be for each shift.



Review of the facility's online ABST indicated multiple residents' ABST data had not been updated quarterly.



The need to use the ABST to determine appropriate staffing levels and to review the ABST for each resident at least quarterly was discussed with Staff 1 and Staff 2 (Assistant Executive Director/Business Office Manager) on 10/04/24 at 3:05 pm. They acknowledged the findings.

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements

(1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall:
(a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule.

(2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule.
(a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements:
(A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule.
(B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element.
(C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident.
(D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day.
(E) Identify the date the resident’s ABST evaluation was last completed.
(F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule.

(b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following:
(A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule.
(B) Completed ABST PDRR Form.
(C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes.
(D) The facility’s ABST policy required under OAR 411-054-0025(7)(i).
(c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form.
(d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time.
(e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference.
(f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31.
(g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST.

(3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements:
(a) Personal hygiene.
(b) Grooming.
(c) Dressing and undressing.
(d) Toileting, bowel, and bladder management.
(e) Bathing.
(f) Transfers.
(g) Repositioning.
(h) Ambulation.
(i) Supervising, cueing, or supporting while eating.
(j) Medication administration.
(k) Providing non-drug interventions for pain management.
(l) Providing treatments.
(m) Cueing or redirecting due to cognitive impairment or dementia.
(n) Ensuring non-drug interventions for behaviors.
(o) Assisting with leisure activities, assist with social and recreational activities.
(p) Monitoring physical conditions or symptoms.
(q) Monitoring behavioral conditions or symptoms.
(r) Assisting with communication, assistive devices for hearing, vision, and speech.
(s) Responding to call lights.
(t) Safety checks, fall prevention
(u) Completing resident specific housekeeping or laundry services performed by care staff.
(v) Providing additional care services. If additional services are not provided, this element can be omitted.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired direct care staff (#s 6, 12, and 15) had documented demonstration of competency in abdominal thrust within 30 days of hire. Findings include, but are not limited to:



Staff training records were reviewed on 10/02/24 at 1:15 pm with Staff 2 (Assistant Executive Director/Business Office Manager).



Staff 6 (MT), hired 06/05/24, Staff 12 (CG), hired on 07/22/24, and Staff 15 (CG), hired 08/08/24, lacked documented evidence they had completed abdominal thrust training within 30 days of hire.



The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 1 (Executive Director) and Staff 2 on 10/04/24 at 2:32 pm. They acknowledged the findings.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff

(5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF.
(a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned.
(b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to:
(A) The role of service plans in providing individualized resident care.
(B) Providing assistance with the activities of daily living.
(C) Changes associated with normal aging.
(D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition.
(E) Conditions that require assessment, treatment, observation and reporting.
(F) General food safety, serving and sanitation.
(G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised.

(9) ADDITIONAL REQUIREMENTS. Staff:
(a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services.
(b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required.
(c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed.

(10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule.
(a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

This Rule is not met as evidenced by:

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



On 10/02/24, fire drill records and staff fire and life safety instruction from 04/01/24 through 09/30/24 were reviewed with Staff 5 (Maintenance Tech). Fire drill records lacked documentation of the following required elements:



* Fire drills were conducted every other month;

* Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Number of occupants evacuated; and

* Evidence alternate routes were used.



The facility failed to provide documented evidence of fire and life safety instruction being provided to staff on alternating months from fire drills.



On 10/04/24 at 3:15 pm, the OFC requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director/Business Office Manager). They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:



On 10/03/24, Staff 1 (Executive Director) was asked to explain the facility’s process and to provide documentation for instructing residents in fire and life safety procedures on admission and annually. Staff 1 was unable to provide documentation of training residents in fire and life safety procedures on admission and acknowledged the facility was not providing fire and life re-instruction to residents annually.



The need to instruct residents upon move-in and annually in general fire safety procedures was discussed with Staff 1 on10/03/24 at 9:55 am. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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



The interior of the facility was toured on 10/01/24 at 11:30 am. The following were identified:



* Walls, baseboards, door frames and corner walls had paint chips and gouges in multiple areas throughout the facility;

* Air vent located outside the charting room door was broken, and air vents throughout the facility were covered with dust;

* Multiple stand-up fans in the hallways were covered with dust;

* Four dining chair seat cushions had multiple large dark stains; and

* Broken mini blinds were observed in all the windows of the dining and television common areas, as well as in multiple resident rooms.



The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) 10/03/24 at 11:00 am. She acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure resident’s rights of privacy in his or her own unit for multiple sampled and unsampled residents. Findings include, but are not limited to:



Refer to C 200.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(d) Each individual has privacy in his or her own unit.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to:



During the survey residents were observed being let into their rooms with a key held by care staff.



In an interview with Staff 1 (Executive Director) on 10/04/24, she stated that some but not all residents had been provided keys to their units.



The need to ensure all residents were provided keys to their units was discussed with Staff 1 (Executive Director) on 10/04/24. She acknowledged the findings.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

This Rule is not met as evidenced by:

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



Refer to C150, C154, C156, C200, C231, C295, C372, C361, C420, C422, and C513.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 6, 12, 15, and 19) completed all required pre-service orientation training topics and received a written job description; failed to ensure 3 of 3 newly-hired direct care staff (#s 6, 12, and 15) completed all required pre-service dementia training topics; failed to ensure 3 of 3 newly-hired direct care staff (#s 6, 12, and 15) demonstrated competency in all assigned job duties within 30 days of hire; failed to ensure 1 of 1 long-term direct care staff (#10) completed the required number of annual in-service training hours, including at least six hours of training on dementia care; and failed to ensure 1 of 2 long term non-care staff (#18) completed annual infectious disease training. Findings include, but are not limited to:



Staff training records were reviewed on 10/02/24 at 1:15 pm and on 10/03/24 at 1:10 pm with Staff 2 (Assistant Executive Director/Business Office Manager).



a. There was no documented evidence Staff 6 (MT), hired 06/05/24, Staff 12 (CG), hired 07/22/24, Staff 15 (CG), hired 08/08/24 and Staff 19 (Cook), hired 04/04/24, had a written description of their job responsibilities and/or completed one or more of the following pre-service orientation topics before completing any job duties:



* Abuse reporting requirements;

* Fire safety and emergency procedures;

* Home and Community Based Services course; and

* Infectious disease prevention.



b. There was no documented evidence Staff 6, Staff 12 and Staff 15 completed one or more of the following pre-service dementia training topics required of direct care staff prior to providing care and services independently:



* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach;

* Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.);

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; and

* Use of supportive devices with restraining qualities in memory care communities.



c. There was no documented evidence Staff 6, Staff 12 and Staff 15 demonstrated competency in one or more of the following areas within 30 days of hire:



* Changes associated with normal aging;

* Identification, documenting and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.



d. Documented annual in-service hours acquired between 08/23/23 and 08/22/24 were reviewed for Staff 10 (CG), hired 08/23/21. There was no documented evidence Staff 10 had completed the required number of annual in-service training hours, including at least six hours of training related to dementia care.



e. There was no documented evidence Staff 18 (Cook), hired 01/16/22 completed the required annual infectious disease training.



The need to ensure the required pre-service and annual training was completed by staff in the time frames specified in the rules was discussed with Staff 1 (Executive Director) and Staff 2 on 10/04/24 at 2:32 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

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



Refer to C252, C260, C270, C280, C300, C303, C304, C305, C310, C330 and C340.

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

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

This Rule is not met as evidenced by:

a. Based on interview and record review, during a site visit conducted on 08/20/24, it was confirmed the facility had not ensured the implementation of services for 1 of 6 sampled residents (#2). Findings include, but are not limited to:During an interview, Staff 1 (ED) indicated there had been an agency staff member who had neglected to provide required services to Resident 2 including not assisting with the toileting assistance. That staff member had not abandoned his/her shift but had neglected to provided services, s/he was immediately put on the "do not return to the facility" list. A review of Resident 2's progress notes from 08/01/24 through 08/16/24 indicated the following; On 08/04/24, Resident has urinated in the hallways twice during the shift. S/he may need to be toileted more often, check for UTI. On 08/05/24, Resident urinated and defecated in the hallways five times during the shift. A review of Resident 2's service plan dated 04/03/24, indicated for bladder management, staff will ensure that resident is dry, clean, and odor free throughout the shift. Resident has occasional accidents. It was confirmed the facility had not ensured the implementation of services.On 08/20/24, the findings were reviewed with and acknowledged by Staff 1 and Staff 2.Verbal plan of correction: ED will continue to post open shifts with agency and need agency staff to pick up the shift. ED has "do not returned" the agency staff who was responsible for ensuring resident to have been changed after soiling themselves.b. Based on observation and interview, during a site visit conducted on 08/20/24, it was confirmed the facility failed to have service plans readily available to staff. Findings include, but are not limited to:During an interview, Staff 1 (ED) indicated the care staff access the current service plans from the service plan binders in the medication room. Staff 1 acknowledged that not all residents current service plans had been added into the service plan binders and had not been readily available to all staff. CS observed the service plan binders in the medication room which had all out-of-date service plans. It was confirmed the facility failed to have service plans readily available to staff.On 08/20/24, the findings were reviewed with and acknowledged by Staff 1 and Staff 2 (Assistant ED).Verbal plan of correction: ED will print all the current service plans. Speak with RN on any service plans that may need to be completed and will have the binders that are accessible up to date and signed by staff by the end of the month.

Based on observation and interview conducted during a site visit on 08/20/24, it was determined the facility did not have a system for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications for 1 of 1 sampled resident (#6). Findings including, but are not limited to:On 08/20/24, Staff 1 (ED) indicated s/he had concerns around Resident 6's Morphine, which was under investigation. It appeared the bottle leaked or had been missing around 4 ml of medication. Staff 3 (MT) confirmed medication had leaked or went missing and additional non-narcotic medication had been sitting on the med room floor waiting to be disposed of. CS's and Staff 3 (MT) observed a bottle of medication in a sealed bag which appeared to have leaked around the bottle cap. Review of disposal and destruction policy revealed: Both staff members must witness the destruction of medication Disposes of the medication in a medical waste receptacle Review of tracking of controlled substance policy revealed: Both staff members review controlled substances at shift changes and track any discrepancy to manager on duty.Review of narcotic log for Resident 4's Morphine 20 MA/ML revealed a post-it note which stated, "Staff 9 (RN) to look into more" dated 08/18/24.Only one staff signature appeared on narcotic log from 08/18/24. The findings were reviewed with and acknowledged by Staff 1 on 08/20/24.It was determined the facility did not have a system for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications.Verbal plan of correction: Staff in internal investigation for Morphine on suspension pending outcome of investigation. MT's and ED will dispose of medications on floor of med room. This will be completed by 09/01/24.

Based on interview and record review, during a site visit conducted on 08/20/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 2 of 6 sampled resident (#'s 2 and 3). Findings include, but are not limited to:During an interview, Staff 1 (ED) indicated there had been an agency staff member who had neglected to provide required services to Resident 2 and Resident 3, including not assisting with the removal of compression stockings and applying cream.A review of Resident 2's progress notes from 08/01/24 through 08/16/24 indicated the following; 08/03/24, [Resident placed on alert charting for skin condition: lower legs appearance, redness, warm at touch, weeping and small open areas below knee.] 08/04/24, [Resident has skin damage due to compression stockings being worn longer than anticipated. It appears resident is not having his/her stockings removed at bedtime.] and [med tech noticed compression stockings had not been changed again since the day shift yesterday.]A review of Resident 2's MARs from 08/01/24 through 08/20/24 indicated wound care to both legs, put on every morning and take off in the evening. On 08/11/24 and 08/13/24 in the mornings staff did not document completing the task. A review of Resident 3's MARs from 08/01/24 through 08/20/24 indicated the resident missed the following medications; Atorvastatin 20MG for high cholesterol, one tablet by mouth every evening. Resident missed doses on 08/16/24 and 08/17/24. Boudreauxs cream for dermatitis. Resident missed doses on 08/16/24 and 08/17/24. Famotidine 20MG for acid indigestion by mouth twice daily. Resident missed both doses on 08/16/24 and 08/18/24, resident missed one dose on 08/17/24. On 08/20/24, the findings were reviewed with and acknowledged by Staff 1 and Staff 2.Verbal plan of correction: The ED will pull the medications exception report daily and follow-up. ED has "do not returned" the agency staff who was responsible for ensuring resident services.

Based on interview and record review, during a site visit conducted on 06/05//24, it was confirmed the facility failed to conduct and record unannounced fire drills every other month at different times of day, evening, and night shifts. Findings include, but are not limited to: During an interview on 06/05/24, Staff 1 (ED) and Staff 2 AED) indicated the last documented fire drill occurred on 05/23/23. Staff 1 indicated s/he believed the facility had conducted a fire drill more recently, however, could not provide documentation of it. A review of the fire drill form dated 05/23/23 indicated the facility conducted a fire drill at 11:15 AM. It was confirmed the facility failed to conduct and record unannounced fire drills every other month at different times of day, evening, and night shifts.On 06/05/24, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: The facility will have a planned fire drill by the end of this week and conduct one the following week.

Based on observation, interview, and record review, during a site visit conducted on 05/29/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 3 of 3 sampled residents (#1, #2, and #3). Findings include, but are not limited to: On 05/29/24, CS observed the following: " Three CG's, two working the floor while one provided the one-on-one assistance and one MT working. " Resident 1, Resident 2, and an unsampled resident had hair that was greasy, nails unclipped and dirty with particles under the nails. In separate interviews on 05/29/24, staff stated the following: " There have been no showers completed yet today. " There are no activities personnel, Caregiver's have been expected to absorb those job duties. " A resident who as of last week, required 24-hour one on one assistance. " There are two residents that require two-person transfer.On 05/29/24, Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) stated the facility had been short staffed on multiple occasions resulting in resident needs having been missed, such as showers. Staff 1 stated the system for documenting and auditing showers has not been working effectively. Staff 1 could not ensure showers were being completed. Staff 1 stated there had been multiple occasions when there was only one CG and one MT working during day shift. On 05/29/24, Resident 1 stated s/he has not been getting the services required. Resident 1 had no knowledge of his/her last shower and indicated the facility often said s/he refused the shower when that was not the case. A review of the facility's posted staffing plan indicated the following:" The facility used two 12-hour shifts;" Day shift required two CGs and one MT; and" Night shift required one CG and one MT.A review of the staff schedule, dated 02/01/24 through 05/29/24, indicated the facility was consistently short staffed, often scheduling one CG one MT for day shift. A review of timecards from 05/01/24 through 05/29/24, indicated the facility had been short staffed on multiple days. A review of service plans indicated Resident 1 dated 04/18/24 required one CG assist every Tuesday and Saturday. Resident 2 dated 05/01/24 required full assistance with showering. Resident 3 dated 05/13/24 required one CG assist with showers every Monday and Saturday day shift.A review of the facility's "shower sheets" from 04/01/24 through 05/29/24 revealed no documented evidence showers had been completed according to the shower schedule. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.On 05/29/24, the findings were reviewed with and acknowledged by Staff 1 and Staff 2.Verbal POC: ED will bring back the shower sheets to document showers have been completed. ED has been working on hiring more staff members, recently able to use agency staff for supports, and intends to move from two twelve-hour shifts to three eight-hour shifts.

Based on interview and record review, during a site visit conducted on 05/29/24, it was confirmed the facility failed to verify that direct care staff had demonstrated satisfactory performance in any duty assigned within 30 days of hire. Findings include but are not limited to: During an interview on 03/19/24, Staff 1 (Executive Director) and Staff 2 (Assistant Executive Director) acknowledged staff training records were incomplete or non-existent. A review of current facility staffs 30-day competency training checklist indicated the following; ·Staff that had no training records were as follows: o Staff 9 (CG) Date of Hire: 02/09/24.o Staff 10 (CG) Date of Hire: 02/15/24.o Staff 13 (CG) Date of Hire: 02/15/24.·Staff to have incomplete training records were as follows: o Staff 4: (Housekeeper/CG) Date of Hire: 03/03/22.o Staff 8: (CG) Date of Hire: 05/16/22.o Staff 11: (CG) Date of Hire: 05/03/24.o Staff 12: (CG) Date of Hire: 03/05/24.It was confirmed the facility failed to verify that direct care staff had demonstrated satisfactory performance in any duty assigned within 30 days of hire.On 05/29/24, the findings were reviewed with and acknowledged by Staff 1 and Staff 2.Verbal POC: Staff 3 (MT), Staff 5 (CG) working during site visit had complete training records. Staff 4 was scheduled as housekeeper during the site visit not providing care and Staff 12 (CG) training was completed and needed his/her signature on the training records to show completion. The Executive Director will get the additional staff training records completed on his/her next time of work. ED stated all staff had been fully trained in his/her job duties, however staff did not have complete training records.

The findings of the on-site investigation conducted 10/31/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Based on interview and record review, conducted during a site visit on 10/31/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:In review of the facility's ABST and resident roster on 10/31/23, it was found there were 20 residents listed on the roster and only 19 residents were entered into the ABST.In an interview on 10/31/23, Staff 1 (ED) stated the current census was 20 residents. S/he also stated they had not updated the ABST in the past 30 days. The last move in was 10/23/23, the last move out 10/29/23, and last service plan update was 10/23/23. On 10/31/23, findings were reviewed with and acknowledged by Staff 1.The facility failed to fully implement and update an ABST.

The findings of the on-site investigation, conducted on 10/31/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseNotes on Abbreviations: " The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. " Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate." Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. " If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on observation and interview, during a site visit conducted on 10/31/23, it was confirmed the facility failed to post the name of the administrator or designee in charge in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to: During a site visit on 10/31/23, CS observed no posted sign naming the administrator or designee in charge. In an interview on 10/31/23, Staff 1 (ED) confirmed, there was no sign to indicate who the manager on duty was. It was confirmed the facility failed to post the name of the administrator or designee in charge. On 10/31/23, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: Staff 1 will post a manager on duty on the board by the med room along with the other staff posted working for that shift starting immediately.

Based on interview and record review, during a site visit conducted on 10/31/23, it was confirmed the facility failed to carry out medication orders as prescribed, for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but not limited to:A review of Resident 1, 2, and 3's 10/01/23 through 10/30/23 MARs, indicated the following routine medications had not been reordered, were on backorder, or were "unavailable":·Resident 1: oMetoprolol hypertension was to be administered one time daily, had not been administered between 10/18/23 to 10/26/23. oAmlodipine for high blood pressure was to be administered one time daily, had not been administered between 10/17/23 to 10/19/23. oMelatonin for sleep was to be administered one time daily, had not been administered between 10/27/23 to 10/30/23. oSenna for constipation was to be administered one time daily, had not been administered between 10/04/23 to 10/12/23. oVitamin D3 to be administered one time daily, had not been administered between 10/15/23-10/17/23.·Resident 2: oKetoconazole cream was prescribed and ordered on 10/18/23 and had not been administered until 10/23/23 and 10/25/23. oNitrofurantoin Macro for urinary tract infections was to be administered one time daily, had not been administered between 10/10/23 to 10/13/23. ·Resident 3: oKetoconazole cream was prescribed on 10/16/23 and arrived at the facility on 10/17/23. The cream was not administered until the evening of 10/24/23 at 7:00 pm. oMelatonin for sleep was to be administered two tablets one time daily, had not been administered between 10/02/23 to 10/09/23. oOxycodone for pain was to be administered three times daily, had not been administered between 10/20/23 to 10/24/23.During an interview on 10/31/23, Staff 2 (AED/BOM) stated, "There have been several medication errors, and we are still in the process of turning them into APS. On 10/19/23 we had a MT meeting telling them to call myself, the ED, or the Nurse if an order needed to be imputed into the system. The staff during the following weekend did not do this resulting in many medications having been missed. We had another meeting with the staff on 10/25/23." It was confirmed the facility failed to carry out medication orders as prescribed.On 10/31/23, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: The facility self-reported medication error to APS, completed an Incident Report, ISP's, placed resident on Alert Charting. Staff 1 has been working with all MT's and has a MT meeting weekly.

Based on observation, interview, and record review, during a site visit conducted on 10/31/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, for 1 of 1 sampled resident (#3) and an unsampled resident. Findings include, but are not limited to: In an interview on 10/31/23, Staff 3 (CG) stated the following: "There have been no showers completed yet today." "Last Tuesday, on 10/24/23, I worked as the only CG for a 12-hour shift and was so busy I was unable to take a lunch break." "The ED works on NOC shift as a MT at least one to two times a week." "There are no activities personal or housekeeper working today, CG's are expected to absorb those job duties. On days like this, housekeeping often does not get completed." "The facility schedules two 12-hour shifts with two CG's and one MT for days and one CG and one MT for nights." On 10/31/23, Staff 1 (ED) confirmed, s/he had been working as a MT on noc shift "typically one to two times a week for months." Staff 1 also stated, the facility no longer had any two- person transfers. On 10/31/23, CS observed the following: Two CG's and one MT working. Resident 3 and an unsampled had hair that was greasy, nails unclipped and dirty with particles under the nails. CS did not observe a housekeeper or activities staff working. A review the posted staffing plan indicated the staffing for the facility was two 12-hour shifts, day shift needed two CG ' s and one MT and night shift needed one CG and one MT. A review of the staff timecards for 08/28/23 to 10/01/23 indicated the facility was consistently short staffed often scheduling one CG for day shift. The timecards, dated 10/24/23, indicated for day shift one CG and one MT worked and for night shift two CG worked and Staff 1 (ED) worked as the MT. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.On 10/31/23, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: The facility has been and continues to work on hiring more staff. Staff 1 stated s/he will ensure all showers are completed.

Based on observation and interview, conducted during a site visit on 10/31/23, it was confirmed the facility failed to ensure directions were posted on the outside of the entry door to allow access to the building. Findings include, but not limited to:On 10/31/23, CS observed a door with a sign stating, "welcome, main entrance visitors enter here." CS did not observe a doorbell at the main entrance or a sign instructing visitors to go to a different door. CS went to the old entrance door, and observed a sign that stated, "ring doorbell and use other door." During an interview on 10/31/23, Staff 2 (AED/BOM) stated, "We have changed the location of our front entrance door permanently. You must go to the old entrance to ring the doorbell to let staff know you are wanting to be let in and then walk to the new entrance door." It was confirmed the facility failed to ensure directions were posted on the outside of the entry door to allow access to the building. On 10/31/23, the findings were reviewed with and acknowledged by Staff 1.Verbal plan of correction: Staff 1 put a sign on the new door explaining clearer direction as CS left the building.

The findings of the on-site investigation, conducted 07/10/23 and 07/13/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered NurseNotes on Abbreviations: "The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. "Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate."Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. "If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on interview and record review, during a site visit conducted on 07/10/23 and 07/13/23, it was confirmed the facility failed to be responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. Findings include, but not limited to: During an interview on 07/13/23, Staff 1 (Executive Director) stated, "Before I was the ED there was a staff member who did smoke marijuana outside the property on their break and came back to the facility to provided services to residents. No repercussions were given to the staff member for this however, the staff member was later terminated for other reasons. The facility did not follow their policy on drug use at the facility." A review of the facility's policy and procedure signed by all staff members when hired stated the following, "The company has adapted an alcohol and drug-free work site policy. Our policy prohibits the use, sale, distribution, manufacture, or possession of alcohol or drugs, paraphernalia, and the unauthorized use of prescription drugs. This policy forbids reporting to work or working while under the influence of alcohol or drugs. Any violation of this policy will result in disciplinary action, up to and including termination." It was confirmed the facility failed to be responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties.On 07/13/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: Staff 1 will follow the facility's policy and procedure.

The findings of the kitchen inspection, conducted 07/10/23 through 07/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection of 07/11/23, conducted 10/17/23 through 10/18/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.


The findings of the second revisit to the kitchen inspection 07/11/23, conducted 12/05/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observation of the kitchen on 07/10/2023 at 10:00 am revealed the following areas needing cleaning, repair and stored properly: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* Industrial mixer;* Interior of both ovens, stovetop, grease trap and adjacent wall;* Two of three blinds in main kitchen;* Trash can and lid;* Rolling cart were stained and un-cleanable;* Interior and exterior of cupboards and drawers beneath prep table;* Flooring in corners, edges, between and under equipment in main kitchen and dry storage; * Dead bugs/debris on windowsill in dry storage room;* Interior of Freezer #s 3 and 4, and Cooler # 2; and * Storage table below warming pans.b. The following areas were found in need of repair:* Hole on floor below prep table on side closest to oven;* Can opener dull with metal shavings observed;* Multiple cooking pans damaged and stained;* Oven missing left bottom front cover exposing wiring; * Ice build-up in Freezer #s 3 and 4;* One set of blinds broken in main kitchen; and * Small holes and black stains on wall next to handwashing sink.c. The following food items observed were not stored appropriately: * A bin of flour had a scoop in the product; * Industrial mixer lacked a cover to protect from possible contamination; and * Multiple food items found in Cooler #1 and Freezer # 3 were not properly covered, labeled, and/or dated.Staff did not know how to use the test strips available to validate concentration of sanitizer used for surface sanitation buckets.During an interview and tour with Staff 3 (Culinary Director) on 07/11/23, he acknowledged the identified areas needing to be cleaned, repaired, improper storage of food in freezers and coolers, and use of test strips for proper sanitizing. On 07/11/23, the Surveyor reviewed areas in need of cleaning, repair and improper storage of food and utilization of test strips with Staff 1 (Executive Director) and Staff 2 (Assistant ED/Business Office Manager). They acknowledged the identified areas reviewed.
Based on observation and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observation of the kitchen on 10/17/2023 at 09:30 am revealed the following areas needing cleaning and repair: a. An accumulation of food spills, splatters, loose food and debris, dirt, dust and black matter was visible on or underneath the following:* Trash can and lid;* Interior and exterior of cupboards and drawers beneath prep table;* Flooring under the shelving in the dry storage room; and* Storage table and wheels below warming pans.b. The following areas were found in need of repair:* Multiple cooking pans damaged and stained;* Ice build-up in Freezer three, reported by staff to be related to a broken seal; and* Three sets of blinds broken in main kitchen.During an interview and tour with Staff 2 (Assistant ED) and Staff 4 (Cook) on 10/17/23, they acknowledged the identified areas needing to be cleaned and repaired.On 10/18/23, the Surveyor reviewed areas in need of cleaning and repair with Staff 1 (Executive Director) and Staff 3 (Culinary Director). They acknowledged the identified areas reviewed.
C240 - Resident Service Meals, Food Sanitationa. An accumulation of food spills, splatters, loose food and debris, dirt, dust and black matter was visible on or underneath the following:* Trash can and lid;- Those areas were cleaned immediately.* Interior and exterior of cupboards and drawers beneath prep table Those areas were cleaned immediately;* Flooring under the shelving in the dry storage room; and* Storage table and wheels below warming pans. Those areas were cleaned immediately.b. The following areas were found in need of repair:* Multiple cooking pans damaged and stained;- New pans will be ordered by the Executive Chef by date the community alleges compliance.** Ice build-up in Freezer three, reported by staff to be related to a broken seal- To be completed soon; and* Three sets of blinds broken in main kitchen.The kitchen blinds will be replaced by the date the community alleges compliance. A) Executive Director will implement a new daily, weekly, monthly cleaning task sheet. The kitchen staff will be responible to mark off each item completed daily, weekly, and monthly. The cleaning task sheet will be reviewed by the Executive Chef, and turned into the Executive Director at the end of each week. Executive Director will conduct random audits on the kitchen and dry storage area. The Executive Chef will conduct audits of the kitchen weekly, and monthly.

Based on observation and interview, it was determined the facility failed to ensure their annual kitchen inspection survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C 240.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.
Z142-Administration ComplianceRefer to C240 Plan of Correction

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 unannounced complaint investigation conducted 10/11/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.