Everbloom Memory Care

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

Based on interview and record review, it was determined the facility failed to ensure initial evaluations addressed all required elements, including pronouns, for 1 of 1 sampled resident (#2) whose initial evaluation was reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 01/2026 with diagnoses including Alzheimer’s disease with early on-set. The resident’s 01/06/26 pre-admission evaluation was reviewed. The following required elements were not addressed in the evaluation: * Pronouns; * Mental health issues, including history of treatment and effective non-drug interventions; * Personality, including how the person copes with change or challenging situations; * Ability to use call system; * Pain – pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident’s behavior, including, but not limited to: noise, lighting, room temperature. The need to ensure all required elements were addressed in initial evaluations was discussed with Staff 1 (ED), Staff 2 (Administrator), and Staff 3 (Health & Wellness Director/LPN) on 02/03/26 at 2:05 pm. They acknowledged the findings.

C252: OAR 411-054-0034 (1-6) (1-2) Initial Screening and move-in, Resident Evaluation-General: The community evaluation tool will be updated to ensure all elements of the initial screening and move-in evaluation are addressed. An audit will be completed on all existing resident files and corrections will be made by the Health & Wellness Director to ensure they meet the rule requirements. The community will utilize this updated tool with all required areas for future move-ins to ensure continued compliance. This tool will be evaluated at the time of any future rule changes. The community nurse will complete and monitor this correction. The Administrator will audit this correction for 60 days to ensure compliance is met, then will review quarterly thereafter. (3-4) Evaluation Requirements at move-in, Quarterly Evaluation Requirements: The community evaluation tool will be updated to ensure the following elements are included: Pronouns, mental health issues & hx of treatment and effective non-drug interventions. Personality including how a person copes with change or challenging situations, ability to use call system, pain including interventions and how a person expresses pain or discomfort, complex medication regimen, history of dehydration or unexplained weight change, recent losses, unsuccessful prior placements, and environmental factor that impact a person’s behavior. This updated evaluation tool will be used for all new move-ins and evaluations with current residents. An audit will be completed and on all existing resident files and corrections will be made to ensure they meed the rule requirements. The community nurse will complete and monitor this correction. The Administrator will audit this correction for 60 days to ensure compliance is met, then will review quarterly thereafter

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

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

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had written, resident-specific parameters and that non-pharmacological interventions were attempted prior to administering the medication for 2 of 2 sampled residents (#s 1 and 2) who were prescribed PRN medication to address behaviors. Findings include, but are not limited to: 1. Resident 1 moved into the community in 06/2025 with diagnoses including dementia and anxiety. a. The facility failed to ensure there were specific parameters for staff describing how Resident 1 expressed anxiety and agitation and failed to include potential adverse effects for the high-risk medication: * Haloperidol 0.25 ml every four hours as needed for agitation, anxiety, and nausea. b. The facility administered the PRN Haloperidol 10 times during January 2026. There were no non-pharmacological interventions on the MAR for staff to attempt prior to administering. In an interview on 02/03/26 at 9:15 am, Staff 3 (Health & Wellness Director/LPN) verified there were no resident-specific instructions on the resident’s MAR for the haloperidol and that staff had not been attempting non-pharmacological interventions prior to administering the medication. The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and agitation, potential adverse effects listed, and non-drug interventions for staff to attempt prior to the administration of PRN psychotropic medications was reviewed with Staff 1 (ED), Staff 2 (Administrator) and Staff 3 at 1:30 pm on 02/03/26. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2026 with diagnoses including Alzheimer’s disease, depression, and bi-polar disorder. The resident’s clinical record was reviewed, and the following was identified: The resident had physician orders for haloperidol concentrate 2 mg/ml, 0.5 ml every 4 hours as needed for agitation and for lorazepam 0.5 mg, one tablet every 4 hours as needed for agitation, anxiety, or nausea. The 01/01/26 through 01/31/26 MAR did not include: * Resident-specific instructions indicating how agitation and anxiety presented for the resident; * Instructions to staff regarding the order of administration of the two PRN psychotropic medications; * Potential adverse effects for the high-risk medications; and * Non-pharmacological interventions for staff to attempt and document as ineffective prior to administering the PRN psychotropic medications. In an interview on 02/03/26 at 9:15 am, Staff 3 (Health & Wellness Director/LPN) verified there were no resident-specific instructions on the resident’s MAR for either the haloperidol or the lorazepam and that staff had not been attempting non-pharmacological interventions prior to administering either medication. On 02/03/26 at 1:30 pm, the need to have resident-specific instructions for non-licensed staff for PRN psychotropic medications, and to attempt non-pharmacological interventions and document them as being ineffective prior to administering PRN psychotropic medications, was discussed with Staff 1 (ED), Staff 2 (Administrator), and Staff 3. They acknowledged the findings.

C330: OAR 411-054-0055 (6) (6) Systems: Psychotropic Medication: The facility will ensure PRN psychotropic medications used to treat a resident’s behavior has written, resident-specific parameters and that non-pharmacological interventions are attempted prior to administering the medication, and documented. An audit will be conducted to review current PRN psychotropic medication orders and any resident orders missing written, resident-specific parameters and non-pharmacological interventions will be corrected. MAR instructions will be updated to match the corrected orders and staff will be trained on psychotropic medications, procedures, and documentation. The Health & Wellness Director will review the MARs weekly for 8 weeks to evaluate the effectiveness of this correction. The Health & Wellness Director will review the MARs monthly thereafter to ensure continued compliance.

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

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

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in for 2 of 2 sampled residents (#s 1 and 2) and three unsampled residents who moved into the facility in the last three months; whenever there was a significant change of condition for 1 of 1 sampled resident (#1); and no less than quarterly, at the same time the resident’s service plan was updated, for 13 unsampled residents. Findings include, but are not limited to: The facility was using the Department’s ABST, which was reviewed on 02/02/26 and 02/03/26. The following was identified: a. Residents 1 and 2 moved into the facility on 06/09/25 and 01/07/26, respectively. Resident 1’s ABST evaluation was created on 0611/25, and Resident 2’s ABST evaluation was created on 01/08/26. The ABST evaluations for three unsampled residents who moved into the facility within the last three months were also created after their move-in date. b. Resident 1 experienced a significant change of condition on 12/30/25, and his/her ABST evaluation was not updated. c. Thirteen of 24 residents’ ABST evaluations had not been updated within the last 90 days. The need to update resident ABST evaluations as required by rule was discussed with Staff 1 (ED), Staff 2 (Administrator), and Staff 3 (Health & Wellness Director/LPN) on 02/03/25 at 1:30 pm. They acknowledged the findings and stated they had updated the ABST as required and did not know why the updates were not reflected in the ABST. No additional documentation was provided.

C363: OAR 411-054-0037 (4-6) (4) Frequency of Updates, Develop and Maintain Updated Posted Staffing Plan, ABST Reporting of Specific Needs Contracts and Exceptional Payments: A full audit of the ABST tool has been performed and updates were completed for all residents to ensure accuracy of staffing needs. A conversation via email occurred with Administrator and an ODHS Operations and Policy Analyst, who provided a resource on the ABST tool and clarification on saving updates. The Administrator will ensure the ABST tool is updated prior to any new admission, in coordination with any service plan updates, and in coordination with any quarterly service plan reviews. Each update will be exported and saved in an electronic file to provide evidence of compliance in the event the online tool isn’t reflective of the dates of these updates. The Administrator will be reviewing the individual ABST records weekly for 8 weeks, then monthly thereafter, and with every significant change of condition and service plan update to confirm the ABST is updated as required to accurately reflect staffing needs.

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

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all required elements, including pronouns, for 1 of 1 sampled resident (#2) whose initial evaluation was reviewed. Findings include, but are not limited to: Refer to C252.

L252 - OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation: Referring to C252, the initial evaluation for residents will be updated to include pronouns. The evaluation tool will be updated to include this element and an audit of all current residents will be completed by the Health & Wellness Director to ensure this is updated. Initial evaluations moving forward will include this element to ensure compliance is met. The Health & Wellness Director will monitor resident files quarterly to ensure corrections are completed

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name (B) Pronouns. (C) Gender identity.

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

Based on 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, C330, and C363.

Z162 - OAR 411-057-0160 (2b) Compliance with Rules Health Care: Referring to C252, C330, and C363. Resident records for initial Screening and move-in, and updates, will include information to promote person-centered care, and any variance from legal record indicated by resident. The resident evaluation will be updated to include pronouns. All resident files will be audited and updated by the Health & Wellness Director to include these missing elements. New move-ins will be evaluated with this updated initial screening to ensure compliance. The Health & Wellness Director will review resident evaluations quarterly, and more often as appropriate.

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

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's service plan for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to: Resident 1 and 2's current service plans were reviewed during survey. Each of the service plans, dated 11/13/2015 and 01/07/26, respectively, lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED), Staff 2 (Administrator), and Staff 3 (Health & Wellness Director/LPN) on 02/03/26 at 1:30 pm. They acknowledged the findings.

Z163 - OAR 411-057-0160 (2)(c)(A)(B) Nutrition and Hydration: The evaluation tool will be updated to include an individualized service plan addressing resident’s nutrition and hydration needs. An audit will be completed on all existing resident files and corrections will be made by the Health & Wellness Director to ensure they meet the rule requirements. The community will utilize this updated tool with all required areas for future move-ins to ensure continued compliance. This tool will be evaluated at the time of any future rule changes. The Health & Wellness Director and Administrator will complete and monitor this correction, reviewing for 60 days, then quarterly thereafter

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

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

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 12/11/25 showed the following areas needed cleaning or repair: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, white billowy matter, and/or black matter was visible on or underneath the following: * Food debris, dried spills/liquids observed on dining room chairs before and after cleaning of area between meal periods: * Hood vents above range; * Bottom of cabinets on prep island; * Baseboard at bottom of center prep island; * Windowsill of window in kitchen next to back door; * Bottom of freezer in dry storage area; * Reach-in refrigerator in dry storage area; * Threshold of back door into kitchen; * Underside of Kitchen Aid mixer head; * Toaster; and * Floor drain under prep island. b. Items in need of maintenance or repair: * Multiple cutting boards observed with scoring and or embedded black debris; * Black gasket/seal on lower door of stand-up reach-in freezer; * Ice build-up on lower shelf of freezer in dry storage; * Enamel/caulking on floor drain under prep island; * Reach-in refrigerator in dry storage area not holding proper temperature, and * Exhaust hood removable vents dented and not fitting properly. c. Multiple open containers found beyond manufacturer’s use-by date. Staff 2 (Cook/Person-in-Charge) acknowledged the items were outdated and should have been discarded. Multiple items found in cold storage without legible open and/or prepared dates. d. Staff 3 (Cook) was observed to have a towel attached to their person instead of being stored in the sanitation bucket. The towel was observed to be touched multiple times with gloved hands, potentially contaminating them. The towel was not observed being returned to the sanitation bucket after use. e. Staff 3 was observed to drop a paring knife used for food prep on the floor and return the knife to the work station without washing/rinsing/sanitizing it first. f. Staff 3 was observed to use their thermometer, and then sanitize the thermometer in quaternary ammonia based solution but did not rinse it afterwards. Staff 3 then was observed to use that thermometer, potentially contaminating food with sanitizing solution. g. Staff 2 was unable to adequately describe the two-stage cooling method for hot foods. h. The reach-in refrigerator in the dry storage area did not contain a thermometer. A large metal container of soup for residents was observed being stored in the refrigerator. Staff 2 was asked to temp the resident food and the food was found to be at 50 degrees Fahrenheit, which is an unsafe temperature. The surveyor’s thermometer was used to check the temperature of the refrigerator, and it was found at 47 degrees Fahrenheit, six degrees higher than the required temperature. i. Staff 2 and Staff 3 were not able to state which sanitizing method (heat or chemical) was being used for the ware washing machine final cycle. Staff 2 was not able to state the appropriate sanitizing heat temperature. The facility did not have a system to effectively monitor the sanitizing agent of their ware washing machine. j. Test strips for the ware washing machine had been dropped in liquid and were no longer functional. The facility was using a different chemical for surface sanitizing buckets, and they did not have test strips for that chemical. The facility did not have a system for ensuring that surface sanitizing solution was at appropriate concentration levels for effective sanitation. k. Multiple dented/damaged food products were observed in the dry storage area, stored with ready-to-use products. l. Staff 3 was observed to wash dishes without a protective barrier over their clothing. Staff 3, after washing dirty dishes, continued with food preparation and service. This practice caused a potential for contamination. m. All care staff were observed to handle/deliver food to residents without wearing aprons/protective barriers over their clothing to minimize the potential for cross contamination. n. Multiple dishwashing racks were observed to be stored on the floor. o. Surveyors observed food that had not been properly cooled and instructed Staff 2 to discard the food product. Staff 3 was not able to demonstrate knowledge of proper cook-to and reheat temperatures. p. The facility staff identified as the Person-in-Charge was not able to effectively demonstrate adequate knowledge of multiple food code principles. The facility did not demonstrate effective systems to ensure safe food service operations during the survey. Upon entrance to the facility for the kitchen inspection, Staff 1 (Executive Director) was interviewed and indicated there was not a “Kitchen Manager” or designated person for oversight of the kitchen and food operations. Staff 1 stated that the facility was “too small” to have a position like that. Staff 2 indicated they did have a designated “person in charge,” which was the cook on duty for each day/shift when food was prepared and served. During the kitchen survey, the staff that were designated “person in charge,” Staff 2 and Staff 3, lacked sufficient knowledge to ensure safe and sanitary practices were upheld and enforced. There was no clear kitchen/foodservice leadership and/or oversight. Both Staff 1 and Staff 2 were full time cooks working 4 days per week cooking/preparing food for residents. Both Staff 1 and Staff 2 were unable to demonstrate the necessary knowledge, practices, or oversight to ensure safe food operations. At approximately 12:45 pm, the surveyors reviewed the need to ensure the kitchen was kept clean and in good repair with Staff 1 (Administrator) and Staff 4 (Facility Owner). The staff acknowledged the findings.

C0240: OAR 411-054-0030 (1)(a) a. A cleaning checklist and training will be completed with the community care staff to ensure dining room chairs and areas between meal periods are thoroughly cleaned, and free of food debris and dried spills/liquids. Care staff will document completion of these tasks on a paper checklist during their shifts and management will review for task completion. A weekly cleaning checklist has been implemented and shared with the kitchen staff to ensure routine cleaning of all kitchen areas is completed. This cleaning checklist includes hood vents above range, bottom of cabinets on prep island, baseboard at bottom of center prep island, windowsill of window in kitchen next to back door, bottom of freezer in dry storage area (now located in activity room), threshold of back door in kitchen, underside of KitchenAid mixer head, toaster, and floor drain under prep island. Reach-in refrigerator in dry storage area has been removed. The kitchen staff member on duty during scheduled cleaning task is responsible for its completion in that respective week. The community administrator will ensure that the cleaning checklists are implemented and adhered to, and will verify with staff each month that tasks are being performed, in addition to daily and weekly visual reviews of the kitchen and dining areas. b. Items in need of maintenance or repair have been addressed and will be monitored by the kitchen staff, who will report any future maintenance or repair needs to the administrator immediately. The cutting boards with observed scoring and/or embedded black debris have been removed and replaced with new. The black gasket/seal on lower door of stand-up reach-in freezer has been repaired. Ice build up on the lower shelf of the freezer in dry storage (now the activity room) has been removed and cleaned. Enamel/caulking on floor drain under prep island has been cleaned and re-caulked. Reach-in refrigerator in dry storage has been removed from the facility as it was observed to not hold proper temp at time of survey. Exhaust hood removable vents will be repaired/secured. c. Open and undated items found in cold storage were removed at time of survey. Kitchen staff will check for open or undated items daily during their scheduled shifts to ensure these items are removed and discarded. d. Kitchen staff observed to have a towel attached to her person at time of survey was immediately educated/reminded of the potential for contamination and now ensures the towel is returned to the sanitation bucket after use. e. Kitchen staff have been educated/reminded of the potential for contamination when dropping items/tools on the floor and will ensure items are either disposed of or washed/rinsed/sanitized as appropriate. f. Kitchen staff have been educated/reminded of the necessity to rinse items after sanitizing with the quaternary ammonia-based solution to avoid potentially contaminating food with sanitizing solution. g. Kitchen staff have been re-educated on the two-stage cooling method for hot foods and CBC educational resources have been provided as a resource to reference. h. The reach-in refrigerator in the dry storage area has been removed from the facility as it did not hold proper temp. The food found in this refrigerator at the time of the survey was discarded immediately after determining it was at an unsafe temp. i. The kitchen staff have been educated/reminded of the chemical sanitizing method used for the ware washing machine. The machine’s chemical log has been updated to track the daily testing of the sanitizer levels and monitoring the sanitizing agent’s effectiveness. Sanitizer test strips were immediately delivered by Rose’s to implement this monitoring system. j. Test strips for the ware washing machine were found to be no longer functional and Rose’s delivered new ones immediately. Extra test strips were ordered and available to ensure daily monitoring can be completed. Test strips for the surface sanitizing chemical were ordered and are used each time surface sanitizer solution is prepared in the bucket to ensure appropriate concentration levels for effective sanitation. k. Kitchen staff have been educated/reminded to check and refuse any dented/damaged food products at time of delivery. Any food products found to have become dented/damaged while in the facility will be discarded. l. Two rubber aprons were immediately ordered and are used by staff when washing dishes to ensure there is a protective barrier over their clothes. m. Additional cloth aprons were ordered and care staff were educated/reminded of the requirement to wear aprons/protective barriers over their clothing when handling.delivering food to minimize potential for cross contamination. n. Kitchen staff have been educated/reminded to store dishwashing racks on proper holder, not on the floor. o. Kitchen staff have been educated/reminded of proper cook-to and reheat temps, in addition to food cooling process. Additional CBC resources have been provided for kitchen staff to reference. p. The facility Person-in-Charge was identified and has been provided with additional education and training to ensure they are able to effectively demonstrate adequate knowledge of food code principles. All kitchen staff will be provided with additional training and education to ensure they have sufficient knowledge for safe and sanitary practices. The Person-in-Charge will continue to monitor the other kitchen staff to identify additional training/education needed, as any kitchen staff member on duty should have the ability to demonstrate the same knowledge of kitchen practices to ensure safe food operations as the Person-in-Charge.

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

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff.

Based on observation and interview, it was determined the licensee failed to ensure adequate administrative oversight of facility operations regarding kitchen sanitation practices, which posed a risk to the safety of residents. Findings include, but are not limited to: During the annual kitchen inspection, conducted 12/11/25, administrative oversight to ensure adequate food sanitation practices in the facility kitchen was found to be ineffective based on multiple systems and practices which did not meet the Oregon Food Sanitation Rules and which put residents at risk, Refer to C240.

See C 240

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff.

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

Based on 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.

See C 240

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

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

Based on observation, and interview, it was determined the facility failed to 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.

1. The kitchen manager has worked on basic cleanliness addressing the issues identified in section a: food spills, loose food and trash debris, dirt, dust, black matter and grease; Section b: holes by electrical conduits are scheduled to be fixed; Section c: dishwasher racks are no longer being stored on the floor; Section d: hair nets/restraints have been ordered; Section e: kitchen manager has labeled and dated items; Section f: thermometers have been ordered; Section g: sanitizer test strips have been ordered ; Section h: dry storage items have been secured; Section i: diet orders have been reviewed with staff and the kitchen is obtaining a larger food processor to ensure timely provision of mechanically altered meals; Section j: kitchen staff have access to food sanitation rules. Section k: kitchen manager is ensuring appropriate amounts of food are being prepared to ensure each resident gets a full meal. 2. The kitchen manager is developing a daily, weekly and monthly cleaning schedule. The kicthen manager and the administrator to complete a weekly walk-through looking at kitchen cleanliness, organization and needed repairs. All kitchen staff to be in-serviced on infection control measures including and not limited to: hair restraints, the use of test strips for sanitation bucket testing, safe food handling. Food handler's cards will be obtained for all employees requiring cards. All diet orders will be confirmed and the kitchen will have a list of diet orders for each resident that is to remain current. All staff will be trained on the importance of following diet orders. The kitchen manager is developing a par list to determine proper amounts of food to order and prepare to ensure the kitchen does not run out of food. 3. The systems will be reviewed weekly during kitchen audits and walk-throughs, and monthly in the Quality Improvement Meeting. 4. Kitchen Manager and Administrator.

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

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

Based on 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.

See Plan of Correction for 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.

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.

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.

C150 OAR 411-054-0025 Facility Administration: Operation 1) Executive Director, Assistant Executive Director, and Registered RN will review systems for accuracy and implemention to all operational systems to ensure compliance. A plan of correction binder is being implemented to track progress in each area. 2) Quality Improvement Meeting will be initiated monthly, clinical meeting several times per week, routine auditing by administrator and maintenance. 3) Monthly in the Quality Improvement Meeting . 4) The Executive Director.

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.

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.

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.

C154 OAR 411-054-0025 - Facility Administration: Policy & Procedure 1) All residents packages and mail have been delivered. The broken blinds will be replaced and is on the maintenance repair list. The restroom locks have been installed. The laundry has been cleaned and returned to resident. The Executive Director has reviewed and responded to grievances and documented resolution and follow up. 2) The Executive Director will ensure the community grievance binder is located in the chartroom. An in-service regarding the grieviance policy and location of the binder was held on with staff on 10/10/24. The Executive Director will also explain grievance policy to residents and encourage their feedback. Mail notification and delivery system is being implemented to ensure residents receive their mail and packages timely. Laundry processing will be reviewed with staff to ensure clean laundry is returned timely to residents. Routine audits of locks on doors will be completed monthly by maintenance and reviewed monthly in the quality improvement meeting. 3) Weekly review of grievance binder, laundry and mail systems, monthly Quality Improvement Meetings. 4) The Executive Director.

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.

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.

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.

C156 411-054-0025 - Facility Administration: Quality Improvement. 1) The Executive Director has inititiated scheduled Quality Improvement Meetings monthly. 2) The Executive Director will ensure follow up on items identified in the Quality Improvement Meeting. Consultant team is providing guidance on Quality Improvement Meeting process and documentation. 3) Monthly in the Quality Improvement Meeting. 4) The Executive Director.

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.

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

Based on observation, 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.

C200 - OAR 411-054-0027 - Resident Rights and Protection - General 1) The Executive Director held an all-staff mandatory meeting on 10/10/24 to review the resident policies and procedures regarding resident rights. The staff have been inserviced on resident rights including dignity while assisting with feeding, and rights related to privacy. All residents now have keys available to their apartments, and have been assessed for ability to have a key. During the all staff manadatory meeting on 10/10/24 The Executive Director provided training on the HIPPA policy reminding staff to ensure the laptops are locked when they are away from them to protect the resident's medical information.The Maintenance Director installed the privacy/dignity curtains in all occupied shared apartments.The Maintenance Director is in the process of installing the final locks on the shared residents bathrooms. 2) The Assistant Executive Director has included the resident rights into the on-boarding process, and all staff will receive this pre-service training upon hire. All residents upon admission will be offered a key and ability to use will be service planned. Managers on duty will include daily community walk-throughs to observe for compliance with resident rights including observations at mealtimes, ensuring laptop information is not exposed, privacy curtains in room and functioning locks and keys. 3) The Executive Director and the Assistant Executive Director will review the resident rights quarterly during an all staff mandatory meetings. 4) The Executive Director and Assistant Executive Director will monitor the resident rights and dignity quarterly and upon move-in.

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

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

Based on interview and record review, it was determined the facility failed to ensure 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.

C231 OAR 411.054.0028 - Reporting & Investigating Abuse - Other Action 1) Resident samples 1, 2, and 3 Incidents that were identified in the survey as needing investigations will be investigated by the Exececutive Director. The incident reports regarding resident samples 1, 2, and 3 were reported to Adult Protective Services. 2) During clinical meetings, the incident reports, ADL sheets, electronic observation notes and ISP's will be reviewed to identify any potential investigation and reporting needs. All staff received training on abuse and neglect reporting during the all staff mandatory meeting on 10/10/24. The consultant team is reviewing incident reports and providing training to the clinical team on investigations.The Executive Director or designee will complete timely investigations of incidents regarding and report to APS per regulation guidelines. 3) The system will be monitored multiple times weekly in clinical meetings, and reviewed monthly in the Quality Improvement Meeting. 4) The Executive Director, Assistant Executive Director, and the Licensed Nurse.

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

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

Based on interview and record review, it was determined the facility failed to ensure 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.

C252 - OAR 411-054-0034 - Resident Move-In & Evaluation: Res Evaluation. 1) The sample resident's 2, 3, and 4 evaluations will be reviewed and updated to include missing components. The Executive Director implemented a new initial evaluation tool that includes verbage within the State of Oregon's requirement for initial evaluations. 2) The evaluations due will be reviewed multiple times a week during clinical meetings. Consultant has provided an evaluation checklist to ensure all components of the Oregon evaluation have been addressed. The Executive Director & Licensed Nurse will utilize the new initial evaluation tool and checklist for all evaluations. 3) Evaluations will be completed upon admission, within 30 days and quarterly thereafter, and with significant change of condition. 4) The Executive Director, Assistant Executive Director, Resident Care Coordinator and the License Nurse.

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ 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.

C260 - OAR 411-054-0036 - Service Plan: General 1) Resident samples 1, 2, and 3 service plans will be audited and updated to include the missing components to ensure staff have clear directions specific to residents current needs and preferences. Current service plans have been printed and placed in the service plan binder for staff to review. 2) Service plans will be updated utilizing consultant provided checklist for ensuring all components addressed. Consultant will review updated service plans and provide feedback. A Service Planning training session will be held to ensure compliance. A tracking schedule is to be used to ensure service plans updated upon admission, within 30 days, quarterly thereafter and with significant change of condition. 3) The Licensed Nurse, Executive Director, and RCC will review and update the service plans per the 30, 90 day and significant change of conditions requirements. 4) The Executive Director, Licensed Nurse, and Resident Care Coordinator will be responsible to monitor.

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

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

Based on 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.

C270 - OAR 411-054-0040 - Change of Condition and Monitoring. 1) Resident samples 1, 2, and 3 will be re-evaluated for current condition status. Resident 3's falls will be referred to the community RN for needed interventions and monitoring. Resident 2 will be evlauated for skin monitoring and behavioral plan developed for reisdent altercations. Resident 3 will be evaluated for skin concerns and and weight change and will be referred to the community RN for significant change of condition for weight loss. The service plans will be reviewed and updated accordinly based on resident evaluation needs. Changes to service plan will be communicated to staff on each shift. 2) All-staff training will be done on change of condition identification, monitoring and documentation. This training to include conditions requirig referral to the RN for sigificant change of condition. Wounds will be tracked weekly on the whiteboard. Weights will be reviewed and referred to the RN for significant changes. Residents with challenging behaviors will be reviewed and interventions developed and revised as needed for effectiveness. The clinical team will take the NurseLearn course on change of condition and consultants will provide ongoing training and audits of the change of condition system. LPN to be on-site 24 hours a week and RN 16 hours per week per the updated condition to help manage change of condition system. 3) Routine monitoring of change of condition will be ongoing and reviewed multiple times per week in clinical meeting process. 4) The Executive Director, Licensed Nurse, and RCC.

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

OAR 411-054-0045 (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.

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.

C280 - Resident Health Services - OAR 411-054-0045 1) Resident 1 and 2 have been referred to the RN for significant change of condition assessments. Based on these assessments, the service plan will be reviewed and updated accordingly. 2) All-staff will receive training on conditions requiring referral to the RN. The RN will show current or prior training on significant changes of condition. Significant changes of conditions will be tracked weekly on the whiteboard. The RN will be on-site 16 hours per week per the updated condition to help manage change of condition. 3) Multiple times weekly during clinical meeting and weekly progress notes by the RN until sig change of condition resolves or new baseline is determined. Audit monthly in the Quality Improvement Meeting. 4) The RN and Executive Director.

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.

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

Based on observation and interview, it was determined the facility failed to establish and maintain 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.

C295 - OAR 411-054-0050 - Infection Prevention & Control 1) All dining service staff have been trained to wear aprons during meal service. An appropriate number of aprons have been ordered. All staff have been retrained on hand hygiene and infection control at mealtimes during all-staff 10/10/24. All staff were inserviced on infection control measures to prevent cross contamination to include the need to cover food and provide proper utensils during meal delivery. 2) Infection prevention and control policy training will be completed within the first 30 days of being hired, and the Executive Director will hold quarterly all-staff meetings to review the infection prevention and control policies. Daily walk-throughs willl be conducted by the management team to observe hygiene and manager on duty will be implemented at mealtimes to ensure proper hygiene at meal service. 3) Daily walkthroughs, training reviewed monthly in the Quality Improvement Meeting. 4) The Executive Director, Assistant Executive Director, RCC, Nursing and the Kitchen Manager.

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

OAR 411-054-0055 (1)(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.

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.

C300 - OAR 411-054-0055 - Systems: Medication & Treatments See citations 303, 304, 305, 310 and 330

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.

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

Based on interview and record review, it was determined the facility failed to ensure 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.

C303 - Medication and Treatment Orders. 1) The orders for Resident 3 have been reviewed and implemented, service plan updated for changes. 2) All orders will be processed timely utilizing the 3rd check system. Orders will be reviewed routinely in the clinical meeting by nursing. PharMerica to complete full three-way audit on all residents, and audit the medication system. Med techs to be in serviced by LN on elements of a safe medication system and order processing. Physician orders are being sent out for quarterly review to ensue all current orders are in place and will be reviewed by the RN. Diet orders will be reviewed and the kitchen will have a complete list of diet orders for each resident. Medication variance and exceptions reports will be reviewed routinely in the clinical meeting with follow up documented on missed medications. Weekly medication cart audits for reordering medications will be completed by RCC. 3) Multiple times weekly in the clinical meeting, monthly in Quality Improvement Meeting, and quarterly in scheduled pharmacy audits and quarterly physician order review. 4) The Executive Director, Licensed Nurse, and RCC.

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

OAR 411-054-0055 (1)(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.

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.

C304 Medication and Treatment Orders 1) The 90 day orders have been sent and RN is reviewing them as they are returned. The community has arranged for Pharmerica to complete quarterly review of all medications and treatments. 2) The community will ensure a quarterly pharmacist review is scheduled and that an RN reviews the orders quarterly. Orders will be tracked as received to ensure completion of all quarterly physician orders. The community will correct all items on the pharmacy review and pharmacy audit binder is being initiated to track progress. Consultant will provide routine MAR audits and feedback to the community. 3) Monthly review in the Quality Improvement Meeting, and RN and pharmacist quarterly review of physician orders. 4) The Executive Director and Licensed Nurse.

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.

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

Based on interview and record review, it was determined the facility failed to notify the physician 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.

C305 Resident Right to Refuse 1) Resident 1 and 2 providers have been notified of medication refusals. 2) Licensed Nurse will conduct a Med Tech in-service training on documentation requirements for medication refusals. Facility is sending a form to providers to clarify when they would like to be notified of refusals. Medication refusals will be reviewed routinely in the clinical meeting by administrator, RCC and nursing to ensure appropriate follow-up. 3) Multiple times weekly review in the clinical meeting. Monthly follow-up in the Quality Improvement Meeting. 4) The Executive Director, Licensed Nurse and Resident Care Coordinator.

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

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

Based on interview and record review, it was determined the facility failed to ensure 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.

C310 - Medication Administration 1) Resident 2 and 3 MARS have been reviewed and updated for indications of use and/or diagonses. reason for usage. Resident 1 MAR reviewed and parameters were added. 2) A full MAR review will be completed looking for indications of use and PRN parameters. Licensed Nurse will review orders routinely in the clinical meeting and diagnoses/indications of use will be confirmed in the third check process. Consultant will provide training on PRN parameters, and staff will be trained on documentation requirements when giving PRNs. 3) Review in the clinical meeting several times per week. Quarterly with physician order review and pharmacist review. 4) The Executive Director, Licensed Nurse.

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

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

Based on interview and record review, it was determined the facility failed to ensure 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.

C330 - Psychotropic Medications 1) Resident sample 1, 2, 3 MARS have been reviewed by RN and non pharmological interventions were included as well as resident specific description of behaviors that may indicate appropriate need for psychotropic medication. 2) A full MAR review is being completed for PRN parameters and non-pharmaceutical interventions. Training is to be done with med-techs on documentation requirements when giving PRN psychotropic medications. Consultant will provide resources on PRN parameters for psychotropic medications. 3) RN will review all Psychotrpic medications during the 90 day Physician Order reviews. Routine review of new orders in the clinical meeting several times per week. 4) The RN and Executive Director.

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure a 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.

C340 - OAR 411-054-0060 - Restraints and Supportive Devices. 1) Resident 3's supportive device was assessed by the RN and the service plan was updated with instructions to staff for correct use and precautions related to use. 2) A full audit of resident apartments was completed to ensure all supportive devices are accounted for, and communicated to nursing for assessments and service planning. Training will be provided to all-staff on supportive device use and the need to monitor for safety. Consultant has provided assessment form to utilize to meet the assessment criteria and has provided resources on how to service plan assistive devices with restraining characteristics. 3) Monthly in the Quality Improvement Meeting, quarterly reviews and as needed with significant change of condition. 4) The Executive Director, Licesned Nurses, RCC.

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

OAR 411-054-0037 (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.

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.

C361 - OAR 411-054-0037 - Acuity Based Staffing Tool 1) The Executive Director, and RCC will work with the RN Consultant, and the State of Oregon to ensure the ABST is current and matches with the resident's service plans. 2) The Executive Director will receive training from the consultants, and the State of Oregon. The ABST will be updated to meet the needs and unexpected needs of the residents upon move-in, quarterly and for any change of condition. Residents will be capped at 24 residents until condition is ammended. 3) Daily review of staffing levels. Updates to the ABST with each new admission, scheduled evaluation and service plan review and with significant change of condition. Monthly audits of the ABST in the Quality Improvement Meeting. 4) The Executive Director and RCC.

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.

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.

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.

C372 - 411-054-0070 - Training Within 30 Days of Hire - Direct Care Staff 1) Staff samples 6, 12, and 15 have been assigned missing abdonmial thrust and pre-service new hire training. 2) The Assistant Executive Director added the additional required within 30 day training videos to the new hire orientation packet. The Assistant Executive Director also is using the State of Oregon new hire checklist as a guide. The Assistant Director will ensure new hire staff members have all required trainings completed prior to beginning training on the floor. Consultant will provide ongoing audits of training files with the Assistant Executive Director. 3) Weekly tracking of new hires by the Assistant Executive Director. Monthly audit of employee files in the Quality Improvement Meeting. 4) The Executive Director and Assistant Executive Director.

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.

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

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted 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.

C420 - Fire and Life Safety: Safety 1) The Maintenance Director received training on how to complete fire drills, and received an appropriate form to use provided by the consultant. A fire drill is scheduled in November using consultant provided form that contains all the necessary elements. 2) The Maintenance Director will conduct in-services on fire, life and safety training, and fire drills on alternating shifts every other month. Maintenance Director received training on when, and how often fire, life, and safety drills should be conducted. The Maintenance Director is utilizing a tracker to ensure timely fire drills on alternating shifts every other month. 3) Monthly audit in the Quality Improvement Meeting. 4) The Executive Director and Maintenance Director.

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

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

Based on interview and record review, it was determined the facility failed to 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.

C422 - OAR 411-054-0090 - Fire and Life Safety: Training for Residents. 1) The Maintenance Director is scheduling a fire and life safety meeting will all residents and review the fire safety plan with exisiting residents. 2) The Maintenance Director will add the fire and life safety information to the admission packet to be reviewed with residents and families to ensure that training has been received within 24 hours of admission. Training will be tracked to ensure all residents have received this initital training and then anually. Consultant team will provide resources on information to include during the training. 3) Monthly in the Quality Improvement Meeting, and annual review. 4) The Executive Director and Maintenance Director.

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

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

Based on observation and interview, it was determined the facility failed to 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.

C153 - OAR - 411-054-0200 - Doors, Walls, Elevators, Odors. 1) Maintenance Director is working on cleaning and correcting the identified areas: walls, baseboards, door frames, air vents, dust buildup on fans, stains on dining room chairs, and replacing blinds. Bids are in place for furniture replacement. 2) The Maintenance Director will develop a cleaning schedule and walk-through log to identify items that need fixing. Staff will be in-serviced on how to report concerns to maintenance. Executive Director and Maintenance will complete routine walk-throughs to identify areas for correction. 3) Review of maintenance logs several times per week. Weekly walk-throughs with Executive Director and Maintenance. Monthly audit in the Quality Improvement Meeting. 4) The Executive Director and Maintenance Director.

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

OAR411-004-0020(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.

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.

H1517 - OAR 411-004-0020 - Individual Privacy: Own Unit. 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.

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.

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.

H1518 - OAR411-004-0200 - Individual Door Locks: Key Access. 1) The Executive Director held an all staff mandatory meeting on 10/10/24 to review the resident policies and procedures regarding the resident rights. All residents have received individual keys to their apartments. The residents whom are unable to cognitively use a key have access to a key located in their apartment. The Maintenance Director installed the privacy/dignity curtains in all occupied shared apartments. 2) The Assistant Executive Director has included the resident rights into the on-boarding process, and new residents and/or families will be offered keys to their apartment upon move-in, and documented on the residents serice plans. Routine walk-throughs will be completed to ensure residents have access to keys and apartments. 3) Weekly walk-throughs, and review monthly in the Quality Improvement Meeting. . 4) The Executive Director and Assistant Executive Director.

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.

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

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C150, C154, C156, C200, C231, C295, C372, C361, C420, C422, and C513.

Z0142 - OAR 411-057-0140 - Administrator Compliance. Refer to C150, C154, C156, C200, C231, C295, C372, C361, C420, C422, and C153.

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

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

Based on interview and record review, it was determined the facility failed to ensure 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.

Z155 - OAR 411-057-0155 - Staff Training Requirements. 1) Staff 6, 12, 15, and 19 have received job descriptions. These staff members have been assigned missing orientaion preservice training. Staff 6, 12, and 15 have been assigned missing pre-service dementia training topics and competency training within the first 30-days of hire. Staff 10 is assigned annual in-service training. Staff 18 has been assigned annual infectious disease training. 2) The Assistant Director will ensure new hire staff members have all required trainings completed prior to beginning training on the floor and competency training has been completed within the first 30-days. All training records will be audited for completion and training tracker will be developed to ensure staff completion of all training requirements. 3) The Assistant Executive Director will audit the employee files using the Quality Improvement Audit on a monthly basis. 4) The Executive Director and Assistant Executive Director.

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

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

Based on 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.

Z162 - OAR 411-057-0160 - Compliance with Rules Health Care 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.

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.

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 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 living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse Notes 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, 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 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 living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:                        Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

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 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 living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse Notes 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, 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.

C240 Resident Services Meals, Food Sanitation Rule A) Dining Service Director coordinated for the kitchen to be deep cleaned focusing on the areas identified during the survey.  All areas under this citation were cleaned on 7/20/23.  The Dining Service Director will create kitchen cleaning schedules for daily, weekly, and monthly cleaning, and will review each cleaning lists accordingly.  This will ensure the kitchen remains clean and avoids future citations in this area. *The Maintenance Director will replace the kitchen blinds. *The Dining Service Director will make sure the kitchen staff is reeducated and make sure the garbage can lids remain in tact. *The Executice Director &  Dining Service Director will order new rolling carts. C240 Resident Services Meals, Food Sanitation Rule B) *The Maintanence Director will coordinate the repairs to the hole on the floor below the prep table. * Dining Services Director will order a new can opener. *Dining Service Director will order new cooking pans to replace the damaged and stained pans. *Dining Service Director put the missing front cover back on the oven where the wires were exposed. *Dining Service Director defrosted freezers #3 & #4, and will add defrosting of freezers to the cleaning schedule. *Maintenance Director will replace kitchen blinds. *Maintenance Director will repair small holes and Dining Service Director will clean the black walls on the wall next to the handwashing station sink. C) *Dining Service Director will ensure scoops are not left in dry storage food bins. *Kitchen staff will keep the industrial mixer clean, and covered when not in use to limit possibilities of contamination. *Dining Service Director will audit weekly the cooler's and freezers to ensure all foods are covered, labled, and dated properly. The Executive Director will coordinate a in-service training with the chemical supplier to properly train staff how to use the test strips to validate concentration of sanitizer used for surface sanitation buckets.

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 Sanitation 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;- 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, 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 Compliance The Executive Director will work with the Dining Service Director and Maintenance Director to ensure all cleaning and repairs are completed and maintained.  Executive Director will also work with the departments to replace any equipment identified within this survery. The Executive Director will audit all cleaning schedules and audits of the kitchen to ensure iuditas MC remains in compliance.

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

Z142-Administration Compliance Refer to C240 Plan of Correction

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.

C455 - Inspections and Investigations Executive Director and Executive Chef will work together weekly to maintaing kitchen compliance and cleanliness.

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.

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.

2. Resident 4 was admitted to the memory care community in July 2022, with a diagnosis of dementia. During the acuity interview, Resident 4 was identified as having a physical altercation with another resident on 08/15/22. A review of the residents record indicated: *There was no documented evidence the facility reported the altercation to the local SPD office; and *There was no documented evidence the incident was investigated by the facility, or that measures were taken to protect residents and prevent reoccurrence of abuse. On 09/14/22 the need to report all resident to resident altercations to the local SPD office and promptly investigate the incidents was discussed with Staff 1 (ED). The surveyor informed Staff 1 the altercation must be reported to SPD prior to the survey team's exit. Staff 1 completed the reporting and presented documentation to the survey team.

Based on interview and record review, it was determined the facility failed to promptly investigate injuries of unknown cause to rule out abuse, and failed to document all required areas of an investigation for 2 of 2 sampled residents (#s 1 and 4) who had incidents of suspected abuse and/or injuries of unknown cause. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance. a. A Resident Incident Report form dated 08/15/22 documented a resident-to-resident physical altercation in the hallway witnessed by a visitor. There was no documentation the incident had been investigated to include Administrator's review or reported to the local SPD office. b. Staff documented in a progress note, dated 08/24/22, Resident 1 was using profanity directed at another resident whom s/he was accusing of using his/her cup. There was no documentation the incident of suspected verbal abuse had been investigated or reported to the local SPD office. c. Resident 1 had an unwitnessed fall on 09/07/22 and was sent to the hospital with a bump on his/her head. There was no documented evidence of an investigation to rule out abuse, or notification to the local SPD office. The need to thoroughly investigate incidents of suspected abuse and/or neglect, unwitnessed falls, and injuries of unknown cause immediately, and the need to report to SPD if unable to reasonably rule out abuse and neglect was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings. Staff 1 was asked to report the incidents to the local SPD office. Confirmation of report was provided prior to survey exit.

C231  OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-other action 1.  Immediate actions taken to correct the rule violation include thoroughly investigating and self-reporting incidents to APS for Resident #1 and #4. Reports were confirmed as sent to APS for each incident prior to Survey exit. Resident specific interventions have been put in place to reduce risk for these incidents to happen again. Service plan has been updated with the interventions for staff to know how to assist the Residents and redirect as needed. 2. The system will be corrected so the violation will not happen again: The MA on shift is responsible for initiating the Resident incident report on the shift the incident occurred. The MA will notify the Manager on Duty immediately if abuse and neglect can not be immediately ruled out. All incidents will be fully investigated and proper reporting will be completed if needed in a timely manner. Abuse reporting and investigating guide for providers for Oregon has been reviewed with the department management team and will be reviewed with Staff at the next all Staff meeting. Additional training will be completed to ensure all staff are aware of the current policy, know where to find blank incident reports and how to fill them out as well as knowing what criteria in the IR triggers immediate notification of the Administrator and self-reporting of abuse/neglect. All MA and MOD staff will take the Oregon Care Partners training "Elder Abuse Prevention, Investigation and Reporting" course for additional education. Continuous quality improvement audits on abuse and neglect reporting and investigation will be completed to ensure all incidents are investigated timely, and are reported to APS if we cannot rule out abuse and neglect. 3. This area needing correction will be reviewed on a daily and monthly basis. All incidents will be reviewed and followed up on appropriately during weekday stand up meetings. The system will be reviewed on a monthly basis during continuous quality improvement reviews.   4. The Executive Director and Residents Care Coordinator will be responsible to ensure the corrections are completed and monitored.

3. Resident 5 was admitted to the facility in 04/2021 with diagnoses including dementia, Diabetes (type 2) and depression. Review of Resident 5's progress notes, dated 01/15/23 through 02/27/23, and incident reports, identified a physical altercation between Resident 5 and another resident. Resident 5's clinical records noted the following: * On 02/12/23 - "While another resident was using the restroom [Resident 5] opened the door and got very upset". "[He/she] then slapped [him/her] in the face very hard" There was no documented evidence the facility reported this incident to the local SPD office. In an interview on 03/01/23, Staff 22 (Interim Executive Director) stated no self-reporting to SPD had been completed for the incident. Staff 1 was informed the incident must be reported prior to survey team's exit from the building. On 03/01/22, Staff 22 presented the surveyor documentation of self reporting the incident, and acknowledged the need to report any future altercations.

Based on interview and record review, it was determined the facility failed to conduct investigations of injuries of unknown cause to rule out abuse or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office, and failed to have documented evidence of an administrator review and follow-up action by the facility, for 3 of 3 sampled residents (#s 2, 5, and 7). This is a repeat citation. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in March 2022 with diagnoses including dementia. Interview and record review revealed the following deficiencies: * On 01/25/23, Resident 2 was involved in a resident-to-resident altercation. There was no documented evidence of an administrator review, or that the altercation had been reported. On 03/02/23, survey reported the incident to the local SPD office; * On 02/01/23, a progress note indicated Resident 2 had a skin tear on their inner left thigh. There was no documented evidence of an investigation, as to how the resident sustained the injury, or that the injury of unknown cause had been reported. On 03/02/23, survey reported the incident to the local SPD office; and * On 02/03/23, Resident 2 was involved in a resident-to-resident altercation. There was no documented evidence of an administrator review of the altercation, or the altercation had been reported. On 03/02/23, survey reported the incident to the local SPD office. On 03/03/23, the need to ensure all allegations of abuse and neglect were reviewed in a timely manner by the facility administrator and reported to the local SPD office was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings. 2. Resident 7 was admitted to the facility in November 2022 with diagnoses including dementia. Interview and record review revealed the following: *Resident 7's service plan, dated 1/17/23, indicated the she/he needed assistance with transfers and ADL care. * On 02/22/23, a temporary service plan indicated Resident 7 had redness to lower coccyx and was to be monitored for increase in redness and opening skin. There was no documented evidence the facility administrator had conducted an investigation to rule out abuse and neglect. On 03/09/23, survey reported the incident to the local SPD office. On 03/03/23, the need to ensure all allegations of abuse and neglect were reviewed in a timely manner by the facility administrator and reported to the local SPD office was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

C231 OAR 411-054-028 (1-3) Reporting and Investigating-abuse-other-action. 1. Immediate actions taken to correct the rule violation include throughly investigating and self-reporting incidents to APS for Residents 2, 5, 7. 2. This system will be corrected so that the violation will not happen again. The Med Tech on shift is responsible for initiating the incident report for the shift, the day the incident occurred. The Med Tech will notify the Manager on Duty if abuse or neglect cannot be ruled out. All incidents will be fully investigated and reported as needed in a timely manner. 3. All incidents will be discussed and reviewed in daily stand up. All incidents will be reviewed and monitored during monthly QA meetings and audits. 4. The Executive Director and/or the Registered Nurse will be responsible for ensuring the corrections are completed and monitored.

Based on observation and interview, the facility failed to conduct a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large. Findings include, but are not limited to: During the survey, conducted 09/12/22 through 09/14/22, observations were made in the MCC's common areas. Staff members were observed interacting with residents in one-on-one activities, such as a game or puzzle. However, there were no organized group activities observed. The survey team was presented with an activity calendar on 09/12/22. No specific times were listed, and none of the scheduled activities were observed during the survey. The activities schedule included the following: *09/12/22:  Daily brain teaser                     Chocolate milkshake day                     Grandparents day *09/13/22:  Daily brain teaser                     Positive thinking day   *09/14/22:  Daily brain teaser In an interview 09/13/22 Staff 1 (ED) confirmed the facility had not been conducting group activities. On 09/14/22 the need to conduct a daily program of social and recreational activities that were based on individual and group interests was discussed with Staff 1. She acknowledged the findings.

C242 OAR 411-054-0030 (1)(c-d) Resident Services: Activities 1. Immediate actions taken to correct the rule violation include active recruiting for a Life Enrichment Director (posting is on Indeed.com and Zip Recruiter). Until hiring for this position, an activity calendar will be updated to reflect daily planned/timed group activities that the department heads will oversee and assist with. The activities will be tailored to Resident preferences and abilities to participate. Staff will continue to also offer spontaneous and scheduled activities, including 1:1 activities. 2. The system will be corrected so this violation will not happen again by ensuring there is an organized program in place of social and recreational activities that are based on individual and group interests. Until an activity director can be hired, the MOD for each day, including weekends, will oversee and ensure that the planned and spontaneous activities for the day are held. Caregiving staff will be identified per the employee schedule for designation of activities. A life enrichment director will be hired and trained to take over and drive the activities program. 3. The activities calendar will be reviewed daily at Iuditas' standup meetings. The identified MOD for the day will report on the activities planned for the day. The ED or designee will review the calendar weekly (per a recurring meeting on their calendars) and confer with the BOM to ensure that petty cash and/or any needed supplies are available in advance of the coming activities. The BOM will audit current Resident Assessment/Interest profiles to personalize the activity program and fit the needs and preferences of the current Resident population overall. 100% of Residents care plans will be audited and updated with each Residents personalized activity preferences, interests and abilities. This area will be updated with quarterly service plan updates, with significant changes of condition, and as needed. 4. The ED, BOM and daily MOD will be responsible to ensure the corrections above are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. This is a repeat citation. Findings include, but are not limited to: a. During the revisit survey the activity program was observed in the memory care community.  The activity calendar was posted, and included the following schedule for 02/27/23: * 9:00 - Exercise Video; * 10:30 - Snacktivity; * 11:00 - Card Games; * 1:30 - Puzzle Mania; * 2:30 - Snacktivity; * 3:00 - Kick Balloon; and * 4:00 - Stories for Daze. On 02/27/23 observations were made in the MCC's common area from 9:15 am through 4:30 pm. None of the scheduled activities were conducted. Residents were observed wandering the unit, sitting or talking quietly, or watching television. On 02/28/23, Staff 11 (MT) stated, activities do not happen often, and residents complained about not having anything to do. On 03/03/23, the need to provide an activities program based on individual and group interests was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Regional Support). They acknowledged the findings .

C242 OAR 411-054-0030 (1)(c-d) Resident Services: Activities 1. Immediate actions taken to correct the rule violation by reviewing the Activity Calendar every day in stand up and making sure all supplies are out and ready for scheduled activities. 2. This system will be corrected so this violation will not happen again by ensuring there is an organized program in place of social and recreational activities that are based on individual and group interests. 3. The activities calendar will be reviewed daily during stand up meetings. 4. Each resident's care plan will be updated at move-in, within 30 days of admission, quarterly, or with change of condition documentating the resident's personal activity perferances, interests, and abilities. 5. The Executive Director will be responsible for ensuring the corrections are completed and monitored daily.

Based on interview and record review, it was determined the facility failed to ensure resident evaluations were completed quarterly for 2 of 3 sampled residents (#s 1 and 2) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in April 2022, with a diagnosis of dementia. Review of Resident 1's clinical records showed the most recent evaluation was completed 06/02/22. There was no documented evidence a quarterly evaluation had been completed after 06/02/22. The need to ensure quarterly evaluations were completed in a timely manner was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings. 2. Resident 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance. Resident 2's most recent quarterly evaluation was completed on 04/21/22. There was no evidence an evaluation had been completed after 04/21/22. The need to ensure quarterly evaluations were completed in a timely manner was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

C252 OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation 1. Immediate actions taken to correct the rule violation include updating the quarterly evaluations for Residents #1 & #2 to reflect all required components per OAR's. These evaluations will be updated at least quarterly, and with any significant change of condition moving forward. 2. The system will be corrected to prevent this violation from happening again by ensuring the resident evaluation will be reviewed and updated by the clinical staff prior to move in, within 30 days and quarterly thereafter. Iuditas has also hired a move-in coordinator responsible for making sure that the appropriate move-in policy is followed, and that all initial move-in evaluations are completed and reflective of all required components. The ED will be responsible for the final approval, after which the RCC or designee will track and update evaluations in a timely manner for the initial, 30 day, then quarterly thereafter. 3. This area needing correction will need to be reviewed and audited prior to any new Resident move in, and the system will be reviewed on a quarterly basis to ensure compliance with OAR's. 4. Administrator, Nurse or designee will be responsible to ensure the corrections are completed and Monitored.

3. Resident 1 was admitted to the facility in April 2022, with a diagnosis of dementia. Review of Resident 1's clinical records indicated the following: *Resident 1's service plan dated 06/02/22, stated the resident was receiving hospice services and was at risk for aspiration. The service plan instructed staff to provide the resident thickened liquids, as needed. The service plan did not provide clear direction to staff related to how staff would identify when the resident might need thickened liquids or what consistency of thickening would be required; and * Resident 1's current service plan was completed 06/02/22. There was no documented evidence the service plan had been reviewed and/or updated quarterly. The need to ensure service plans provided clear direction to staff and were reviewed and/or updated quarterly was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings. 2. Resident 3 was admitted to the memory care community in July 2022, with diagnoses including dementia and depression. Review of the resident's clinical records indicated the following deficiencies: Resident 3's current service plan was completed on 04/30/22. There was no documented evidence the service plan had been reviewed or updated quarterly. On 09/13/22 the need to ensure service plans were reviewed and updated quarterly was discussed with Staff 1 (ED). She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current health status and care needs, provided clear direction to staff regarding the delivery of services, were completed quarterly, and/or were reviewed and updated when residents experienced a change of condition 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 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance. a. Observations of the resident, interviews with staff, and review of the resident's 04/21/22 service plan, showed the service plan was not reflective of the resident's current care needs and did not give clear direction to staff in the following areas: * Level of assistance for multiple ADLs; * Behaviors and interventions; and * Use of bedrails; and * Weight loss. b. There was no evidence Resident 2's service plan had been reviewed or updated when the resident showed a significant change of condition on 06/15/22 related to weight loss. c. Resident 2's service plan was completed 04/21/22. There was no documented evidence the service plan had been reviewed and/or updated quarterly. The need for service plans to be reflective of residents' current status with clear instructions to staff, updated as needed for significant changes of condition, and completed quarterly was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

C260  OAR 411-054-0036 (1-4) Service Plan: General 1. Immediate actions taken to correct the rule violation include updating Residents #1, #2 & #3 service plans to reflect all required components. Resident #1's SP has been updated to reflect their level of assistance for multiple ADL's, Behaviors and interventions to minimize and support them, Use of bedrails, and recent weight loss including interventions to maintain current weight and clarification on diet texture. A comprehensive RN assessment will be completed to evaluate Resident #2 for recent significant change of condition related to weight loss. Resident specific Interventions to support weight/nutritional status will be added to the service plan per nursing assessment. The plan to monitor weight will be added to the service plan and changes will be made to support Resident #2's weight loss needs as needed. Resident #3's Service plan will be audited and updated to reflect current needs and preferences, and all Residents will have at least a quarterly service plan review and update moving forward. 2. To ensure this violation will not happen again, 100% of Resident service plans will be audited and updated to reflect person-centered directions for care and preferences. Families/Responsible parties will be contacted and provided with copies of the service plans. The service plan is created to reflect the Residents current status prior to  Move in, within 30 days, every 90 days thereafter or with any significant change of condition per company policy and Oregon State Rule. All Resident Service plans will be reviewed and updated to reflect any changes or personalization via "Temporary service plan". All updates to the service plan are placed in the 24 hr book for all staff to review and sign off on.The ED will be responsible for ensuring implementation of new changes and verifying that staff have read and signed each new service plan. Staff will be observed providing care to ensure that the information was followed. Software will track dates of service plans and needed updates to ensure these take place within the required timeframe. The Service plan update schedule will be discussed at stand-up meetings daily. Bi-Weekly staff meetings involving caregivers and med techs will be held to keep the service plan schedule in compliance, and give staff opportunity to give input on care.   3. The area needing correction will be evaluated at least quarterly and with any significant changes of condition. 4. The ED, RCC or designee will be responsible to see that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status, provided clear instructions to staff and were followed for 3 of 4 sampled residents (#s 2, 5 and 7) whose service plans were reviewed.  This is a repeat citation. Findings include, but are not limited to 1. Resident 5 was admitted to the facility in 04/2021 with diagnoses including dementia, Diabetes (type 2) and depression. In an interview on 02/27/23, Staff 24 (Business Office Manager/Assistant ED) stated Resident 5 had exhibited aggressive behaviors, been involved in a resident to resident altercation, and was often resistant to care. Review of Resident 5's service plan, dated  01/25/23 and temporary service plans determined the service plan was not reflective, or did not provide clear instructions to staff in the following areas: * Depression; * Resistance to care; and * Combative/aggressive behaviors. On 03/03/23 the need to ensure service plans were reflective of residents' current status, and provided clear instructions to staff was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Regional Support). They acknowledged the findings. 2. Resident 2 was admitted to the facility in March 2022 with diagnoses including dementia. Observations of the resident, interviews with staff from 02/27/23 to 03/03/23, review of the service plan, dated 01/26/23, evaluation dated 01/26/23, progress notes, incident reports, and temporary service plans from 01/15/23 to 02/27/23, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Depression; * Anxiety; * Agitation; * Communication; and * Judgement. On 03/03/23, the need to ensure residents' service plans were reflective of current care needs and provided direction to staff was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings. 3. Resident 7 was admitted to the facility in November 2022 with diagnoses including Dementia. Observations of the resident, interviews with staff from 02/27/23 to 03/03/23, review of the service plan, dated 01/17/23, evaluation dated 01/17/23, progress notes, incident reports, and temporary service plans from 01/15/23 to 02/27/23, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: *Resistance to care; *Judgement; *Use of side rails; and *Hospice services provided. On 03/03/23, the need to ensure residents' service plans were reflective of current care needs and provided direction to staff was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

C260 OAR 411-054-0036 (1-4) Service Plan: 1. Immediate actions taken to correct the rule violation include updating resident service plans to reflect their level of assistance for multiple ADL's, behaviorsm and interventions to minimize and support them. 2. To ensure this violation will not happen again, Registered Nurse will review all Resident Service Plans, update as needed to reflect person centered directions for care and preferances. 3. The area needing correction will be evaluated quarterly and with any significant change in condition. 4. The Executive Director and Registered Nurse will be responsible for ensuring that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 1 of 3 sampled residents (# 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia with behavioral disturbances, HIV infection, and depression. During an interview on 7/12/23 at 8:35 am, Resident 8 was observed with a dressing on his/her  right wrist. During an interview with Staff 16 (CG) she indicated that due to Resident's 8 diagnosis of HIV infection, they try to cover any area of his skin that could be a potential exposure. Resident 8's service plan dated 04/12/23, and behavioral plan dated 05/09/23, lacked clear direction regarding the delivery of services including a written description of who shall provide the services and what, when, how, and how often the services should be provided in the following areas: * Assistance with dressing, bathing, personal hygiene, and shopping; * Depression/suicide talk interventions; * Written communication ability; and * Infection prevention related to compromised skin integrity. In an Interview with Staff 32 (Executive Director), Staff 34 (Consultant RN) and Staff 39 (RN) on 07/11/23, the need to ensure service plans provided clear caregiving direction which included a written description of who shall provide services and what, when, how and how often the services shall be provided was discussed, and they acknowledged the findings.

3. Resident 1 was admitted to the facility in April 2022, with a diagnosis of dementia. Clinical records were reviewed during survey and indicated the following: On 07/26/22, the facility received an order for a COVID-19 rapid test for Resident 1. A progress note dated 07/27/22 indicated Resident 1 had episodes of gastrointestinal symptoms and nausea. There was no documented evidence the facility tested the resident for COVID-19 or evaluated and monitored Resident 1 for possible symptoms of COVID-19.   The need to ensure changes of condition were evaluated and monitored through condition resolution was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings. 2. Resident 4 was admitted to the memory care community in July 2022, with a diagnosis of dementia. During the acuity interview, Resident 4 was identified as having a physical altercation with another resident on 08/15/22. There was no documented evidence the facility evaluated the resident following the altercation, monitored the resident for injuries or adverse effects, or developed interventions to prevent further altercations. On 09/14/22 the need to document resident to resident altercations, monitor residents involved for adverse effects, and provide clear instructions to staff was discussed with Staff 1 (ED). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed when residents experienced changes of condition, communicate the actions and interventions to staff and monitor weekly progress until the conditions resolved for 3 of 3 sampled residents (#s 1, 2 and 4) who experienced short-term changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance. Resident 2's clinical record was reviewed. Multiple changes of condition were identified with the following deficiencies: a. No actions or intervention developed, no communication to staff on each shift, or evidence of monitoring for the following changes of condition: * Significant weight loss of 5.76% between 05/15/22 and 06/15/22; * Change in behavior, with resident-to-resident physical altercation 08/15/22; and * Resident-to-resident verbal altercation 08/24/22. b. Lack of monitoring at least weekly to resolution for: * Urinary tract infection 06/14/22; * Urinary tract infection 08/25/22; * New medication Cephalexin (antibiotic) 08/25/22; * Four missed doses of antibiotic discovered 09/1/22; and * Bruise noted on lower left buttock/upper hip area 09/9/22. The need to determine and document what actions and interventions were needed for the resident when s/he experienced short-term changes of condition, communicate them to staff, and monitor them at least weekly through resolution was discussed with Staff 1 (ED) 09/14/22. She acknowledged the findings.

C270  OAR 411-054-0040 (1-2) Change of Condition and Monitoring 1. Immediate actions taken to correct this rule violation include completing a comprehensive RN assessment related to recent significant changes of condition for Residents # 2, and 4. A comprehensive Physician Order audit will be completed for Resident #1 to ensure accuracy of current orders and follow up to any order change is in place. To ensure all Physician orders are followed in the future refer to C300 for POC. Resident #2: Comprehensive RN assessment to be completed to include causative factors and personalized interventions to support recent significant weight loss, multiple UTI's, missed medications and skin issues. Also focused on behavioral concerns to identify non-pharmacological interventions that would be beneficial to attempt with ongoing behaviors, as well as identify any causative factors that may be triggering undesired behaviors for Resident #2. Changes in behavior (physical alt 8/15/22 and verbal alt 8/24/22) were reported to PCP and Resident has been seen by their PCP for these areas of concern. Physician made no changes and requested continued monitoring. On 9/21/22 PCP approved use of scheduled THC/CBD gummies per family request as an alternative to a new  psychoactive medication. This treatment was initiated, and a TSP for adverse effects, desired effect of the gummies, and effective non-pharm interventions to attempt with any future undesired behaviors was initiated. No incidences of Resident to Resident altercations (verbal or physical) since this was initiated, and their behavior has been more stable from morning to evening hours. Resident #4: RN to complete a comprehensive assessment and behavioral review to reduce risk of future altercations. Potential causative factors as well as triggers will be identified as part of the RN assessment, and Resident specific non pharm interventions will be initiated to reduce risk of negative behaviors or altercations in the future. Changes will be made to the Service plan based off findings in RN assessment. 2. The system will be corrected so this violation will not happen again the community will follow their 24 hr communication system. The "24 hr binder" is set up to include:  a. Shift to Shift Communication LOG  b. Alert charting log  c. TSP's and updated Service Plans for staff review  d. Significant change of condition LOG Staff will follow the Short Term Monitoring and Communication System for any Resident identified to have an acute change of condition such as UTI, missed med, resident to resident altercation, return from hospital, fall for example. When a change of condition is identified, Staff add the Residents name to the alert log to ensure they monitor the Resident and identify when to report concerns to Nursing or MD. The Staff will be aware of what to report to Nurse/MD per the temporary service plan (TSP) that has been put in place, which correlates with the Residents change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the ISP. Staff should monitor Resident status until Resident condition resolves and they are back at their baseline. To monitor weight changes, weights are taken monthly (or per doctor orders) and sent to the nurse consultant for review. Significant or unexplained weight gain/loss of 5% or more over 30 days, 7.5% over 90 days or 10% over 180 days  will trigger an RN assessment to determine the underlying cause. The Nurse will direct staff to any intervention or monitoring plans via a TSP for staff instructions. 3. The area needing correction will be evaluated daily during stand up with the 24 hr review.  The Community will audit to ensure clinical systems are in compliance with company policy and Oregon Administrative Rules. 4. The Nurse, RCC or designee will be responsible to see that the corrections are completed and monitored.

2. Resident 5 was admitted to the facility in 04/2021 with diagnoses including dementia, Diabetes (type 2), and depression . Resident 5's progress notes, dated 01/15/23 through 02/27/23, service plan dated 2/20/21, temporary service plans, and incident reports indicated the resident had experienced the following: On 02/12/23, Resident 5 had a witnessed resident-to-resident altercation, in which [he/she] "slapped the other resident hard in the face". In an interview on 02/28/23 Staff 20 (CG) stated "[Resident 5] does have aggressive behaviors sometimes, but we just try to anticipate the problem, and redirect [him/her]". The resident's records lacked documented evidence the negative behavior was evaluated, with needed actions and interventions determined. On 03/03/23 the need to evaluate changes of condition and determine interventions needed was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Regional Support).  They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed, when residents experienced changes of condition for 2 of 4 sampled residents (#s 2 and 5) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance. Resident 2's clinical record was reviewed for changes of condition and revealed the following: * On 01/31/23, Resident 2 and three un-sampled residents were involved in a verbal altercation and Resident 2 attempted to punch an unsampled resident. Staff were able to step between to prevent the unsampled resident from being struck. There was no documented evidence the facility determined and documented what resident specific actions or interventions were needed to minimize further occurrences. On 03/03/23, the need to determine and document what actions and interventions were needed  when a resident experienced a short-term change of condition was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

C270 OAR 411-054-0040 (1-2) Change in Condition and Monitoring: 1. Actions taken to correct this rule violation include completeing a comprehensive RN assessment related to significant change od condition for resident #2 & 5. 2. The system will be corrected so that this violation does not happen again the communication binder is set up to include the following: a. shift to shift Communication Log b. Alert Charting Log c. TSP's and updated Service Plans for staff review d. Significant change of condition log 3. The Registered Nurse will review the 24-hr communication binder daily and complete a comprehensive RN assessment for significant change of condition. 4. The area needing correction will be evaluated during daily stand up with the 2-hour review. The community will audit to ensure clinical systems are in compliance. 5. The ED and RN will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to document what action or interventions were needed or document weekly progress for 1 of 3 sampled residents (# 8) who experienced short-term changes of condition. Findings include, but are not limited to: Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia with behavioral disturbance. The resident's progress notes, dated 06/16/23 through 07/07/23 and temporary service plans were reviewed and noted the following: *On 06/16/23, Resident 8 was noted to be found on the floor. There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident; *06/19/23, Resident 8 was involved in a resident to resident altercation. There was no documented evidence the facility determined and documented what actions or interventions were needed to help minimize future occurrences; *06/28/23, Resident 8 was involved in a staff to resident altercation. An investigation was completed, Adult Protective Services was notified, a temporary service plan was created however, there was no documented evidence of weekly progress noted through resolution; and *On 06/29/23, Resident 8 was involved in a resident to resident altercation. There was no documented evidence the facility determined and documented what actions or interventions were needed to help minimize future occurrences. During an interview on 07/11/23 at 12:12 pm, Staff 34 (Consultant RN) stated he believed there was a temporary service plan completed related to the resident to resident altercation however, was unable to find documentation that it had been completed. Determining actions and interventions for short term changes of condition and monitoring changes weekly through resolution was discussed with Staff 32 (Executive Director), Staff 34 (Consultant RN) and Staff 39 (RN) on 07/11/23 at 12:12 pm. Staff acknowledged the findings.

Based on interview, and record review, it was determined the facility failed to ensure an RN assessment was performed for all residents who had significant changes of condition, with interventions communicated to staff and service plans updated for 1 of 2 sampled residents (#2) who experienced a significant change of condition. Findings include, but are not limited to: Resident 2 was admitted to the facility in March 2022 with diagnoses including Alzheimer's disease with behavioral disturbance, hypertension, and bilateral leg edema. Review of the resident's monthly weight records from 3/15/22 through 9/14/22 showed the following: The resident experienced a 9.5 lb weight loss from 05/15/22 to 06/15/22, which constituted a 5.76% weight loss in one month. The resident weighed 171.4 on 05/15/22 and 161.9 on 06/15/22. There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition. A current weight was requested by the surveyor on 09/14/22; the resident weighed 177.0. On 09/14/22 the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (ED). She acknowledged the findings.

C280 OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services 1. Immediate actions taken to correct the rule violation for each example/resident include completing an RN assessment of current weight to evaluate for recent and any current weight loss. Interventions to maintain or gain weight if weight loss is identified to be unintentional will be added to the SP and monitored to ensure effectiveness. Changes will be made as needed. Weight will continue to be monitored on a monthly basis and sent to the nurse consultant for review and reassessment. The Nurse will direct staff to any intervention plans that will be put in a TSP along with instructions regarding when to notify nursing or PCP of concerns related to ongoing weight loss. 2. The system be corrected so this violation will not happen again by following current policy for significant changes of condition. Staff will be re-educated on this policy, definition of and examples of a significant change of condition, and when/how to utilize the 24/7 phone and video call access to the on-call RN provided through Ally Senior Management Co. When a significant change is identified, the Nurse/designee will add Resident name and area of concern to the Significant change of condition LOG. The RN will perform a comprehensive change of condition assessment within 48 hrs to identify interventions required to support the resident, review effectiveness of current interventions put in place, and follow up with their provider on any noted concerns or recommendations. A weekly RN assessment will continue until Residents health status returns to baseline, or a new baseline can be established.To monitor weight changes, weights will be taken monthly (or per doctor orders) and sent to the nurse consultant for review. Significant or unexplained weight gain/loss of 5% or more over 30 days, 7.5% over 90 days or 10% over 180 days will trigger an RN assessment to determine the underlying cause. The Nurse will direct staff to any intervention or monitoring plans via a TSP for staff instructions. 3. This area needing correction will need to be evaluated on a Monthly basis and as needed per individual Resident orders for monitoring. 4. The ED, Nurse or Designee will be responsible to ensure these corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to provide health services and have systems in place to respond to the 24-hour care needs of residents including an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation. Resident health and care needs were placed at risk. This is a repeat citation. Findings include, but are not limited to: During the survey on 02/27/23 through 03/03/23, it was disclosed the Facility had been without an Oregon licensed nurse since 02/15/23, who was regularly scheduled to be onsite or available for phone consultation. In an interview on 03/02/23, Staff 22 (Interim Executive Director) and Staff 23 (Regional Support), confirmed the facility had been without a regularly scheduled RN since 02/15/23. The Surveyors requested an immediate plan of correction to acquire an Oregon licensed nurse to be scheduled onsite or available for phone consultation. The facility failed to provide health services and have systems in place to respond to the 24-hour care needs of residents including an Oregon licensed nurse who was regularly scheduled for onsite duties placed resident health and care needs at risk. On 03/03/23, Staff 22 provided the surveyors with a plan of correction noting the facility retained a regularly scheduled onsite Oregon licensed nurse and the situation was abated.

C280 OAR 411-054-0045 (1) (A)(C-F) Resident Health Services 1. Immediate action taken to correct the rule violation for failure to provide health services and have systems in place respond to the 24-hour care need of residents including having an Oregon Licensed Registered Nurse who is regularly scheduled for onsite visits. 2. The system is being corrected by having an Oregon Licensed Registered Nurse on site 40 hours per week and available 24/7 via phone, video call to the on-call Registered Nurse. 3. This area needing correction will be evaluated daily during stand up to ensure nursing coverage. 4. The Executive Director will be responsible for ensuring these corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure it had a trained and designated Infection Control Specialist. Findings include, but are not limited to: In an interview on 09/13/22 Staff 1 (ED) stated the facility did not have a designated Infection Control Specialist. On 09/14/22 the need to designate an Infection Control Specialist, who has completed all required training was reviewed with Staff 1. She acknowledged the findings.

C295  OAR 411-054-0050 (1-5) Infection Prevention & Control 1. Immediate actions taken to correct the rule violation include the community registering their RCC as well as the ED for the IFS class. The RCC will act as the communities infection control specialist, and the ED will act as back up. 2. The system will be corrected so this violation does not happen again by adding the required training for "infection control specialist" to the RCC training/ orientation record as well as to the ED's. The community will maintain a designee for this position to be 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 annual training record will also reflect the need for this training to be completed on a bi annual basis per OAR's. 3. This area needing correction will need to be evaluated on an annual basis with annual inservice/ training review. 4. The ED, BOM or designee will be responsible to see that corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to: a. During the initial licensure survey, conducted 09/12/22 through 09/14/22, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas: C 303: Systems: Medication and Treatment Orders; C 310: Systems: Medication Administration; b. During a review of staff training records, 09/14/22, four newly hired MT's lacked documentation medication administration competency training had been completed. Refer to Z155 Failure to ensure a safe medication system and to ensure adequate professional oversight, based on deficiencies related to medication administration was discussed during the exit meeting on 09/14/22.

C300 SS=F OAR 411-054-0055 (1)(a) Systems: Medications and Treatments Please refer to Z155, C303 and C310 for the plan of correction for this citation.

2. Resident 1 was admitted to the facility in April 2022, with a diagnosis of dementia. Clinical records were reviewed during survey and indicated the following: On 07/26/22, the facility received a faxed order for a " COVID rapid test, to be tested by facility" from Resident 1's physician. There was no documented evidence the facility carried out the order to complete a COVID-19 rapid test as the physician had prescribed. The need to ensure the facility carried out all physician orders as prescribed was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 2) whose clinical documentation was reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility 03/2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance. Review of Resident 2's MAR, dated 08/01/22 through 09/12/22 and physician orders identified the following deficiencies: a. On 08/23/22 an order was received for Cephalexin (antibiotic) 500 mg Capsule, one capsule by mouth three times daily for 5 days. A fax to the physician from the facility on 09/01/22 at 12:35 pm stated: "Resident was taking ABX [antibiotic] Cephalexin for UTI. Resident's last dose was due 8/28, however resident has two capsules left in AM card and two capsules left in mid-day card. This fax is to inform PCP of med error." b. A fax from Resident 2's physician on 09/01/22 at 3:32 pm ordered "please continue antibiotics to completion" in response to the fax from the facility documenting four missed doses of Cephalexin (see above). There was no documented evidence this medication was administered. The need to ensure that physician orders were carried out as prescribed was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

C303  OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders 1. To correct the rule violation for each example, a comprehensive MAR to cart to Physician order audit will be completed for Residents #1 and #2. The goal of the 3 way audit will be to ensure all medications and treatments are being given per MD order, and identify med errors including missed doses, to correct and evaluate Resident status timely. 2. The system will be corrected so this violation will not happen again by providing re-training/ education for med techs on following the current medication delivery process per company Policy. Staff will be trained on the process to follow and ensure all medications are available and being given per MD order. A missed med report will be reviewed by RCC or designee daily as part of clinical review. The community has initiated use of a new electronic health record, "ALIS", and will be providing training for all clinical staff who oversee and administer medications to run medication reports on a daily basis that will identify any medication that is unavailable, miss med or refusals. The triple check system will be reviewed as part of the medication delivery process training, and when followed accurately, will ensure all provider orders, including orders to test for COVID are processed and carried out per order in a timely manner. 3. The area needing correction will be evaluated each working day in the daily stand up meeting. The Medication/ Treatment processing and delivery system will be reviewed quarterly with the CQI process to ensure a safe system is in place. 4. The ED, RCC or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 2 sampled residents (# 11) whose orders were reviewed. Resident 11 experienced medical complications potentially as a result of not receiving blood pressure medications as prescribed. Findings include, but are not limited to: Resident 11 was admitted to the facility in March of 2023 with diagnoses including hypertension, subarachnoid hematoma (2022), and neurocognitive deficit. Review of Resident 11's current physician orders and MARs and progress notes  from 06/01/23 through 10/17/23 revealed the following: * Amlodipine 5 mg was ordered one time daily for hypertension. There was no documented evidence the Amlodipine was administered on 23 occasions from 06/01/23 through 06/28/23. * Losartan 25 mg was ordered one time daily for hypertension.  There was no documented evidence the Losartin was administered on 23 occasions from 06/01/23 through 06/28/23. The exceptions report indicated the medications were not administered as ordered due to "med unavailable," med on back order," or "med ordered." On 06/28/23 the resident's blood pressure at 08:00 am was documented to be 185/111. A progress note dated 06/28/23 at 2:22 pm stated the resident appeared "drowsy, pale and clammy."  Emergency services were called, and the resident was transported and admitted to the hospital, returning to the facility on 07/01/23 with a diagnosis of syncope (loss of consciousness). The discharge orders included Amlodipine and Losartin to be discontinued. On 07/04/23 Resident 11's blood pressure at 08:35 am was documented as 188/115. The resident was sent by emergency services to the emergency department for hypertension and returned the same day. The Amlodipine and Losartan were ordered to start again, and Metoprolol 50 mg twice daily was ordered for hypertension. On 07/06/23 a signed order from the resident's cardiologist physician discontinued the Amlodipine and Losartan and ordered the Metoprolol to continue at 50 mg a day. On 10/10/23 the facility received signed orders for Losartan 50 mg a day and Amlodipine 5 mg a day from Resident 11's physician. The medications were not transcribed to the MAR upon receipt. Staff 32 (Executive Director) reported the medications had not been brought to the facility by the resident's power of attorney. The medications were not administered as ordered from 10/10/23 through 10/17/23. The additional following medications were not administered as ordered between June 1, 2023 and October 17, 2023 and were documented as not available: * Nutrisource Fiber packet twice daily (for bowel care): 13 occasions in June, five occasions in July, five occasions in August, five occasions in September and 21 occasions between October 1 through October 17, 2023. * Polyethylene Glycol powder, one packet daily (for bowel care): 10 days in June, 28 days in July, four days in August, 10 days in September and 6 days October 1 through October 17, 2023. * Tamsulosin HCL .08 mg daily (for benign prostatic hyperplasia): Three days in June, nine days in July, eight days in August and two days in September. * Quetiapine 50 mg twice daily (for agitation): Eight occasions in July, one in August, seven in September and six times October 1 through 17, 2023. * Metoprolol 50 mg daily (for hypertension): Three days in July, one day in August and five days in September. During an interview with Staff 32, she reported that Resident 11's medications came from an outside pharmacy and were set up to be delivered to the resident's power of attorney. She stated the facility had difficulty getting the medications to the facility, which had caused medications to be missed. On 10/18/23 Staff 32 reported the delivery address for Resident 11's medications was changed to the facility address. She stated that, if needed, facility staff would pick up filled prescriptions from the pharmacy or pay to have a limited supply delivered from the facility's contracted pharmacy. The facility failed to ensure blood pressure medications were administered as prescribed, contributing to medical complications, including hospitalization and an emergency room visit. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 32, Staff 33 (Assistant ED), and Staff 40 (Consultant RN) on 10/18/23. They acknowledged the findings.

C303 - Systems: Treatment Orders Executive Director impelmented immediate chages to medication prescriptions, and doctor's orders for Resident #11 (See attached medication plan for resident #11). Executive Director/RN, and Med Tech's will follow up daily on medications the community is awaiting delivery from the pharmacy or new/renewed prescriptions from the Doctor. RN/Med Tech's will call the pharmacy and/or Doctor's office daily and document in the electronic system the status of the medications. Iudtias MC will use in-house pharmacy Pharmecia as a back up as needed to fill prescriptions if unable to receive it timely from the residents preferred pharmacy.  Iuditas MC will pay for the medication to be delievered when appropriate. RN/Med Tech's will review the medication exception report daily and follow up on any missed medication, and document in the communities electronic system the status of the medications.

2. Resident 3 was admitted to the memory care community in July 2021, with diagnoses including dementia and depression. Review of Resident 3's MAR, dated 08/01/22 through 09/12/22 indicated the following deficiencies: The MAR lacked reason for use of the following medications: *quetiapine (an antipsychotic); and *flutic/salmet (for difficult breathing). On 09/14/22 the need to ensure an accurate MAR was kept for all medications prescribed by a legally recognized practitioner and administered by the facility was discussed with Staff 1 (ED). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included resident-specific parameters and/or reason for use for all routine and PRN medications and treatments the facility was responsible to administer for 2 of 3 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's disease with behavioral disturbance. The resident's 08/01/22 through 09/12/22 MAR was reviewed, and the following deficiencies were identified: a. Cephalexin (antibiotic) was documented on the MAR as being administered by staff 14 times 8/23/28 through 8/28/22 per a 15-dose order: take 1 capsule by mouth three times daily for 5 days. A fax to the physician on 09/01/22 noted the resident had 4 capsules remaining. b. There was no reason for use documented on the MAR for the following medications: * Levothyroxine (for thyroid); * Cephalexin (antibiotic); * Clopidogrel (blood thinner); * Escitalopram (anti-depressant); * Metroprolol (blood pressure; * Pravastatin (cholesterol); * Mirtazapine (depression); and * Diclofenac Gel (pain). c. There were no parameters for when to administer one PRN pain medication versus the other for PRN acetaminophen and tramadol; d. Diclofenac gel lacked instructions as to where staff should apply the gel; and e. On 08/28/22 at 8 pm, the MAR indicated the resident did not receive Cephalexin and no reason was documented for the missed dose. The need to ensure MARs were accurate, included parameters for PRN medication and a reason for use for the administration of all medications and treatments the facility was responsible to administer was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

C310 OAR 411-054-0055 (2) Systems: Medication Administration 1. Actions taken to correct the rule violation include completing a comprehensive MAR to Cart to Physician order audit for Residents #2 and #3 to ensure MAR's are accurate, and the orders include Resident specific parameters and reason for use. The RN will add any directions to the orders as needed for staff to know when to offer which medication, for what specific reason, and location of treatments such as gels or patches. 2. The system will be corrected so this violation will not happen again by reviewing the triple check process with all staff who administer medications and/or oversee the medication processing and delivery system. Correct use of this process will ensure MAR's are accurate, include resident specific parameters and/or reason for use for all routine and PRN medications and treatments the community is responsible for delivering. 3. This area needing correction will be evaluated on a daily and quarterly basis. Order changes will be reviewed daily through the triple check system, where staff verify all required components are located in the order, including resident specific parameters and reason for use. 4. The Nurse, RCC or designee are responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included reasons for use for all medications, and included clear instructions for all medications and treatments the facility was responsible to administer for 3 of 4 sampled residents (#s 2, 5 and 7) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 was admitted to the memory care community in 04/2021 with diagnoses including dementia, Diabetes (type 2) and depression. Review of the resident's MARs, dated 02/01/23 through 02/27/23, and physician orders indicated the following medications lacked reasons for use: * Aspirin; * Citalopram; * Januvia; * Melatonin; * Mirtazapine; * Pantoprazole; and * Valacyclovir. On 03/03/23, the need to ensure Residents MARs were accurate and included reasons for use for all medications was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Regional Support). They acknowledged the findings. 2. Resident 2 was admitted to the facility in March 2022. Review of the Resident's MAR between 02/01/23 through 02/27/23 revealed the following: a. The following medications lacked reasons for use: * Escitalopram; * Levothyroxine; * Mirtazapine; * Pravastatin; and * Dicofenac gel 1%. b. The following PRN medications for pain were prescribed without guidance to non-licensed staff for which medication to administer first: * Acetaminophen 650 mg every four hours as needed for pain; and * Tramadol 50mg once a day as needed. On 03/03/23, the need to ensure residents' MARs were accurate was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings. 3. Resident 7 was admitted to the facility in March 2022. Review of the residents MAR between 02/01/23 through 02/27/23 revealed the following: PRN Acetaminophen failed to have a documented reason for use. On 03/03/23, the need to ensure residents' MARs were accurate was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

C310 OAR 411-054-0055 (2) Systems: Medication Adminsitration 1. Actions taken to correct the rule violation include completeing an audit of all medication orders and relation to diagnosis, medication reason for use. 2. The system will be corrected so this violation does not happen again by reviewing the triple check process with staff who administer medications and/or oversee medication procesing and delivery. Correct use of this processing and delivery. Correct use and processing to ensure MARs are accurate, include resident specific parameters and or reason for use for all routine and PRN medications and treatments. 3.This area needing correction will be evaluated on a daily and quarterly basis. 4. The Executive Director and Registered Nurse are responsible for seeing that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was thoroughly assessed by an RN, PT or OT prior to use for 1 of 1 sampled resident (# 1) who had a half-length side rail on their bed. Findings include, but are not limited to: Resident 1 was admitted to the facility in April, 2022 with a diagnosis of dementia. On 09/13/22 and 09/14/22, a half-length side rail was observed in use on Resident 1's bed. During an interview on 09/13/22, Staff 21 (CG) stated Resident 1 was bed bound and used the side rail to assist with bed mobility. Review of the resident's clinical record revealed there was no documented evidence an assessment for use of the side rail had been completed by an RN, Physical Therapist or Occupational therapist. The need to ensure a supportive device with potentially restraining qualities was thoroughly assessed by an RN, PT or OT was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

C 340  OAR 411-054-0060 Restraints and Supportive Devices 1.) Actions taken to correct violations include: Facility RN will complete a supportive device assessment as per regulations, for resident #1. Facility will update resident's service plan to be reflective of the supportive device, staff instructions, and risk vs benefits. 2.) The system will be corrected as follows: Facility will conduct a room-to-room audit to identify any supportive devices and ensure appropriate RN assessment is in place. Facility will review all supportive devices when updating the residents' service plan(s) and facility RN will complete assessment at that time as well. 3.) This correction will be evaluated every time a request for consideration for an assistive device with restraining qualities is made. If a hospital bed arrives for a resident, and assistive devices are not needed then devices (i.e. bed rails) will be removed from the room and stored separately. Ongoing supportive device assessments will be completed, quarterly and with changes of condition when applicable. 4.) Who will be responsible to see that the corrections are completed/monitored? RCC and ED

2. Resident 6 was observed during the survey on 02/27/23 through 03/03/23, and was noted to have side rails attached to his/her bed in the up position. Review of the resident's clinical record revealed the following: * No documented evidence Resident 6 requested or approved of side rails being used, and was informed of the risks and benefits of the side rails; * No documented evidence of an assessment completed by an RN, PT or OT for the use of the side rails; * No documented evidence other less restrictive alternatives had been attempted prior to use; and * There was not clear instruction to caregivers on the correct use and precautions related to the use of side rails. On 03/03/23, the lack of an assessment and documentation of requirements for side rail use was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Corporate Support). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 2 of 2 sampled residents (#s 6 and 7) who had side rails on his/her bed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was observed during the survey on 02/27/23 through 03/03/23 and noted to have side rails attached to his/her bed in the up position. Review of the resident's clinical record revealed the following: * No documented evidence Resident 7 requested or approved of side rails being used and was informed of the risks and benefits of the side rails; * No documented evidence of an assessment completed by an RN, PT or OT for the use of the side rails; * No documented evidence other less restrictive alternatives had been attempted prior to use; and * There was not clear instruction to caregivers on the correct use and precautions related to the use of side rails. On 03/03/23, the lack of an assessment and documentation of requirements for side rail use was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

C340 OAR 411-054-0060 Restraints and Supportive Devices 1. Actions taken to correct violations include Facility Registered Nurse will complete a supportive device assessments as per regulations, for resident #6 & #7. Facility will update resident's service plan to be reflective of the supportive device, staff instructions and risk vs benefits. 2. The system will be corrected as follows: Facility will conduct an audit to identify any supportive devices and ensure an appropriate RN assessment is in place. 3. This correction will be evaluated every time a request for consideration for an assistive device with restraining qualities is made. 4. The Executive Director or Registered Nurse will be responsible for ensuring the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to select and implement an Acuity-Based Staffing Tool (ABST), complete an ABST assessment for each resident, and develop the facility's staffing plan based on the ABST. Findings include, but are not limited to: In an interview on 09/13/22, Staff 1 (ED) stated the facility had not selected or implemented an ABST to use in developing the facility staffing plan. On 09/13/22 the need to complete an assessment of each resident and implement an ABST was discussed with Staff 1. She acknowledged the lack of an ABST.

C361 OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool. 1.) Actions to correct this violation include: a. Facility is completing the Acuity-Based Staffing Tool on The Department's Site, b. Facility RCC will receive training related to ABST requirements, to ensure the staffing schedule meets requirements. 2.) Acuity-Based Staffing Tool: This system is being corrected to eliminate future violations, as follows: a. Facility IDT will receive training related to the requirements of the Acuity-Based Staffing Tool, b. Facility will maintain ABST and update resident care needs in the ABST at time of each resident evaluation &/or with any significant change of condition c. Facility Administrator will review staffing schedule to ensure that the schedule is reflective of staffing requirements based on the ABST. 3.) Acuity-Based Staffing Tools: This system will be evaluated as follows: a. Facility will update the ABST with each resident evaluation: initial, 30-days, quarterly, and with significant change of condition, b. Facility Administrator will review monthly staffing schedule to ensure that schedule is reflective of staffing needed per the ABST at least once monthly. 4.) Facility Administrator and Facility RCC will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 direct care staff (#s 14 and 15) had completed first aid/abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Training records for Staff 14 (CG/MT) hired on 06/27/22, and Staff 15 (CG) hired on 05/17/22, were reviewed during survey. There was no documented evidence Staff 14 and Staff 15 had completed first aid/abdominal thrust training within 30 days of hire. The need to ensure all direct care staff completed first aid/abdominal thrust training within 30 days of hire was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings .

C372 OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff 1.) Facility will correct each violation per example given as follows: Employees #14 & 15 will successfully complete first aid and abdoiminal thrust training. 2.) Facility will audit all employees training records to ensure that employees are up-to-date on required training within 30 days of employment. All employee training(s) and upcoming training(s) will be kept on a training grid to ensure completion of required training in a timely manner. Facility B.O.M. will bring the training grid to monthly QA meeting to review with IDT and ensure all trainings are done according to the regulations. 3.) Facility will audit the training grid at least once monthly, and with each new hire. Facility IDT will review training grid status at monthly QA meetings. 4.) Facility Administrator & Facility B.O.M will be responsible for overseeing all employee trainings.

Based on interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 2 of 2 sampled residents (#s 6 and 7) who had side rails on his/her bed. This is a repeat citation. Findings include, but are not limited to:a repeat citation. Findings include, but are not limited to: Training records for Staff 29 (MT) hired on 01/03/2023, and Staff 27 (RCC) hired on 12/30/2023, were reviewed during survey. There was no documented evidence Staff 29 and Staff 27 had completed First Aid and abdominal thrust training within 30 days of hire. On 03/02/23, the need to ensure all direct care staff completed First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 23 (Regional Support). She acknowledged the findings.

C372 OAR 411-054-0070 (6) (9) Training within 30 days: Direct Care Staff 1. Facility will correct each violation per example given: Employee #27 & #29 will complete First Aid and Abdominal Trust Training. 2. Facility will audit all employee training records to ensure that all employees are up to date on required training within 30 days of employment. 3. Facility has implemented a training compliance tracking system. 4. The Executive Director or Designee and Business Office Manager will audit the training compliance tracker weekly and at least once per month at monthly QA meetings. 5. The Excutive Director and the Business Office Manager will be responsible for overseeing all employee training.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and fire and life safety training's to staff on alternate months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of fire and life safety records from 03/01/22 through 09/12/22 identified the following deficiencies: *There was no documented evidence the facility conducted fire drills every other month, as required; and *There was no documented evidence the facility conducted fire and life safety training instruction to staff on alternate months. On 09/14/22, the need to conduct and document fire drills every other month and fire safety training's on alternate months, in accordance with the OFC was discussed with Staff 1 (ED). She acknowledged the findings.

C420 OAR 411-054-0090 (1-2) Fire and Life Safety: Safety 1.) Facility will audit Fire & Life Safety binder to identify past fire drills and staff education. Facility will ensure that a fire drill is completed every other month, with staff training on the alternative months. Facility will provide an in-service for all staff to receive fire and life safety training, and will document training as required. 2.) Facility maintenance director will turn in all fire and life safety documents (fire-drills and/or education)  to facility administrator during monthly QA meeting. IDT will review fire-drills and staff education during once monthly QA meeting to ensure all required components are present. 3.) All fire-drills and fire and life safety training will be reviewed at minimum on a monthly basis, by IDT during monthly QA meetings. Facility administrator will audit fire and life safety binder once monthly to ensure oversight and compliance. 4.) Facility maintenance director and facility administrator will be responsible for overseeing ongoing compliance.

Based on interview and record review, it was determined the facility failed to conduct fire drills and to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to: Review of facility records from 01/15/23 to 03/01/23 identified the following deficiencies: * There was no documented evidence a fire drill or fire and life safety instruction had been conducted between 0/15/23 through 03/01/23. On 03/03/23 the need to conduct regular fire drills, and to provide fire and life safety instruction to staff in accordance with the OFC, was discussed with Staff 22 (Interim Executive Director) and Staff 23 (Regional Support). They acknowledged the findings.

C420 OAR 411-054-0090 (1-2) Fire and Life Safety 1. Facility will audit Fire & Life Safety binder to identify past fire drills and staff education. Facility will ensure that a fire drill is completed every other month on each shift, with staff training on the alternative months. 2. The Executive Director and Designee will document all Fire and Life Safety trainings and fire drills for review during monthly QA meetings. 3. All fire drills and fire and life safety training will be reviewed at minimum monthly, by the Executive Director and Designee during monthly QA meetings. The Executive Director and Designee will audit fire and life safety to ensure oversight and compliance. 4. The Executive Director will be responsible for overseeing ongoing compliance.

Based on interview and record review, it was determined the facility failed to provide fire safety instruction for residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Review of fire and life safety records from 03/01/22 through 09/12/22 indicated the following deficiencies: There was no documented evidence the facility provided annual fire safety instruction for residents, as required. On 06/02/22 the need to provide and document annual fire safety instruction for residents, in accordance with the OFC was discussed with Staff 1 (ED). She acknowledged the findings.

C422 OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents 1.) Fire & Life Safety Training for Residents: The following actions are being taken to correct each violation per examples given on the S.O.D: a. All residents will be instructed on General safety procedures, Evacuation Methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire, and re-instructed annually. Residents who do not have the mental capability to understand fire & life instructions and/or training, will have clear evacuation instructions in their service plans, for staff to reference. Facility will conduct an audit on 100% of residents to identify residents who have not received fire and life safety training, and facility will provide education to these residents. 2.) All new residents will be instructed on fire and life safety within 24hrs of move-in, and reinstructed annually thereafter. All resident fire and life safety training will be documented and filed on-site. Facility maintenance director will keep an on-going spreadsheet of residents' admission dates and dates of reinstruction. 3.) Facility maintenance director will be required to bring all resident fire and life safety training to QA meeting each month for IDT to review. Facility maintenance director will review fire and life safety spreadsheet at least once weekly to ensure on-going and timely resident training. 4.) Facility maintenance director and facility administrator will be responsible for overseeing ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to: On 09/12/22, the surveyor measured water temperatures in two common area bathrooms, two laundry rooms and two resident apartments. These water temperatures were as follows: South laundry room:  101.2 North laundry room:  100.4 Lobby restroom:  97.6 North restroom:  103.4 Apartment 26:  101.4 Apartment 7:  100.8 On 09/12/22 at 1:10 pm the Surveyor reported the temperatures to Staff 1 (ED). She indicated the water heater would be adjusted before the end of the day.   On 09/14/22 at approximately 10:30 am hot water temperatures were re-checked in three locations in the building. The readings were as follows: North laundry room:  101.8 Lobby restroom:  102.8 Apartment 34:  103.2 The need to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 1. No further information was provided.

C545 OAR 411-054-0200 (9) Plumbing Systems 1.) Water heater has been serviced as of 9/16/22 - thermostat was reset and water temps checked are within range. 2.) Facility will create a temp log that facility maintenance director will use to check water heater temps. Any temperatures outside of range will be reported to facility administrator for correction. Facility maintenance director will bring all temp logs to monthly QA meeting to turn into facility administrator and for IDT to review for quality improvement. 3.) Facility maintenance director will check temps and document at least once weekly. Temp log will be brought to QA meeting once monthly for review. 4.) Facility administrator and facility maintenance director will responsible for overseeing ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit (F). This is a repeat citation. Findings include, but are not limited to: On 02/27/23 survey recorded the following water temperatures: * First floor shower room: 88.6 degrees F; * Resident room 18: 92.4 degrees F; and * Resident room 23: 95.8 degrees F. On 02/28/23 at 9:20 am, survey rechecked the water temperatures in the same locations, the temperatures were as follows: * First floor shower room: 78.4 degrees F; * Resident room 18: 82.6 degrees F; and * Resident room 23: 87.2 degrees F. On 02/28/23 at 1:10 pm the Surveyor reported the temperatures to Staff 22 (Interim Executive Director). She indicated the water heater would be adjusted before the end of the day.   On 03/01/23 at approximately 10:30 am hot water temperatures were re-checked in the same three locations. The readings were as follows: * First floor shower room: 116.4  degrees F; * Resident room 18: 117.6 degrees F; and * Resident room 23: 115.2 degrees F. On 03/02/23 at 11:15 a follow-up temperature check was conducted in two different locations. The water temperatures were as follows: Central restroom:  158.4 degrees F; and North shower room:  145.2 degrees F. The surveyor immediately spoke with Staff 22 and Staff 23 (Regional Support), and asked them to re-adjust the water temperatures. On 03/02/23 at 3:30 pm a final water temperature check was conducted. The water temperatures where within the required range. The need to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 22 and Staff 23. They acknowledged the findings.

C545 OAR 411-054-0200 (9) Plumbing Systems 1. The water heater has been reset and checked as of 3/2/23 with no further issues. Weekly water temps are being recorded. 2. Facility will check water temps and record on the temp log. Any temperatires outside of the range will be reported to Executive Director and Designee for correction. Water Temp Logs will be reviewed during monthly QA Meetings. 3. The Excutive Director and Designee will check temps and record at least once per week. Temp log will be brought to QA meeting monthhly for review. 4. The Excutive Director will be responsible for overseeing ongoing compliance.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents exited the MCC. Findings include, but are not limited to: The facility was toured on 09/12/22 at 11:15 am. There was no system in place which alerted staff when a resident exited the building into the courtyard area. In an interview on 09/13/22 Staff 10 (MT) stated the door to the courtyard was locked after 8:00 pm, and unlocked in the morning. He/she stated staff pay attention to the exit door during the day, and periodically check the courtyard throughout each shift. The need to have a system which alerted staff when residents exited the building was discussed with Staff 1 (ED) on 09/12/22. She acknowledged the findings.

C555 OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable 1.) A wireless door sensor chime with 600' range was installed on 9/16/2022 - there are two recieivers that were placed throughout the building that alert staff at anytime that the back patio door is opened. 2.) The facility will conduct weekly spot-checks to ensure alarm is in working order and that staff respond appropriately when alarm engages. Facility will provide an inservice to all staff related to exit door alarms. 3. Facility administrator and maintenance director will do weekly walk-throughs to ensure alarms are in good working order. 4. Administrator and maintenance director will ensure and oversee ongoing compliance.

Based on 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 231, C242, C295, C361, C372, C420, C422, C545 and C555.

Z142 OAR 411-057-0140(2) Administration Compliance   Please refer to the following tags: C231, C242, C295, C361, C372, C420, C422, C545, and C555.

Based on observation, interview and record review, it was determined the facility failed to provide non-health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 156, C 231, C 242, C372, C 420 and C 545.

Z142 OAR 411-057-0140 (2) Administration Compliance Please refer to the following tags: C156, C231, C242, C372, C420, and C545

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 8, 14, 15 and 18) completed all required pre-service training and all direct care staff demonstrated competency in the required topics within 30 days of hire for 6 of 7 direct care staff (#s 11, 12, 13 14, 15 and 18) whose training records were reviewed. Findings include, but are not limited to: Training records for the following staff were reviewed during survey: * Staff 8 (Cook) hired on 01/16/22; * Staff 10 (CG/MT) hired on 04/13/21; * Staff 11 (CG/MT) hired on 12/10/21; * Staff 12 (CG/MT) 09/20/21; * Staff 13 (CG/MT) hired on 02/1/22; * Staff 14 (CG/MT) Hired on 06/27/22; * Staff 15 (CG) Hired on 05/17/22; and * Staff 18 (CG) hired 07/20/22. 1. There was no documented evidence Staff 8, 15 and 18 completed training on the following required pre-service orientation topics: * Resident rights; * Abuse reporting; * Fire safety and emergency procedures; and * Infectious disease prevention. Additionally, there was no documented evidence Staff 14 had completed infectious disease prevention training. 2. There was no documented evidence 30 day competency demonstration had been completed for Staff 14, 15 and 18 related to the following topics: * Role of the service plan; * Providing assistance with ADLs;: * Changes associated with normal aging; * Indentation documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. Additionally, medication administration competency training was reviewed for Staff 10, 11, 12, 13 and 14 who administered medications. There was no documented evidence Staff 11, 12, 13, and 14  had completed medication administration competency training. The survey team requested the facility provide documented evidence to show all staff who administered medications had been trained and demonstrated competency of the task prior to those staff continuing to administer medications. The facility provided documentation of training prior to survey exit for all required staff. The need to ensure staff completed all required pre-service training and all direct care staff demonstrated competency in the required  topics within 30 days of hire was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

Z155 OAR 411-057-0155(1-6) Staff Training Requirements 1.) A complete audit of all employee files will be performed and missing training items will be completed. BOM will monitor monthly staff in-services and record topic and attendance for staff present, and follow up with staff who did not attend, to meet the requirements. 2.) Upon hire, new staff will complete all pre-service trainings before working on the floor with residents. Monthly staff meetings will be used for 1 hour of CEU's and attendance and training topics will be documented by BOM. 3.) BOM will track staff's anniversary dates and accumulated CEU's and will work with RCC to ensure staff know their CEU status and have access to online CEUs through Relias and Oregon Care Partners to make up 16 CEUs for that year. 4.) BOM and RCC will be responsible for working with staff to ensure their pre-service orientations are completed upon hire and they maintain 16 CEUs per year based on their hire date.

Based on interview and record review, it was determined the facility failed to ensure newly hired staff completed all required pre-service training and/or demonstrated competency in the required topics within 30 days of hire for 2 of 2 direct care staff (#s 27 and 29) whose training records were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Staff training records for Staff 29 (MT) hired on 01/03/23 were reviewed on 03/02/23. a. There was no documented evidence Staff 29 completed training on the following pre-service orientation topics: *Infectious Disease Prevention; *Fire safety and emergency procedures; and *Written job description. b. There was no documented evidence Staff 29 completed the following pre-service dementia training topics: * Dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms; * 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; * Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; * Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, identify and address pain, provide food and fluid, prevent wandering and elopement, use a person-centered approach; * Environmental factors that are important to resident's well-being; * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment. * How to provide personal care to a resident with dementia, including an orientation to the resident and the resident's service plan; and * The use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence 30 day competency demonstration had been completed for Staff 29 related to the following topics: * Role of the service plan; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Other job duties as applicable (Medication pass, treatments). 2. Staff training records for Staff 27 (RCC) hired on 12/30/22 were reviewed on 03/02/23. a. There was no documented evidence Staff 27 completed training on the following pre-service orientation topics: *Written job description. b. There was no documented evidence 30 day competency demonstration had been completed for Staff 27 related to the following topics: * Role of the service plan; * Providing assistance with ADLs; * Changes associated with normal aging; * Indentation documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Other job duties as applicable (Medication pass, treatments). On 03/02/23 the need to ensure staff completed all required pre-service orientation and pre-service dementia training, and all direct care staff had documented evidence of demonstrated competency within 30 days of hire was discussed with Staff 23 (Regional Support). She acknowledged the findings.

Z155 OAR 411-057-0155 (1-6) Staff Training Requirements 1. An audit of all employee files will be performed and missing training items will be completed. The Business Office Manage will monitor monthly staff in-services and record topic and attendance for staff present and follow up with stadd who did not attend. 2. All newly hired staff will be complete all pre-service training before working on the floor with residents. Monthly staff meetings will be used for 1 hour of CEUs and attendance and training topics will be documented by the Business Office Manager. 3. The Business Office Manage will track staff's anniversary dates and accumulated CEUs and will work with the supervisor to ensure staff know their CEU status and have access to online CEU's through Relias and Oregon Care Partners to make up 16 CEU's for the year. 4. The Excutive Director and Business Office Manager will be responsible for working with staff to ensure their pre-service orientation is completed upon hire and they maintain 16 CEU's per year based on their hire date.

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, C310 and C340.

Z162 OAR 411-057-0160(2b) Compliance with Rules Health Care Please refer to the following tags: C252, C260, C270, C280, C300, C303, C310, and C340.1

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. This is a repeat citation. Findings include, but are not limited to: Refer to C 260, C270, C 280, C 310 and C 340.

Z162 OAR 411-057-0160 (2b) Compliance with Rules of Health Care Please refer to tag # C260, C270, C280, C310, & C340

Based on interview, and record review, it was determined the facility failed to ensure compliance with healthcare related Residential Care and Assisted Living regulations. This is a repeat citation. Findings include, but are not limited to: Refer to C 260 and C 270.

Based on interview, and record review, it was determined the facility failed to ensure compliance with healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to: Refer to C 303.

Z162 - Refer to C303

Based on observation, interview and record review, it was determined the facility failed to ensure a nutrition and hydration plan was included in each residents' service plan and was based on the residents' individual preferences and needs for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in April, 2022 with a diagnosis of dementia. Observations made on 09/13/22 and 09/14/22, showed Resident 1 was dependent on staff for all ADLs and required full assistance from staff for eating and drinking. The following information was documented in Resident 1's current service plan: Resident 1 was bed bound, at risk for dehydration and required staffs full assistance for eating and drinking. The service plan lacked clear direction to staff related to the resident's nutrition and hydration preferences. The need to ensure each resident's service plan included an individualized nutrition and hydration plan, based the residents' preferences, was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings . 2. Resident 2 was admitted to the facility in March 2022 with a diagnosis of early onset Alzheimer's disease with behavioral disturbance. There was no individualized nutrition plan documented in the service plan based upon the resident's needs and preferences. The need to develop individualized nutrition plans based on residents' preferences and needs was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

Z163 OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration 1.) Facility will create an individualized nutrition and hydration plan for resident #1 and resident # 2. Individualized nutrition and hydration plan(s) will be made a part of residents' service plan(s) for all staff to follow. 2.) Facility will conduct an audit to ensure all all residents have an individualized nutrition and hydration plan. Nutrition and hydration plans will be completed/reviewed at admission, within 30 days of admission, quarterly, and/or with change of condition. All direct-care staff will access to each resident's nutrition and hydration plan, via TSP. 3.) Facility administrator, LN, and/or RCC will review all nutrition and hydration plans during each residents evaluation/SP: At admission, within 30 days of admission, quarterly thereafter, and with changes of condition. 4.) Facility administrator, RCC, and LN will oversee ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure a nutrition and hydration plan was included in each residents' service plan and was based on the residents' individual preferences and needs for 2 of 4 sampled residents (#s 6 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 6 and 7's current service plans were reviewed and lacked an individualized nutrition and/or hydration plan. On 03/03/23, the need for individualized nutrition and hydration plans was discussed with Staff 22 (Interim Executive Director). She acknowledged the findings.

Z163 OAR 411-057-0160 (2) (C) (A) (B) Nutrition and Hydration 1. Facility will create an individualized nutrition and hydration plan for resident #6 & #7. Individualized nutrition and hydration plan(s) will be made as part of resident's service plan(s) for all staff to follow. 2. Facility will do an audit to ensure all residents have individualized nutrition and hydration plan. Nutrition and hydration plans will be completed/reviewed at admission. Within 30 days of admission, quarterly and or with change of condition. All direct-care staff will have access to each resident's nutrition and hydration plan. 3. The Executive Director or Designee and RN will review all nutrition and hydration plans during each residents evaluation/SP: at admission, 30 days, quarterly thereafter, and with any change of condition. 4. The ED and RN will oversee ongoing compliance.

2. Resident 8 was admitted to the facility 11/2022 with a diagnosis of dementia with behavioral disturbances and neurocognitive disorder. On 07/10/23 at 12:10 pm, Resident 8 was observed to eat independently and consumed approximately 100 % of his/her meal.  Resident 8 drank approximately 50% of his/her red drink. The service plan dated 04/12/23 noted, Resident 8 needed consistent one on one cueing in finishing a meal, and the behavior plan, dated 05/09/23 noted the resident enjoyed cookies, chips and juice. Resident 8's individualized hydration and nutrition plan, dated 04/18/23 listed the preferences for likes/dislikes as "food" and fluid preferences as "drink." During an interview on 07/11/23, Staff 16 (CG) stated Resident 8 loved coffee.   The need to ensure each resident's service plan included an individualized nutrition and hydration plan, based the residents' preferences, was discussed with Staff 32 (Executive Director), Staff 34 (RN Consultant) and Staff 39 (RN) on 07/11/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure individualized nutritional plans for each resident were developed and included in service plans for 2 of 3 sampled residents (#s 8 and 9). This is a repeat citation. Findings include, but are not limited to: 1. Resident 9's was admitted to the facility 09/2021 with diagnoses including dementia. The current service plan was reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs. The lack of an individualized nutritional plan was discussed with Staff 32 (Executive Director) and Staff 33 (Assistant ED/BOM) on 07/12/23. They acknowledged the findings.

Based on observation, interview and record review it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans and evaluations were reviewed. Findings include, but are not limited to: Resident 1, 2 and 3's evaluations and service plans were reviewed during survey and revealed the activity evaluation and activity service plan was not completed and/or did not include the following required information: * Past and current interests; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. The need to ensure an individualized activity plan was developed for each resident based on their activity evaluation was discussed with Staff 1 (ED) on 09/14/22. She acknowledged the findings.

Z164 OAR 411-057-0160(2d) Activities 1.) Facility will create an individualized activity plan for residents #1, 2, & 3. Activitiy plan will be made apart of residents' service plan and available for all staff to review. 2.) Facility will conduct an audit to identify any residents who do no have an individualized activity plan. All identified residents will have an activity plan created for them, including: Past and current hobbies, current abilities and skills, emotional needs and patterns, physical abilities and limitations, adapatations necessary for the resident(s) to participate, and identification of activities for behavioral interventions. 3.) Facility administrator, LN, and RCC will review/complete all activity plans as follows: At admission, within 30 days of admission, quarterly thereafter, and with changes of condition. 4.) Facility administrator, LN, and RCC will be responsible for ongoing compliance.1

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms which negatively impacted the resident or others in the community for 1 of 2 sampled residents (#2) with documented behaviors. Findings include, but are not limited to: Resident 2 was admitted to the facility in 03/2022 with diagnoses including early onset Alzheimer's dementia with behavioral disturbance. Resident 2's record documented behaviors including directing profanity toward staff and residents, being physically aggressive toward staff, and a resident-to-resident physical altercation on 08/16/22. The resident's service plan, dated 04/21/22, lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 09/14/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED). She acknowledged the findings.

Z165 OAR 411-057-0160(e) Behavior 1.) Facility will create and implement a behavior plan for resident # 2. Facility will make resident(s) behavior plan a part of the residents permanent service plan. All direct care staff will have access to behavior plan at all times. 2.) Facility will review any residents with ongoing behaviors and ensure a behavior plan is created, with clear staff instructions and interventions. All behavior plans will become a part of the residents permanent record via interim service plan. 3.) Facility administrator, RCC and LN will review/complete all behavior plans as follows: At admission, within 30 days of admission, quarterly thereafter, and with changes of condition. Facility LN and RCC will review any interim service plans written related to behaviors and determine if resident would benefit from a behavioral plan, during daily 24hr process. 4.) Facility Administrator, RCC, & LN will responsible for ensuring ongoing compliance.

2. Resident 2 was admitted to the facility in March 2022 with diagnoses including early onset Alzheimer's dementia with behavioral disturbance. Resident 2's service plan, dated 01/26/23, 01/15/23 through 02/27/23 progress notes, and temporary service plans were reviewed, observations were made, and interviews with staff revealed the following: *Resident 2's record documented behaviors such as yelling towards staff and residents, being physically aggressive toward staff, and resident-to-resident physical altercations on 01/25/23 and 02/03/22. There was no documented evidence the facility evaluated the residents behaviors, or initiated and coordinated outside consultation. The need to ensure the facility evaluated residents behaviors, or coordinated with outside providers, was reviewed on 03/03/23 with Staff 22 (Interim Executive Director). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident or others for 2 of 2 sampled residents (#s 2 and 5) who exhibited behaviors. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility 04/2021 with diagnoses including dementia, Diabetes (type 2), and depression. Review of Resident 5's service plan, dated 01/25/23, progress notes, dated 01/15/23 through 02/27/23, and incident reports revealed s/he had been involved in a resident to resident altercation on 02/12/23. Staff witnessed the resident "slapping another resident hard in the face". There was no documented evidence the facility had evaluated the residents behaviors, updated the service plan to address the behaviors,  or initiated contact or coordination with outside providers. The need to ensure the facility evaluated residents behaviors, updated the service plan, or coordinated with outside providers, was reviewed on 03/03/23 with Staff 22 (Interim Executive Director) and Staff 23 (Corporate Support). The staff acknowledged the findings.

Z165 OAR 411-057-0160 9e) Behavior 1. Facility will create and impliment a behavior plan for resident #2 & #5. Facility will make resident(s) behavior plan part of the residents permanent service plan. All direct care staff will have access to behavior plan at all times. 2. The facility will review any residents with ongoing behaviors and ensure a behavior plan is created with clear staff instructions and interventions. All behavior plans will become part of the resident's permanent record via interim service plan. 3. Facility ED or Designee and RN will review/complete all behavior plans as follows: At admission, within 30 days of admission, quarterly thereafter, and with changes of condition. Facility RN will review any interim service plans written realated to behaviors and determin if resident would benefit from a behavioral plan during daily 24 hour process. 4. ED and RN will be responsible for ensuring ongoing compliance.

Based on observation and interview, the facility failed to ensure outdoor furniture was of sufficient weight, stability and design, to prevent resident injury or aid in elopement. Findings include, but are not limited to: The facility grounds of the memory care community were toured on 09/12/22 at 11:15 am. Outdoor wicker chairs were observed in the courtyard, to which residents had free access. The chairs were easily movable, and not of sufficient weight to prevent injury or elopement. On 09/14/22 the need to maintain outdoor furniture of sufficient weight, was discussed with Staff 1 (ED). She acknowledged the findings. The furniture was removed prior to the survey teams exit.

Z173 OAR 411-057-0170(6) Secure Outdoor Recreation Area 1.) Facility removed all courtyard furniture that was not weighted or secured, prior to survey exit. Facility will ensure that only weighted or secured furniture is in the courtyard. 2.) Facility administrator and maintenance director will conduct spot-checks to ensure residents, family, and/or staff have not brought any furniture outside in courtyard that may pose a risk to residents. All non-weighted and non-secured furniture will be removed if noted during walk-through. 3.) Facility administrator and maintenance director will conduct weekly walk-through of MCC to ensure all furniture in the courtyard is secured and/or weighted. 4.) Facility administrator and facility maintenance director will ensure ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight, stability and design, to prevent resident injury or aid in elopement. This is a repeat citation. Findings include, but are not limited to: The facility grounds of the memory care community were toured on 02/27/23 at 10:45 am. Outdoor wicker chairs were observed in the courtyard, to which residents had free access. The chairs were easily movable, and not of sufficient weight to prevent injury or elopement. On 02/28/23 the surveyor and Staff 22 (Interim Executive Director) observed the courtyard area. Staff 22 acknowledged the chairs were not of sufficient weight, and stated plans to immediately remove the chairs. On 03/01/23, a follow-up tour of the courtyard was conducted. The wicker chairs had been removed. On 03/03/23 the need to maintain outdoor furniture of sufficient weight, was discussed with Staff 22 and Staff 23 (Regional Support). They acknowledged the findings.

Z173 OAR 411-057-0170 (6) Secure outdoor Recreation Area 1. Facility had new outdoor furniture but the weights were not on the furniture. Furniture was removed from the area prior to survey exit. 2. Facility Executive Director and Designee will conduct spot checks to ensure residents, family, and/or staff have not removed the weights from the furniture in the area or moved it in a way that may pose a risk to residents. All non-weighted and non-secured furniture will be removed. 3. The facility ED and Designee will conduct weekly walk through of the facility to ensure all furniture in the courtyard is secured and/or weighted. 4. The ED will ensure ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to: During the survey, conducted 02/27/23 through 03/03/23, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective. On 03/03/23, Staff 22 (Interim Executive Director) was interviewed about the facility's quality improvement program. She stated the facility did not have a Quality Improvement (QI) Program policy. She acknowledged the facility did not have a quality improvement plan in place. Refer to the deficiencies in the report.

C156 OAR 411-054-0025 (9) Facility Administration: Quality Improvement 1. Immediate actions were taken to correct the rule violation by implimenting Quality Improvement program. 2. The system will be corrected so the violation will not happen again. The ED or Designee will be responsible for scheduling monthly QA Meetings with the management team to go ober monthly findings that have been identified through evaluating services, staff performance, resident outcomes and resident satisfaction. 3. The ED will be responsible to ensure the corrections are completed and monitored monthly.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 140, C 156, C 231, C 242, C 260, C270, C 280, C 310, C 340, C372, C 420, C 545, Z155, Z 163, Z 165, Z 173,

C455 OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval 1. Facility will maintain inspection schedule. Facility will ensure that inspections are completed within scheduled time lines. 2. The Executive Director and Designee will Document all inspections and maintain records for completions. 3. Inspection and investigations wil be monitored by the Executive Director and Designee during monthly QA meetings. The Executive Director and Designee will audit Inspection binder once monthly to ensure oversight and compliance. The Executive Director will be responsible for overseeing ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C260 and C270.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure the quality of care and services that were rendered in the facility. This is a repeat citation. Findings include, but are not limited to: During the re-visit survey, conducted on 02/27/23 through 03/03/23, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations, new citations and identification of harm. Refer to deficiencies in report.

Z 140 OAR 411-057-0140 Administration Responsibilities Refer to deficiencies in Report

The findings of the initial survey, conducted 09/12/22 through 09/14/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 09/14/22, conducted 02/27/23 through 03/03/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day A situation was identified which represented an immediate threat to residents' health and safety and required an immediate plan of correction in the following area: C 280 - Resident Health Services- OAR 411-054-0045 (1)(a-f)(A)(C-F) The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety and the situation was abated.

The findings of the second re-visit to the re-licensure survey of 09/14/22, conducted 07/10/23 through 07/12/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 09/14/22, conducted 10/17/23 through 10/18/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the fourth revisit to the re-licensure survey of 09/14/22, conducted 12/05/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.