Kelly Gardens Residential Care

Based on interview and record review, it was determined the facility failed to ensure the physician or other legally recognized prescriber was notified when a resident refused to consent to a medication or treatment order for 2 of 2 sampled residents (#s 1 and 5) who had medications and treatments administered by the facility. Findings include, but are not limited to:

1. Resident 5 was admitted the facility in 02/2024 with diagnoses including epilepsy, schizophrenia, and bipolar disorder. The resident's 03/01/25 to 04/14/25 MARs and progress notes were reviewed, and the following was identified:

Staff documented the resident refused the following medications and treatments:

* Clozapine (for epilepsy/seizures), on four occasions;
* Amantadine (for anti-parkinson), on one occasion;
* House health shake (for supplement), on 16 occasions; and
* Sodium chloride (for electrolyte), on five occasions.

In an interview with Staff 4 (Community Nurse/LPN) on 04/16/25 at 11:22 am, they confirmed there was an order from the prescriber to notify them monthly of all refusals. Staff 4 acknowledged there was no documented evidence staff notified the prescriber of the above refusals for the month of March.

The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was discussed with Staff 1 (ED), Staff 2 (Administrator in Training), and Staff 3 (Community Nurse/RN) on 04/16/25. They acknowledged the findings, and no further information was provided.

2. Resident 1 was admitted to the facility in 07/2024 with diagnoses including paraplegia. The resident's 03/01/25 to 04/14/25 MARs and current medication and treatment orders were reviewed. The following was identified:

The resident had a signed physician order which included directions for staff to notify the physician monthly for refusal of any medications.

Staff documented the following medication and treatment refusals between 03/01/25 to 03/31/25:

* Senna (for constipation): on five occasions;
* Vitamin B1 (supplement): on one occasion;
* Vitamin B12 (aid for forming blood cells): on one occasion;
* Buprenorphine/naloxone (opioid blocker): on one occasion;
* Omeprazole (for heartburn): on one occasion;
* Potassium Chloride (supplement): on one occasion;
* SSD Chloride: (for wound infection): on 14 occasions;
* Acetaminophen (for pain): on one occasion;
* Boost (for weight loss): on 28 occasions;
* Pregabalin (for pain): on one occasion; and
* Wound care treatment: on seven occasions.

During an interview on 4/15/25 at 11:05 am with Staff 5 (Community Nurse/LPN), she confirmed there was no documented evidence the physician was notified of Resident 1’s March refusals for medications and treatments.

The need to notify the practitioner of resident medication refusals was discussed with Staff 1 (ED), Staff 2 (Administrator in Training), Staff 3 (Community Nurse/RN) on 04/16/25. They acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility failed to ensure they were staffing to meet the requirements under the Specific Needs Contract. Findings include, but are not limited to:

Upon entrance of the facility, a copy of the staffing plan was requested. The facility provided a copy of the staffing plan on 04/14/25, which included the following information:

* Day shift: six CG’s and two MT’s;
* Evening shift: six CG’s and two MT’s; and
* Night shift: four CG’s and one MT.

The Specific Needs Contract stated, “Contractor shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift.” The facility had 33 residents serviced by the contract, which would equate to 11 direct care staff for day/evening, and six for night shift.

In an interview with Staff 1 (ED) and Staff 2 (Administrator in Training) on 04/15/25 at 9:30 am, it was stated the facility was using a “combination” of the ABST tool, contract and acuity at the facility to determine appropriate staffing levels.

The need to ensure the facility was staffing to meet the requirements under the Specific Needs contract was discussed with Staff 1, Staff 2 and Staff 3 (Community Nurse/RN) on 04/16/25 at 12:00 pm.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:
Based on interview and record review, the facility failed to ensure they were staffing to meet the requirements under the Specific Needs Contract and consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. This is a repeat citation. Findings include, but are not limited to:

Upon entrance of the facility, a copy of the staffing plan was requested. The facility’s posted staffing plan and staffing schedule from 06/08/25 through 06/14/25 were reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (ED) on 06/18/25 at 1:24 pm. The following was identified:

* Day shift: 11 CGs and two MTs;

* Evening shift: 11 CGs and two MTs; and

* Night shift: six CGs and one MT.

The Specific Needs contract stated, “Contractor shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift.” The facility had 33 residents serviced by the contract, which would equate to 11 direct care staff for day/evening, and six for night shift. One resident serviced by the contract was in the hospital.

In an interview on 06/18/25 at 11:00 am, Staff 6 (MT) indicated she had been working alone as a MT and responsible for all three floors during day shift on 06/15/25. She acknowledged there was no second MT on the day shift for coverage.

Following this interview, the facility staffing schedule was requested and reviewed for additional dates, 06/15/25 through 06/17/25, and identified four shifts that were not covered on 06/15/25, including MT day shift. Although the posted staffing plan matched the Special Needs Contract, review of the facility schedule from 06/08/25 through 06/17/25 revealed the facility failed to staff per the posted staffing plan on six shifts, or 10% of the total shifts reviewed.

The need to ensure consistent staffing to meet or exceed the posted staffing plan requirement under the Specific Needs contract and consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week was discussed with Staff 1, Staff 2 and Staff 3 (Community Nurse/RN) on 06/18/25 at 3:50 pm and 4:28 pm. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:
Based on interview and record review, the facility failed to ensure they were staffing to meet the requirements under the Specific Needs Contract and consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. This is a repeat citation. Findings include, but are not limited to:

Upon entrance of the facility, a copy of the staffing plan was requested. The facility’s posted staffing plan and staffing schedule from 06/08/25 through 06/14/25 were reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (ED) on 06/18/25 at 1:24 pm. The following was identified:

* Day shift: 11 CGs and two MTs;

* Evening shift: 11 CGs and two MTs; and

* Night shift: six CGs and one MT.

The Specific Needs contract stated, “Contractor shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift.” The facility had 33 residents serviced by the contract, which would equate to 11 direct care staff for day/evening, and six for night shift. One resident serviced by the contract was in the hospital.

In an interview on 06/18/25 at 11:00 am, Staff 6 (MT) indicated she had been working alone as a MT and responsible for all three floors during day shift on 06/15/25. She acknowledged there was no second MT on the day shift for coverage.



Following this interview, the facility staffing schedule was requested and reviewed for additional dates, 06/15/25 through 06/17/25, and identified four shifts that were not covered on 06/15/25, including MT day shift. Although the posted staffing plan matched the Special Needs Contract, review of the facility schedule from 06/08/25 through 06/17/25 revealed the facility failed to staff per the posted staffing plan on six shifts, or 10% of the total shifts reviewed.

The need to ensure consistent staffing to meet or exceed the posted staffing plan requirement under the Specific Needs contract and consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week was discussed with Staff 1, Staff 2 and Staff 3 (Community Nurse/RN) on 06/18/25 at 3:50 pm and 4:28 pm. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:
Based on interview and record review, the facility failed to ensure they were staffing to meet the requirements under the Specific Needs Contract and consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. This is a repeat citation. Findings include, but are not limited to:

Upon entrance of the facility, a copy of the staffing plan was requested. The facility’s posted staffing plan and staffing schedule from 06/08/25 through 06/14/25 were reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (ED) on 06/18/25 at 1:24 pm. The following was identified:

* Day shift: 11 CGs and two MTs;

* Evening shift: 11 CGs and two MTs; and

* Night shift: six CGs and one MT.

The Specific Needs contract stated, “Contractor shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift.” The facility had 33 residents serviced by the contract, which would equate to 11 direct care staff for day/evening, and six for night shift. One resident serviced by the contract was in the hospital.

In an interview on 06/18/25 at 11:00 am, Staff 6 (MT) indicated she had been working alone as a MT and responsible for all three floors during day shift on 06/15/25. She acknowledged there was no second MT on the day shift for coverage.

Following this interview, the facility staffing schedule was requested and reviewed for additional dates, 06/15/25 through 06/17/25, and identified four shifts that were not covered on 06/15/25, including MT day shift. Although the posted staffing plan matched the Special Needs Contract, review of the facility schedule from 06/08/25 through 06/17/25 revealed the facility failed to staff per the posted staffing plan on six shifts, or 10% of the total shifts reviewed.

The need to ensure consistent staffing to meet or exceed the posted staffing plan requirement under the Specific Needs contract and consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week was discussed with Staff 1, Staff 2 and Staff 3 (Community Nurse/RN) on 06/18/25 at 3:50 pm and 4:28 pm. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:
Based on interview and record review, the facility failed to ensure they were staffing to meet the requirements under the Specific Needs Contract and consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. This is a repeat citation. Findings include, but are not limited to:

Upon entrance of the facility, a copy of the staffing plan was requested. The facility’s posted staffing plan and staffing schedule from 06/08/25 through 06/14/25 were reviewed with Staff 1 (Regional Director of Operations) and Staff 2 (ED) on 06/18/25 at 1:24 pm. The following was identified:

* Day shift: 11 CGs and two MTs;

* Evening shift: 11 CGs and two MTs; and

* Night shift: six CGs and one MT.

The Specific Needs contract stated, “Contractor shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift.” The facility had 33 residents serviced by the contract, which would equate to 11 direct care staff for day/evening, and six for night shift. One resident serviced by the contract was in the hospital.

In an interview on 06/18/25 at 11:00 am, Staff 6 (MT) indicated she had been working alone as a MT and responsible for all three floors during day shift on 06/15/25. She acknowledged there was no second MT on the day shift for coverage.



Following this interview, the facility staffing schedule was requested and reviewed for additional dates, 06/15/25 through 06/17/25, and identified four shifts that were not covered on 06/15/25, including MT day shift. Although the posted staffing plan matched the Special Needs Contract, review of the facility schedule from 06/08/25 through 06/17/25 revealed the facility failed to staff per the posted staffing plan on six shifts, or 10% of the total shifts reviewed.

The need to ensure consistent staffing to meet or exceed the posted staffing plan requirement under the Specific Needs contract and consistent staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week was discussed with Staff 1, Staff 2 and Staff 3 (Community Nurse/RN) on 06/18/25 at 3:50 pm and 4:28 pm. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:

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

Refer to: C 363 and C 510.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse. Findings include, but are not limited to:

The facility grounds were toured on 04/14/25 at 11:30 am and 04/15/25 at 10:50 am. The following was identified:

Multiple cigarette butts were observed on the ground in the courtyard area off of the dining room and in the parking lot area of the covered driveway.

In an interview with Staff 1 (ED) and Staff 2 (Administrator in Training) on 04/14/25 at 2:00 pm, they acknowledged there were multiple residents who resided at the facility who were smokers and often did not smoke in the designated smoking area.

The need to ensure the facility ensured the grounds were kept orderly and free of litter and refuse was discussed with Staff 1 and Staff 2 on 04/16/25 at 12:00 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on observation and interview, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse. This is a repeat citation. Findings include but are not limited to:

The facility grounds were toured with Staff 1 (Regional Director of Operations) and Staff 2 (Executive Director) at 11:00 am, and then again at 3:30 pm on 06/18/25. The following was identified at all observations:


* Multiple cigarette butts and litter were observed on the ground in the courtyard area off of the dining room and in the parking lot area of the covered driveway;

* A metal food can filled with cigarette butts was covered with a cardboard lid next to the dining room door; and

* A pressure washer, multiple hoses, and other maintenance equipment were stored in the resident use courtyard.

In an interview with Staff 1 and Staff 2 on 06/18/25 at 3:30 pm, they acknowledged there were multiple residents who resided at the facility who were smokers and often did not smoke in the designated smoking area.

The need to ensure the facility ensured the grounds were kept orderly and free of litter, refuse, and maintenance equipment was discussed with Staff 1 and Staff 2 on 06/18/25. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, conducted during a site visit on 04/08/25, the facility's failure to fully implement an acuity-based staffing tool (ABST) was substantiated for 1 of 2 residents (# 1). Findings include, but are not limited to:Resident 1 moved into the facility on 03/31/25 and required a minimal level of care.A review of facility's ABST indicated Resident 1 was new and no data was available for Resident 1 as of 04/08/25.In an interview on 04/08/25, Staff 1 (Regional Director of Operations) stated Resident 1 had resided in the facility for approximately one week.A review of the facility's posted staffing plan indicated the following:Day Shift (6:30 am - 2:30 pm)· Med tech - 2· Care Partner - 6 Evening Shift (2:30 pm - 10:30 pm)· Med tech - 2· Care Partner - 6 Night Shift (10:30 pm - 6:30 am)· Med tech - 1· Care Partner - 4 A review of the facility's Specific Needs Contract, Contract Number 180207, indicated "the facility shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift."A review of the completed ABST Facility Entrance Questionnaire indicated the facility had 32 residents that were served under the Specific Needs Contract.The facility failed to fully implement an ABST.Findings were reviewed with and acknowledged by Staff 1, Staff 2 (LPN) and Staff 3 (Regional Consultant RN).Based on interview, observation and record review, conducted during a site visit on 04/08/25, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated for 2 of 3 sampled residents (# 1 and 6) Findings include, but are not limited to:Compliance Specialist requested Resident 1 press his/her pendant at 2:26 pm, no staff responded to resident's pendant by 2:46 pm. A review of a staff member's call light notifications did not indicate an active call for Resident 1. Compliance Specialist requested Resident 6 press his/her pendant at 1:49 pm, no staff responded to resident's pendant by 2:12 pm. A review of a staff member's call light notifications indicated Resident 6's call light was marked as completed.In an interview on 04/08/25, Resident 1 stated s/he struggles to get staff to respond to his/her call light. Recently s/he needed assistance with toileting and could not find staff to assist.A review of facility's posted staffing plan indicated the following: Day Shift (6:30 am - 2:30 pm)· Med tech - 2· Care Partner - 6 Evening Shift (2:30 pm - 10:30 pm)· Med tech - 2· Care Partner - 6 Night Shift (10:30 pm - 6:30 am)· Med tech - 1· Care Partner - 4 A review of the completed ABST Facility Entrance Questionnaire indicated the facility had 32 residents that were served under the Specific Needs Contract.A review of the facility's Specific Needs Contract, Contract Number 180207, indicated "the facility shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift." Based on the Specific Needs Contract the facility should have had a minimum of 11 direct care staff during day and swing shifts and seven direct care staff at night.A review of the facility's schedule from 04/02/25 - 04/08/25 indicated the facility was consistently not meeting the Specific Needs Contract staffing requirements and 12% of reviewed shifts were staffed below the posted staffing plan.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.Findings were reviewed and acknowledged by Staff 1(Regional Director of Operations), Staff 2 (LPN) and Staff 3 (Regional Consultant RN).

Based on interview and record review, conducted during a site visit on 04/08/25, the facility's failure to fully implement an acuity-based staffing tool (ABST) was substantiated for 1 of 2 residents (# 1). Findings include, but are not limited to:Resident 1 moved into the facility on 03/31/25 and required a minimal level of care.A review of facility's ABST indicated Resident 1 was new and no data was available for Resident 1 as of 04/08/25.In an interview on 04/08/25, Staff 1 (Regional Director of Operations) stated Resident 1 had resided in the facility for approximately one week.A review of the facility's posted staffing plan indicated the following:Day Shift (6:30 am - 2:30 pm)· Med tech - 2· Care Partner - 6 Evening Shift (2:30 pm - 10:30 pm)· Med tech - 2· Care Partner - 6 Night Shift (10:30 pm - 6:30 am)· Med tech - 1· Care Partner - 4 A review of the facility's Specific Needs Contract, Contract Number 180207, indicated "the facility shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift."A review of the completed ABST Facility Entrance Questionnaire indicated the facility had 32 residents that were served under the Specific Needs Contract.The facility failed to fully implement an ABST.Findings were reviewed with and acknowledged by Staff 1, Staff 2 (LPN) and Staff 3 (Regional Consultant RN).

Based on interview and record review, conducted during a site visit on 04/08/25, the facility's failure to fully implement an acuity-based staffing tool (ABST) was substantiated for 1 of 2 residents (# 1). Findings include, but are not limited to:Resident 1 moved into the facility on 03/31/25 and required a minimal level of care.A review of facility's ABST indicated Resident 1 was new and no data was available for Resident 1 as of 04/08/25.In an interview on 04/08/25, Staff 1 (Regional Director of Operations) stated Resident 1 had resided in the facility for approximately one week.A review of the facility's posted staffing plan indicated the following:Day Shift (6:30 am - 2:30 pm)· Med tech - 2· Care Partner - 6 Evening Shift (2:30 pm - 10:30 pm)· Med tech - 2· Care Partner - 6 Night Shift (10:30 pm - 6:30 am)· Med tech - 1· Care Partner - 4 A review of the facility's Specific Needs Contract, Contract Number 180207, indicated "the facility shall provide a minimum ratio of 1 staff for every 3 Residents during day and evening shifts. Contractor shall provide a minimum ratio of 1 staff for every 5 residents during night shift."A review of the completed ABST Facility Entrance Questionnaire indicated the facility had 32 residents that were served under the Specific Needs Contract.The facility failed to fully implement an ABST.Findings were reviewed with and acknowledged by Staff 1, Staff 2 (LPN) and Staff 3 (Regional Consultant RN).

The findings of the initial survey conducted 07/18/22 through 07/20/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 07/20/22, conducted 12/12/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day



The findings of the second revisit, to the initial licensure survey of 07/20/22, conducted on 02/16/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure MARs included resident-specific parameters for PRN medications for 1 of 2 sampled residents (# 1) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 05/2022 with a diagnosis of guillain-berre syndrome. Resident 1's 07/01/22 through 07/17/22 MARs were reviewed during the survey. The following PRN medications lacked clear parameters for administration: * PRN oxycodone, naproxen, Tylenol and diclofenac all prescribed to treat pain, lacked clear parameters for the sequence of administration. * PRN senna, magnesium citrate, polyethylene glycol and bisacodyl suppository all ordered for bowel care lacked clear parameters which medication was to be administered first.* PRN hydrocortisone cream and diphenhydramine both for itching did not have clear parameters to guide staff which to utilize first.The need to ensure MARs included clear parameters for multiple PRN medications that were prescribed to treat the same condition was discussed with Staff 1 (Administrator) and Staff 2 (Administrator in training) on 07/20/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 3 of 3 sampled residents (#s 2, 3 and 4). This is a repeat citation. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 3/2022. Residents 2's MARs were reviewed from 12/01/22 through 12/12/22 and the following was noted:* Reasons for use was not indicated for all medications.The need for the facility to ensure MARs were accurate was discussed with Staff 2 (Administrator) on 12/12/22 at 12:45 pm. She acknowledged the findings. No further information was provided. 2. Resident 3 was admitted to the MCC in 07/2022 with diagnoses which included dementia.Residents 3's MARs, reviewed from 12/01/22 through 12/12/22 revealed the following:* S/he had an order for lidocaine cream to be applied to "affected areas four times a day as needed." The MAR lacked resident-specific instructions for the application of the cream; * Reasons for use was not indicated for all medications; and * The MAR directed staff to administer Seroquel (antipsychotic) 25 mg 1/2 tablet two times a day PRN agitation and anxiety. However, the MAR lacked resident specific instructions for how s/he expressed agitation and anxiety. On 12/12/22, the need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 2 (Administrator). She acknowledged the findings. No further information was provided. 3. Resident 4 was admitted to the MCC in 09/2022 with diagnoses which included Alzheimer's dementia. Residents 4's MARs were reviewed from 12/01/22 through 12/12/22 and the following was noted:* Lack of resident-specific instructions for multiple PRN bowel medications, including sequence of administration;* Reasons for use was not indicated for all medications; and * The MAR directed staff to administer PRN Lorazepam for anxiety, PRN Haldol for agitation, and PRN Morphine for pain. However, the MAR lacked resident specific instructions for how s/he expressed anxiety, agitation, and pain. In an interview on 12/12/22 at 12:45 pm, Staff 2 (Administrator) reviewed the resident's MAR. She confirmed several medications lacked reasons for use, and the multiple PRN bowel medications, PRN Lorazepam, PRN Haldol, and PRN morphine lacked specific instructions for staff. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#3) who was prescribed PRN medications for behaviors. Findings include, but are not limited to:Resident 3 was admitted to the MCC in 07/2022 with diagnoses including dementia. Resident 3 had a physician's order for Seroquel 25 mg ½ tablet twice a day for agitation or anxiety.Review of MARs from 12/01/12 - 12/12/22, revealed staff administered PRN Seroquel on 11 occasions. There was no documented evidence staff consistently attempted non-drug interventions with ineffective results prior to administering the psychotropic medication.In an interview on 12/12/22 at 12:00 pm, Staff 18 (MT) reviewed the MAR and progress notes and acknowledged staff were not consistently documenting non-drug interventions attempted prior to administering the PRN Seroquel. The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 2 (Administrator) on 12/12/22 at 12:45 pm. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:There was no documented evidence the facility was using an ABST which would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.On 07/18/22, Staff 1 (Administrator) reported the facility had not implemented an ABST. Staff 1 stated he would follow up to ensure the ABST was implemented as required.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly-hired direct care staff (#s 9 and 11) completed abdominal thrust and First Aid training. Findings include, but are not limited to: Training records were reviewed on 06/19/22 and revealed the following: Training records for Staff 9 (CG) hired 06/15/22, and Staff 11 (MT/CG) hired 06/11/22, were reviewed on 07/19/22 with Staff 4 (RCC). She confirmed the above mentioned staff did not have abdominal thrust or First Aid training. The need to ensure newly-hired direct care staff completed abdominal thrust and First aid training was reviewed with Staff 1 (Administrator) and Staff 2 (Administrator in Training) on 07/20/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 1 of 3 direct care staff (#13) had documented evidence of completion of First Aid training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 12/12/22 and revealed Staff 13 (CG), hired 09/14/22, lacked documented evidence they had completed First Aid training within 30 days of hire.The need for staff to complete all required training in the specified time frames was discussed with Staff 2 (Administrator) on 12/12/22 at 1:25 pm. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to Z155, C310 and C372.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:Observations during the survey revealed exit doors, including the doors to the enclosed courtyard, had no alarm or other acceptable system to alert staff when residents exited the building. The failure to ensure doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 07/20/22. They acknowledged the findings.

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 361, C 372 and C 555.
Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C372.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 7, 9 and 11) had completed all required orientation, pre-service training prior to beginning their job duties and/or had documented evidence of competency demonstrated within 30-days of hire. Findings include, but are not limited to: Review of training records for newly hired Staff 7 (CG) hired 06/08/22, Staff 9 (CG) hired 06/15/22 and Staff 11 (MT/CG) hired 06/11/22 identified the following deficiencies:*Staff 9 failed to have documented evidence of completing all orientation, pre-service training and demonstrated competency in all areas prior to beginning their job duties; and*Staff 7 and 11 failed to have documented evidence of completing all pre-service training prior to beginning their job duties and documented competency demonstrated within 30-days of hire.On 07/20/22, the need to ensure all orientation, pre-service training and competency demonstrated was completed prior to starting job duties was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly hired staff (#s 13 and 14) completed all required pre-service training, and 3 of 3 newly hired staff (#s 13, 14 and 15) completed competency training within 30 days of hire and prior to independently providing personal care to residents. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 12/12/22 at 1:25 pm. The following were identified:a. Staff 13 (CG) was hired 09/14/22. * There was no documented evidence she completed fire safety and emergency procedure pre-service training prior to performing any job duties.* There was no documented evidence Staff 13 demonstrated competency in assigned job duties within 30 days of hire and prior to working independently in the following areas: - Changes associated with normal aging;- Identification, documentation, and reporting of changes of condition; and- Conditions that require assessment, treatment, observation, and reporting.b. Staff 14 (CG) was hired 10/28/22. There was no documented evidence she had completed the following required training:* Abuse reporting pre-service training; and * There was no documented evidence Staff 14 demonstrated competency in assigned job duties within 30 days of hire and prior to working independently in the following areas: - Changes associated with normal aging;- Identification, documentation, and reporting of changes of condition; and- Conditions that require assessment, treatment, observation, and reporting.c. Staff 15 (CG) was hired 10/26/22. There was no documented evidence Staff 15 demonstrated competency in assigned job duties within 30 days of hire and prior to working independently in the following areas: - Changes associated with normal aging;- Identification, documentation, and reporting of changes of condition; and- Conditions that require assessment, treatment, observation, and reporting.The facility's failure to ensure staff completed all required training in a timely manner and prior to working independently was discussed with Staff 2 (Administrator) on 12/12/22. She acknowledged the findings.

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 310.
Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C310 and C330.