St Andrews Memory Care Community

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 injuries of unknown cause were immediately investigated and, if abuse could not be ruled out, were reported to the local Seniors and People with Disabilities (SPD) office for 1 of 2 sampled residents (# 1) who was reviewed for an injury of unknown cause. Findings include, but are not limited to: Resident 1 moved into the facility in 09/2025 with diagnoses including dementia and was on hospice services. The resident’s record, including progress notes, dated 10/12/25 through 01/11/26, and incident reports were reviewed. The following was identified: On 11/28/25, the facility documented that a hospice bath aide reported that the "[resident] has a swollen eye and wound to right wrist reported to MedTech." There was no documented evidence the facility immediately investigated the wound or was able to reasonably conclude that the physical injury was not the result of abuse. On 01/15/26 at 11:02 am, Staff 1 (ED) confirmed she was unable to locate the investigation. Survey requested the facility report the incident, and confirmation that the facility reported the injury of unknown cause to the local SPD unit was received on 01/15/26 at 1:08 pm. The need to ensure injuries of unknown cause were immediately investigated and, if the investigation could not rule out abuse, reported to the local SPD office was discussed with Staff 1, Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Upon identification of the deficiency on 01/15/2026, the facility immediately reported the injury of unknown cause involving Resident #1 to SPD. Resident #1 no longer resides in the facility; however, staff education, reporting procedures, and audit processes have been implemented to ensure ongoing compliance. 2. How will the system be corrected so the violation does not happen again? All staff were re-educated on: Recognizing injuries of unknown cause, Immediate reporting requirements, Documentation expectations, The requirement to report even when residents are on hospice or have cognitive impairment. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director and or designee will conduct weekly audits for 30 days of: Incident reports, Progress notes, Injury documentation and SPD reporting logs After 30 days, audits will occur monthly for three months. Findings will be reviewed during Quality Assurance/Performance Improvement (QAPI) meetings, and corrective actions will be taken as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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

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 (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 09/2025 with diagnoses including dementia and type 2 diabetes. The move-in evaluation failed to address the following required elements: * Pronouns; * Physical health status including vital signs if indicated by diagnoses, health problems or medications; * Cognition, including decision-making ability; * Independent activities of daily living, including the ability to manage medications, use the call system, housework, and laundry; * Emergency evacuation ability; * Complex mediation regimen; * Recent losses; * Elopement risk or history; and * Alcohol use. The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/14/26 at 2:10 pm. Staff acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. 2. How will the system be corrected so the violation does not happen again? The facility revised its move-in evaluation process from a paper-based system to the facility’s electronic health record (EHR) system to ensure all required elements are addressed prior to move-in. Staff responsible for admissions were trained on the facility’s EHR admission workflow and the regulatory requirements outlined in OAR 411-054-0034. Ongoing audits of move-in evaluations completed in the facility’s EHR will be conducted to ensure continued compliance. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director and or designee will conduct weekly audits for 30 days of all new move-in evaluations to ensure completion of required elements. After 30 days, audits will be completed monthly for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 provided clear direction regarding the delivery of services or were being implemented for 2 of 4 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the facility in 09/2025 with diagnoses including dementia and type 2 diabetes and was on hospice services. The resident's clinical record was reviewed, interviews were completed with staff, and observations were made. The service plan did not provide clear direction to staff in the following areas: * Wandering into other residents’ apartments; * Meal routines and where s/he chose to dine; * Dressing ability; * Favorite food and beverages; * Current ability to express the need to use the restroom; * Refusals, full and partial, to accept shower assistance from the hospice bath aide and direction to staff when the refusals occurred; * Conflicting information relating to the use of an oral medication to treat type 2 diabetes; * Elopement risk; * Fall interventions; * Sleep patterns; and * Frequency of checks while the resident was in his/her apartment. The need to ensure residents’ service plans provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 06/2023 with diagnoses including dementia. The resident's clinical record was reviewed, interviews were completed with staff, and observations were made. The service plan did not provide clear direction to staff or was not being implemented in the following areas: * The use of an electric toothbrush; * Current frequency of being resistive to care; * The need to be in the sitting position while receiving dressing assistance; * Answering "yes" to all questions asked; and * Morning routine. On 01/12/26 during the noon meal, Resident 2 was observed being fed by a staff member. The resident’s service plan reflected that s/he needed “cueing, prompting and reminders for optimal intake.” The service plan did not direct staff to assist in feeding him/her. Resident 2 was observed multiple times during the survey, dated 01/12/26 through 01/15/26, not wearing glasses. The resident’s service plan directed staff to remind him/her to put glasses on in the morning, take them off at night, and for staff to clean and store them. Resident 2 was observed in the dining room on 01/14/26 at 10:30 am sitting in the dining room. The resident’s walker was approximately three feet away, and not within reach. The resident’s service plan directed staff to ensure the walker “is within safe reaching distance.” During an interview with Staff 22 (CG) on 01/14/26 at 10:49 am, she reported that the resident was supposed to be “reminded” to eat and that s/he can eat independently, but “gets distracted and can take a long time.” She confirmed that when the resident was taking “too long” was when staff would assist to feed Resident 2. Staff 22 stated she was not aware of the resident having glasses and had not seen Resident 2 wearing glasses. The need to ensure residents’ service plans provided clear direction to staff and were being implemented was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. Service plan for Resident #2 was comprehensively reviewed and updated to ensure clear, individualized direction for staff regarding care needs, preferences, routines, safety risks, and interventions. Staff were re-educated on the updated plans and expectations for implementation. 2. How will the system be corrected so the violation does not happen again? The facility revised its service plan development and review process to ensure service plans provide clear and consistent direction for staff. Service plans are reviewed to confirm alignment between documented care, observed practice, and staff understanding. Staff education was reinforced regarding adherence to service plans, timely communication of changes in resident needs, and updating service plans as indicated. Coordination with external providers is clarified to ensure roles and responsibilities are accurately reflected in the service plan. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? RCC and or designee will conduct weekly audits for 30 days of service plans and direct care observations for consistency and implementation. After 30 days, audits will occur monthly for three months. Findings will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 determine actions or interventions needed for short-term changes of condition, communicate actions or interventions to staff on all shifts, and monitor changes through resolution, with at least weekly documentation, for 3 of 4 sampled residents (#s 1, 3, and 4) reviewed with short-term changes of condition. Findings include but are not limited to: 1. Resident 4 moved into the MCC in 10/2020 with diagnoses including dementia. The resident’s clinical record was reviewed. Resident 4 experienced the following changes of condition between 11/04/25 and 12/17/25: a. On 11/04/25, staff documented in progress notes that the resident was congested and coughing. On 11/13/25, staff documented Resident 4 didn’t go to his/her adult day services due to a cold. There was no documented evidence the resident’s cold symptoms were monitored through resolution. b. On 12/17/25, staff documented in progress notes that the resident had an unwitnessed fall. The facility initiated a temporary service plan on 12/17/25 to monitor for mobility changes. There was no documented evidence the resident’s mobility was monitored through resolution. Staff 3 (RCC) confirmed the lack of documented monitoring through resolution for both short-term changes of condition on 01/14/26 at 11:27 am. The need to ensure changes of condition were monitored at least weekly until resolution was discussed with Staff 1(ED), Staff 2 (Interim RN), and Staff 3 on 01/15/26 at 10:25 am. The findings were acknowledged, and no additional documentation was provided. 2. Resident 1 moved into the facility in 09/2025 with diagnoses including dementia and type 2 diabetes and was on hospice services. The resident’s clinical record was reviewed. Resident 1 experienced the following changes of condition between 10/01/25 and 12/24/25: a. On 10/23/25, Resident 1 punched a wall which resulted in a skin tear located on his/her right knuckles. There was no documented evidence the facility monitored the resident’s skin tear through resolution. b. On 10/30/25, hospice discontinued the following medications: * Donepezil (for dementia); * Pravastatin (for hyperlipidemia); and * Metformin (for type 2 diabetes). There was no documented evidence staff had been provided monitoring instruction for the change in medication, or the medication changes had been monitored through resolution. c. On 11/12/25, Resident 1 started a new scheduled medication, haloperidol (for dementia with behavioral disturbances). There was no documented evidence the facility monitored the addition of the medication through resolution. d. On 11/25/25, Resident 1’s scheduled haloperidol was decreased due to reports of sedation. There was no documented evidence the facility monitored the resident for decreased sedation with the change in dosage. e. On 12/19/25, the resident started a new medication, melatonin (for sleep management). There was no documented evidence the facility monitored the resident’s sleep due to the addition of the medication through resolution. The need to ensure actions or interventions were determined, documented, and communicated to staff on all shifts for changes of condition and those actions or interventions were monitored for effectiveness, with weekly progress noted in the resident record until the condition resolved, das discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings. 3. Resident 3 moved into the memory care facility in 11/2019 with diagnoses including Alzheimer’s disease and type 2 diabetes. The resident’s clinical record was reviewed. Resident 4 experienced the following changes of condition between 10/12/25 and 01/11/26: a. On 10/14/25, staff documented in progress notes that the resident was “on alert for missed insulin 9/30.” There was no documented evidence the resident’s condition related to the missed insulin was monitored and documented at least weekly through resolution. b. On 11/06/25, staff documented in progress notes that the resident was congested and coughing. There was no documented evidence the resident’s cold symptoms were monitored through resolution. On 01/14/26 at 2:10 pm, the above findings were shared and the need to ensure changes of condition were monitored at least weekly until resolution was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC). They acknowledged the findings, and no additional documentation was provided.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. The facility reviewed the clinical records for Residents #3 and #4 and updated monitoring documentation as appropriate. Staff were re-educated on recognizing changes of condition and documentation requirements. 2. How will the system be corrected so the violation does not happen again? The facility utilizes a weekly change-of-condition and skin monitoring tool to ensure short-term changes of condition are identified, monitored, and documented at least weekly until resolution. In addition, the interdisciplinary team (IDT) reviews short-term changes of condition during daily clinical meetings to confirm appropriate interventions, communication to all shifts, and ongoing monitoring. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Registered Nurse and or designee will conduct weekly audits for 30 days of documentation related to changes of condition, including progress notes, alerts, temporary service plans, medication changes, and monitoring through resolution. Monthly audits will continue for three months, with findings reviewed during QAPI meetings and corrective actions implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 411-054-0050(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 maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 1 of 1 sampled resident (# 3) who received incontinence care and for multiple sampled and unsampled residents during meal service and medication administration. Findings include, but are not limited to: 1. Throughout the change of ownership survey, dated 01/12/26 through 01/15/26, the following observations were made to determine adherence to universal precautions for infection control: a. Multiple meals were observed in the dining room on the fourth floor between 01/12/26 and 01/15/26. Staff were observed delivering food and beverages, providing feeding assistance to residents, using keys to enter the kitchenette, cleaning spilled food items off the floor, touching their faces, maneuvering walkers and wheelchairs, touching a resident’s hand, holding glassware from the lip, moving a garbage can, and grabbing a ready-to-eat dessert with their bare hands then stating it was for a resident without changing their gloves and/or performing hand hygiene between dirty and clean tasks. b. Observations of medication passes were made between 01/12/26 and 01/15/26. MTs were observed pouring and passing medications, touching residents, touching a computer and medication cart, pouring a single pill into their hand prior to handing it to the resident, touching dining room chairs, entering residents’ rooms, touching their face and their cell phone without changing gloves and/or performing hand hygiene between dirty and clean tasks. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene during dining services and completing medication passes to the residents, was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 10:25 am. They acknowledged the findings. 2. Observations were made during the survey to determine adherence to universal precautions for infection control. On 01/12/26 at approximately 1:37 pm and on 01/13/26 at approximately 11:25 am, the surveyor obtained permission and observed Staff 8 (CG) and Staff 9 (CG) on 01/12/26 and Staff 8 and Staff 10 (CG) on 01/13/26 provide incontinence care to Resident 3. During the observations, Staff 8, 9, and 10 failed to change gloves after removing a soiled incontinence product and wiping fecal matter from Resident 3's bottom area. Staff 8 and Staff 9 applied a new brief to Resident 3 and touched the resident's pants and the manual wheelchair while wearing the same soiled gloves. When Staff 8, 9 and 10 were finished providing incontinence care, they removed the gloves and performed hand hygiene. During the observations, staff failed to change gloves between clean and dirty tasks. The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (Interim RN) and Staff 3 (RCC) on 01/14/26 at 2:10 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? The facility re-educated staff on infection prevention and control practices, including hand hygiene and proper glove use with supervisory staff providing real-time correction when improper practices are observed. Resident #3’s care was reviewed, and staff were instructed on appropriate glove changes and hand hygiene, with leadership reinforcing that gloves do not replace hand hygiene and must be changed between tasks or after contact with bodily fluids. 2. How will the system be corrected so the violation does not happen again? The facility reinforced its infection prevention and control program to require proper hand hygiene and glove use during all resident care activities. Infection control education was reinforced for staff involved in incontinence care, meal service, and medication administration. The facility implemented direct observational audits to monitor compliance, incorporated infection control expectations into new hire orientation and ongoing training, and directed supervisory staff to intervene immediately when improper practices are observed. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Registered Nurse and or designee will conduct random infection control audits for 30 days, including observation of incontinence care, meal service, and medication administration. After 30 days, audits will occur monthly for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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

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

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the MCC in 10/2020 with diagnoses including dementia, hypertension, and edema. The resident’s current physician orders and the 12/2025 and 01/2026 MARs were reviewed. The resident had a 12/02/25 physician order to take 20 mg of furosemide two times daily for high blood pressure. Resident 4’s MAR noted s/he received 20 mg once daily, not twice daily, from 12/03/25 to 01/06/26. Therefore, the facility failed to ensure the resident’s furosemide medication orders were carried out as prescribed on 35 occasions. On 01/14/26 at 10:41 am, Staff 2 (Interim RN) and Staff 3 (RCC) acknowledged there were no additional orders indicating the resident was to receive one 20 mg tablet of furosemide daily. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, and Staff 3 on 01/15/26 at 10:25 am. They acknowledged the findings. 2. Resident 1 moved into the facility in 09/2025 with diagnoses including dementia and type 2 diabetes. A review of the resident's physician orders and MARs, dated 10/01/25 through 01/12/26, revealed the following: From 10/30/25 through 01/08/26, the facility did not administer the following medications due to Resident 1 sleeping: * Haloperidol (for dementia with behavioral disturbances) – nine occasions; * Senna (for bowel care) – 12 occasions; * Olanzapine (for dementia behavior management) – 19 occasions; and * Quetiapine (for dementia with behaviors) – one occasion. On 01/15/26 at 11:50 am, Staff 20 (MT) confirmed he did not want to wake the resident up to administer medications due to the resident having behaviors and received no other direction in addition to document that Resident 1 was sleeping. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. For Resident #4, medication orders were clarified and corrected as needed, and provider guidance was obtained regarding missed doses. 2. How will the system be corrected so the violation does not happen again? The facility revised its medication administration process to ensure accurate order verification, provider clarification when medications are not administered, and proper documentation. Staff education and routine MAR audits were implemented, with supervisory oversight to ensure compliance. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Registered Nurse and Resident Care Coordinator will conduct weekly MAR and medication administration audits for 30 days, followed by monthly audits for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 (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 keep an accurate MAR and ensure there were resident specific parameters and instructions for PRN medications for 1 of 4 sampled residents (# 1) whose MARs were reviewed. Findings include, but are not limited to: Resident 1 moved into the facility in 09/2025 with diagnoses including dementia, type 2 diabetes, and had recently been admitted onto hospice services. The resident’s physician’s orders and MARs, dated 10/01/25 through 01/12/26, were reviewed. The following was noted: a. The MAR was blank for the following treatment, monitoring, and medication administration: * Triamcinolone ointment (for dry skin/other skin conditions) on 10/10/25; * Bowel monitoring on 10/10/25; * Meal monitoring on 10/10/25 and 11/07/25; * Behavior monitoring on 11/23/25, 11/26/25, and 12/03/25; and * Olanzapine (for dementia behavior management) on 12/03/25 and 12/14/25. b. Resident 1 was ordered scheduled Senna (for bowel management). The physician’s order directed staff to “hold for loose stools”. The instruction to staff was not transcribed onto the MAR. c. The resident had two PRN medications prescribed for pain, acetaminophen and morphine. The acetaminophen did not have the sequential order of use listed to instruct unlicensed staff on when to administer. d. Resident 1 had two PRN bowel medications ordered, bisacodyl tablets and suppository. Direction to staff for the bisacodyl suppository was to administer “every day as needed for morning of day [four] no [bowel movement] if no results from Milk of Magnesia.” The resident did not have a current order for the Milk of Magnesia nor was it listed on the MAR. The need to ensure the facility kept an accurate MAR and included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 1:25 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. 2. How will the system be corrected so the violation does not happen again? The facility revised its MAR review process to ensure accurate order verification, inclusion of resident-specific parameters and PRN instructions, and timely provider clarification of discrepancies. Routine MAR audits and staff education were implemented, with supervisory oversight to promptly address inaccuracies or unclear instructions. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Resident Care Coordinator and or designee will conduct weekly MAR audits for 30 days, followed by monthly audits for three months, with results reviewed during QAPI meetings and corrective actions implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 document that non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (# 1) who was prescribed PRN psychotropic medications. Findings include, but are not limited to: Resident 1 moved into the facility in 09/2025 with diagnoses including dementia. The resident’s physician’s orders, MARs, dated 10/01/25 through 01/12/26, and progress notes, dated 10/12/25 through 01/12/26, were reviewed. Staff were interviewed and the following was noted: Resident 1 had physician’s orders for the following PRN psychotropic medications: * Haloperidol 2 mgs by mouth every three hours, as needed, for breakthrough agitation or physical aggression; and * Lorazepam 1 mg every four hours, as needed, for severe agitation or physical aggression. The resident received PRN lorazepam five times from 10/31/25 to 11/23/25, and PRN haloperidol twice from 11/20/25 to 12/22/25. On 01/15/26 at 11:50 am, Staff 20 (MT) was able to show the pop-up screen in the electronic MAR system that prompted MTs to document the non-drug interventions tried and failed. Staff 20 confirmed there were no non-drug interventions tried and failed documented in Resident 1’s record. On 01/15/26 at approximately 12:15 pm, Staff 3 (RCC) stated the documentation of non-drug interventions tried and failed prior to the administration of the PRN psychotropic would be on the resident’s progress notes and confirmed the information would not be documented anywhere else. There was no documented evidence that non-drug interventions were tried and failed prior to the seven administrations of a PRN psychotropic in the resident’s progress notes between 10/31/25 and 12/22/25. The need to document that non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was discussed with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 on 01/15/26 at 1:25 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. Staff were re-educated on required documentation, and the resident’s service plan was reviewed to ensure non-pharmacological strategies were clearly identified. 2. How will the system be corrected so the violation does not happen again? The facility revised its psychotropic medication process to require documented non-pharmacological interventions prior to PRN psychotropic use and reinforced use of electronic MAR prompts. Staff education and routine audits were implemented to ensure appropriate use and documentation, with supervisory oversight to address noncompliance promptly. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Resident Care Coordinator and or designee will conduct weekly audits for 30 days of PRN psychotropic medication administration and documentation. After 30 days, audits will occur monthly for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring 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 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

Based on interview and record review, it was determined the facility failed to ensure adequate direct care staff were present at all times according to their staffing plan to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: During the Acuity Based Staffing Tool (ABST) review on 01/15/26, the following was identified: * The facility was a four-story memory care facility; * No residents lived on the third floor during the survey; * The facility was home to 42 residents at the time of survey; * Five residents on the first floor required two staff members’ assistance with transfers and/or ADL care; * Three residents on the first floor required assistance in the dining room, including cueing or physical assistance with eating; * Three residents on the first floor, one resident on the second floor, and one resident on the fourth floor exhibited behaviors that required supervision and redirection; and * All residents required support due to cognitive impairments. The current facility staffing plan was reviewed and indicated the following: * Day shift: Five direct caregiving staff and two Medication Technicians; * Evening shift: Five direct caregiving staff and two Medication Technicians; and * Night shift: Four direct caregiving staff and one Medication Technician. A review of the scheduled staffing for the period of 01/05/26 through 01/11/26 and timecards for the period of 01/09/26 through 01/11/26 revealed the following discrepancies in staffing level. On 01/09/26, 01/10/26 and 01/11/26, the night shift did not meet the posted staffing plan. The need to ensure direct care staff were present at all times according to their staffing plan to meet the 24-hour scheduled and unscheduled needs was reviewed on 01/15/26 at 9:57 am with Staff 1 (ED), Staff 2 (Interim RN) and Staff 3 (RCC). They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? The facility reviewed staffing schedules and timecards, addressed immediate staffing gaps, and reinforced expectations with leadership and scheduling staff to ensure adherence to the posted staffing plan and adequate coverage to meet resident care needs. 2. How will the system be corrected so the violation does not happen again? The facility revised its staffing oversight process to ensure routine review of staffing plans against actual coverage, timely corrective action when staffing falls below plan, regular ABST review, and escalation of staffing concerns. Staffing expectations were reinforced through leadership and scheduling training. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director and or designee will conduct weekly reviews for 30 days comparing posted staffing plans to actual staffing schedules and timecards. After 30 days, reviews will occur monthly for three months. Findings will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

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 an Acuity Based Staffing Tool (ABST) evaluation was completed for each resident prior to admission for 1 of 1 sampled resident (#1) and multiple unsampled residents whose move-in ABST evaluations were reviewed. Findings include, but are not limited to: The facility’s ABST data and resident move-in dates were reviewed during the survey and revealed the following: * Resident 1 moved into the facility in 09/2025. The resident’s ABST evaluation was entered in 10/2025. Therefore, the resident's ABST evaluation was not completed prior to moving into the facility; and * Fifteen unsampled residents’, who moved into the facility within the last six months, ABST evaluations were not completed prior to admission. The need to ensure residents’ ABST evaluations were completed prior to move-in was discussed with Staff 1 (ED), Staff 2 (Interim RN) and Staff 3 (RCC) on 01/14/26 at 2:10 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? Resident #1 no longer resides in the facility. The facility reviewed and completed ABST evaluations for other potential affected residents and reinforced admission expectations with leadership and staff to ensure ABST completion prior to move-in. 2. How will the system be corrected so the violation does not happen again? The facility revised its admission process to require ABST completion prior to move-in, incorporated ABST verification into the pre-admission checklist, assigned responsibility for completion with RN or leadership review, reinforced staff education, and ensured ABST data is used to inform staffing plans. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director and or designee will conduct weekly audits for 30 days of new admissions to ensure ABST completion prior to move-in. After 30 days, audits will occur monthly for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 411-054-0070 (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 4 of 4 newly hired direct care staff (#s 11, 12, 15, and 16) completed First Aid and abdominal thrust training within 30 days of hire. Findings include but are not limited to: Training records were reviewed with Staff 4 (Business Office Manager) on 01/13/26 and showed the following: Training records for Staff 11 (MT), hired 12/02/25, Staff 12 (MT), hired 12/02/25, Staff 15 (CG), hired 11/28/25, and Staff 16 (CG), hired 09/11/25, lacked documented evidence First Aid and abdominal thrust training were completed within 30 days of hire. The need to ensure staff completed First Aid and abdominal thrust training within 30 days of hire was reviewed with Staff 4 on 01/13/26 at 1:00 pm and with Staff 1 (ED), Staff 2 (Interim RN), and Staff 3 (RCC) on 01/14/26 at 2:10 pm. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? The facility reviewed training records for Staff #11, #12, #15, and #16 and ensured First Aid and abdominal thrust training was assigned and completed. Required training was completed or scheduled as needed, documentation was placed in personnel files, and training expectations were reinforced with leadership and staff to ensure completion within 30 days of hire. 2. How will the system be corrected so the violation does not happen again? The facility revised its onboarding process to require verification of First Aid and abdominal thrust training within 30 days of hire, incorporated required trainings into a new-hire checklist with assigned responsibility, clarified tracking accountability, reinforced staff education, and implemented routine personnel file audits to ensure compliance. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director and Business Office Manager will conduct weekly audits for 30 days of new hire training records. After 30 days, audits will occur monthly for three months. Audit results will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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 every other month and recorded according to the Oregon Fire Code (OFC), and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Upon survey’s entrance to the facility on 01/12/26, six months of facility fire drill and fire and life safety records, dated 07/2025 through 12/2025, were requested. The following was determined: a. The facility lacked documented evidence unannounced fire drills were conducted and recorded at least every other month. b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills. On 01/13/26 at 1:45 pm, Staff 1 (ED) confirmed the facility’s lack of documentation of fire drills and fire and life safety training for caregivers. The need to ensure fire drills were conducted every other month according to the OFC and staff were provided fire and life safety instruction on alternate months was discussed with Staff 1, Staff 2 (Interim RN), and Staff 3 (RCC) on 01/15/26 at 10:56 am. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? The facility reviewed fire drill and safety training records, reinforced regulatory requirements with leadership, resumed required fire drills and fire/life safety instruction, and emphasized timely and accurate documentation in accordance with the Oregon Fire Code. 2. How will the system be corrected so the violation does not happen again? The facility revised its fire and life safety compliance process to include an annual alternating schedule for fire drills and safety training, implemented standardized documentation, assigned leadership responsibility, incorporated requirements into staff training, and established routine record reviews to ensure compliance. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Executive Director or designee will conduct monthly reviews of fire drill and fire/life safety documentation to ensure compliance with alternating-month requirements. Compliance will be reviewed during QAPI meetings, and corrective actions will be implemented as needed. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility consisted of four floors. On 01/12/26 at 9:05 am, Staff 1 (ED) reported the third floor was being renovated and there were no residents residing on that floor. On 01/12/26, the interior of the facility was toured, and the following observations were made: a. First Floor Kitchenette and Dining Room * There was chipped paint, scuffs, drips observed on the walls, doors and door frames (including the doors leading out of the dining room and into the kitchen), and baseboards; * The vinyl covering on the seats of the dining room chairs was worn and peeling off; * The interior of the microwave needed cleaning; * A cabinet underneath the microwave was missing a knob; * There were areas in the wooden cabinetry observed with exposed wood, deeming those areas to be uncleanable surfaces; * The lining of the drawers to the right of sink was bubbling up and areas of the lining were missing, deeming them uncleanable surfaces; * There was a panel, located in the ceiling, above the dining room table closest to the television, where the air vent appeared to be pulling away from the casing; * There was dust accumulation observed on the windowsills; * The light fixtures had dead bugs and debris inside of them; and * There was a chair missing a front caster wheel stored next to the activity closet. Resident Use Areas * The elevator casing was observed to be scuffed, there was chipped paint, and a strip of duct tape was located along the threshold; * The light fixtures throughout the floor had debris inside of them; * Multiple doors and doorframes (including the ones to stairwells, kitchen, exits, and resident apartments) had scuffs, drips, and chipped paint observed; and * Walls and baseboards were also observed throughout the first floor with scuff marks and chipped paint. b. Second Floor Kitchenette and Dining Room * There were areas in the wooden cabinetry observed with exposed wood, deeming those areas to be uncleanable surfaces; * Knobs were missing from the upper right cupboard and the lower right middle drawer; * The bottom of the lower, middle cupboard had black and brown debris observed; * The cupboard underneath the sink had black and brown matter located inside, on the bottom, and towards the back; * The right upper corner of the shelving, consisting of two pieces of wood, on top of the cabinetry where items were being stored, was pulling away from each other; * There were broken pineapple string lights circling the banister, to the right of the kitchenette, with sharp edges exposed; * The legs of the moveable chairs had built up food debris observed; * The lower part of the piano was observed to have a layer of dust present; * The stationary wood seating around the room had worn and exposed wood, deeming them uncleanable surfaces; * There was chipped paint behind the wall mounted light fixtures; and * There was dust build up observed on the windowsills, the backs of the stationary seating, and on the wood trim/molding around the room. Resident Use Areas * There was an incline going into apartment 219 which made it difficult for the resident to open the door and made the door close automatically; * Multiple doors and doorframes (including the ones to stairwells, dining room, offices, employee use rooms, and resident apartments) had scuffs, peeling varnish, partially ripped-off stickers, and gouges observed; * The closet door located outside of the dining room, had splintering wood by the doorknob; * The air vent, located across from the closet door outside of the dining room, had a thick layer of dust present; * The windowsills, located in the hallway by the elevator and in a seating area, had dead bugs and dust observed; and * The paint around the windowpanes and sills located in the seating area at the end of a hallway was chipped. c. Fourth Floor Kitchenette * The inside of the door had gray/brown matter observed, and the paint was chipped; * There was an accumulation of built-up ice in the freezer; * Cabinet doors were missing, in disrepair, or had exposed wood present which deemed them uncleanable surfaces; * The wood was coming apart under the counter where the coffee machine and water pitcher was stored; * There was chipped paint observed on the windowsill; and * There were drips, splatters, and chipped paint observed on the walls and baseboards. Resident Use Areas * The blinds in apartment 417 were in disrepair; * The paint around the windowpanes and sills located in the sunroom seating area off the dining room was chipped as was the windowsill across from apartment 404; * There were multiple areas on the flooring where duct tape was placed; * Between apartments 405, 406, 409, and 410, there were multiple, large pieces of clear tape stuck to the ceiling and walls; * The paint in the elevator casing was chipped and there was a gray build-up of debris located on the keypad; * Multiple doors and doorframes (including the ones to stairwells, the kitchenette, and resident apartments) had scuffs, drips, and chipped paint observed; and * Walls and baseboards were also observed throughout the fourth floor with scuff marks and chipped paint. The environment was toured and the need to ensure all interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 and Staff 5 (Maintenance Director) on 01/15/26 at 11:05 am. They acknowledged the findings.

1. What actions will be taken to correct the deficient practice? The facility conducted an environmental review of resident-use and common areas to identify cleanliness and maintenance concerns and completed immediate cleaning and debris removal, prioritized repairs with leadership and maintenance, and removed unsafe or damaged items from resident-use areas pending repair or replacement. 2. How will the system be corrected so the violation does not happen again? The facility revised its environmental maintenance and housekeeping oversight process, implemented routine environmental inspections, assigned repair tracking and prioritization to the Maintenance Director, reinforced cleaning and reporting expectations with staff, and incorporated environmental standards into ongoing training with leadership monitoring through routine rounds. 3. How often will the area needing correction be evaluated and who is assigned to evaluate efforts? The Maintenance Director and or designee will conduct weekly environmental rounds for 30 days. After 30 days, rounds will occur monthly for three months. Findings and corrective actions will be reviewed during QAPI meetings to ensure sustained compliance. 4. Who on your staff will be responsible to ensure corrections are completed and monitored? The Executive Director is responsible for ensuring compliance

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.

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, the facility failed to ensure move-in evaluations addressed all required elements, including pronouns, for 1 of 1 sampled resident (# 1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252.

See C252.

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

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 2 of 4 newly hired staff (#s 12 and 14) whose training records were reviewed. Findings include, but are not limited to: Refer to: Z 155.

See Z155.

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule.

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: C 231, C 295, C 360, C 363, C 372, C 420, and C 513.

See C231, C295, C360, C363, C372, C420, C513.

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

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 11, 12, 13, and 14) completed all required pre-service orientation training, 4 of 4 staff (#s 11, 12, 13, and 15) completed pre-service dementia training and 4 of 4 staff (#s 11, 12, 15, and 16) completed competency training within 30 days of hire. Findings include, but are not limited to: The facility’s training records for Staff 11 (MT), hired 12/02/25, Staff 12 (MT), hired 12/02/25, Staff 13 (CG), hired 01/05/26, Staff 14 (Housekeeping), hired 11/19/25, Staff 15 (CG), hired 11/28/25, and Staff 16 (CG), hired 09/11/25, were reviewed with Staff 4 (Business Office Manager) on 01/13/26 at 1:00 pm. The following was identified: a. There was no documented evidence Staff 11, 12, 13, and 14 had completed pre-service orientation training in one or more of the following required topics: * Resident rights and values and CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Infectious Disease Prevention; * Approved HCBS course; and * Approved LGBTQIA2S+ course. b. There was no documented evidence Staff 11, 12, 13, and 15 had completed pre-service dementia training in one or more of the following required topics: * 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 person with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety f residents with dementia including addressing pain, providing food/fluids, preventing wandering, sue of person-centered approach; * Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lighting, room temperature, noise, etc.); * 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’s service plan; and * Use of supportive deices with restraining qualities in memory care communities. c. There was no documented evidence Staff 11, 12, 15, and 16 had demonstrated competency in one or more of the following required topics: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. d. Staff 11 and 12 failed to complete the required competency demonstration for the medication administration duty. During the survey, Staff 1 (ED), Staff 3 (RCC) and Staff 4 were instructed that Staff 11 and 12 should be removed from the schedule until they completed the competency demonstration, including the medication administration. The facility failed to ensure all required training was completed and staff demonstrated competency was discussed with Staff 1, Staff 2 (Interim RN) and Staff 3 on 01/14/26 at 2:10 pm. They acknowledged the findings.

See C360.

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: C 252, C 260, C 270, C 303, C 310, and C 330.

See C252, C260, C270, C303, C310, C330.

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

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

Based on interview and record review, it was determined the facility failed to ensure activity evaluations and individualized activity plans were completed for 2 of 4 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s service plans and Resident Activities/Interests Assessments were reviewed and offered some information, but the facility had not fully evaluated the residents' activity needs in one or more of the following areas: * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities which could be used as behavioral interventions, if necessary. There were progress notes that documented Resident 1 enjoyed listening to classical music while in his/her apartment. On 01/15/26 at 10:37 am, Staff 18 (CG) reported she was not aware of a radio or any other device for the resident to listen to music on in his/her room. She stated that Resident 1 will watch television and listened to music in the dining room “sometimes”. Staff 18 confirmed the resident did not like a loud environment. Resident 1 lacked a resident-specific activity plan that was developed from the information gathered and detailed what, when, how, and how often staff should offer and assist with relating to his/her individualized activities. The need to ensure activity evaluations were completed for all residents and individualized activity plans were developed and implemented was discussed with Staff 1 (ED), Staff 2 (Interim RN), Staff 3 (RCC), and Staff 6 (Activity Director) on 01/14/26 and 01/15/26. They acknowledged the findings.

See C260.

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

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

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Oregon Food Sanitation Rules. Findings include, but are not limited to: On 07/24/25, observations of the facility's kitchen at 11:17 am identified the following: a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following: * The exterior and handles of all freezers; * Walls and ceilings throughout the kitchen; * Legs and drawers of stainless steel prep counters and shelving; * Can opener casing; * Clean dish carts in the dishwashing area; * Wall behind the dishwasher; * Dish sprayer nozzle, handle, and cord; * Stainless steel shelving storing spice bottles; and * Interior and exterior of the microwave. b. Leftover food items in the refrigerator were dated but not labeled. c. The following areas/items needed repair/replacement: * Several patches of missing/chipped/flaked paint and areas covered in spackle, including above the ice scoop near the ice machine, above/behind/below the dishwasher, and under the food prep sink; and * Rubber spatulas were worn with pieces of rubber missing. The above areas were toured and discussed with Staff 1 (ED) at 12:56 pm on 07/24/25. She acknowledged the findings.

1a.A deep cleaning to be done to remove all food spills, splatters, debris, dirt and black matter from exterior and handles of all freezers, walls and ceilings, legs and draws of stainless steel prep counters and shelving, can opener casing, carts storing clean dishes, wall located behind the dishwasher, dish sprayer nozzle, handle and cord, stainless steel shelving storing spice bottles and interior and exterior of the microwave. b. All left over food items will be labeled and dated. c. All areas of missing/chipped/flaked paint will be repainted. New rubber spatulas were ordered and received and worn spatulas have been discarded. 2a. A preventative cleaning schedule/checklist to be implemented. b. Dietary staff to be in-serviced on proper food storage, dating, and labeling. c. Preventative maintenance checklist to be implemented to identify areas needing repair. 3a. Monthly. b. Daily. c. Quarterly. 4a.Dietary Director. b. Dietary Director/Sous Chef. c. Maintenance Director.

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

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

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

Refer to C240 plan of correction.

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

Based on observation, interview, and record review, it was determined the facility failed to refer a significant change of condition to the facility nurse for 1 of 3 sampled residents (#5) who experienced severe weight loss. Findings include, but are not limited to: Resident 5 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease. The resident's 07/01/24 service plan, 05/15/24 through 07/15/24 progress notes, 07/01/24 through 07/15/24 MAR, and temporary service plans were reviewed. The following was identified: * The service plan indicated Resident 5 should be offered "finger foods and easy to chew foods." Observations during lunch on 07/16/24 and 07/17/24 revealed the resident required his/her food to be cut up. * The MAR indicated a nutritional shake was ordered twice a day after lunch and dinner. Resident 5's weight records from June 2024 to July 2024 were reviewed and indicated the following: * 06/04/24 - 144.3 pounds; * 07/04/24 - 129.6 pounds; and * 07/11/24 - 133.8 pounds. Between 06/2024 and 07/2024, Resident 5 had a severe weight loss of 14.7 pounds in one month, or 10.2% of his/her total body weight. This represented a significant change of condition. During the survey the following was observed: * On 07/16/24 Resident 5 was served pulled pork (not cut up), cut up roasted potatoes, whole pieces of steamed vegetables, salad, a roll, water, and lemonade. S/he consumed 90% of the meal. * On 7/17/24 Resident 5 was served mashed potatoes, cut up pieces of chicken, steamed carrots and green beans, cut up pieces of salad, a roll, water, apple juice, and an orange drink. During the meal s/he attempted to grab a tablemate's personal dessert, the caregiver intervened and brought Resident 5 four small cookies. S/he ate 40% of his/her meal. Following the lunch meal, Staff 13 (MT) provided Resident 5 a nutritional shake. A progress note, dated 07/05/24, from Staff 8 (RCC) indicated, "Faxed [outside provider] PCP (primary care physician) regarding 5% weight change. Requesting health shakes to encourage intake. Awaiting response." While a temporary service plan was implemented by Staff 8 on 07/10/24, there was no documented evidence Resident 5's significant weight loss was referred to the facility nurse. On 7/17/24 Resident 5 was weighed and was 139 pounds. In an interview on 07/17/24 at 1:45 pm, Staff 2 (RN) acknowledged she had not been notified Resident 5 had a significant weight loss. The need to ensure significant changes of condition were referred to the facility nurse was discussed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings.

1. Resident #5 has had a significant change in condition assessment completed by the RN. 2. Changes in resident condition will be monitored and identified through the 24 hour chart review and follow up process and through alerts in PCC. Changes in condition will also be discussed at morning stand up. Nursing staff will be in-services on assess/evaluating weight changes on a weekly basis as needed. 3. Monthly audits will be completed by the Health and Wellness Director (HWD) to ensure that monitoring of any new weight changes have been assessed timely and interventions put in place and communicated to staff. Audit details to be reported at Quarterly QA meeting. 4. HWD to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment had been completed for 1 of 3 sampled residents (# 5) who experienced a significant change of condition. Findings include, but are not limited to: Resident 5 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease. The resident's 11/02/23 through 07/11/24 weight records, 05/15/24 through 07/15/24 progress notes, 07/01/24 service plan, and temporary service plans were reviewed. On 06/04/24, Resident 5 weighed 144.3 pounds. On 07/04/24, the resident weighed 129.6 pounds, which was a 14.7 pound weight loss. This constituted a severe weight loss of 10.2 % in one month, requiring a facility RN assessment. Although progress notes indicated Staff 8 (RCC) notified the physician on 07/05/24 "regarding 5% weight change" and requested "health shakes to encourage intake," there was no documented evidence there was an RN assessment which included findings, resident status, and interventions made as a result of the assessment. No further information was provided. Resident 5's weight during the time of the survey was 139 pounds.  No additional significant change had occurred. The need to have an RN assessment for a significant change of condition was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings.

1. Resident #5 had a significant change in status assessment completed by the RN. 2. Facility RN completed "Role of the RN in CBC setting" July 30th-August 1st. RN to audit weight reports weekly. Med-techs will be in-serviced on reporting weight loss/gain of +/- 3 pounds from previous weight to RN immediately via 24-hour report. 3. Weight audits will be conducted weekly x4 weeks then monthly. Audits will be addressed immediately and taken to the quarterly QA meeting for review. 4. RN is responsible for ensuring compliance.

3. Resident 3 was admitted to the facility in 06/2021 with diagnoses including Alzheimer's Disease. The current service plan, dated 03/07/24, noted the resident was dependent on staff for toileting activities, including changing incontinent products and assistance with perineal care. During an ADL observation on 07/16/24 at 10:00 am, the following was noted: *Staff 9 and Staff 11 (both PCAs) provided incontinence care for Resident 3; *Staff 9 removed Resident 3's soiled incontinence product and placed it in the garbage can; *Staff 9 applied barrier cream to the resident's perineal area and put on a new incontinence product using the same soiled gloves; and *Staff 9 proceeded to open closet doors to retrieve clothing, assist with pants and a shirt, and brushed Resident 3's hair using the same soiled gloves. The observation was discussed with Staff 1 (ED), Staff 6 (RCC), Witness 1 (Consultant RN), and Witness 2 (Regional Director of Operations Consultant) on 07/16/24 at 2:47 pm.  No additional information was provided.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of 2 sampled residents (# 3) who received incontinence care from staff and multiple unsampled residents. Findings include, but are not limited to: Observations were made during the survey to determine adherence to universal precautions for infection control. 1. On 07/15/24, at 12:03 pm, the surveyor observed Staff 12 (PCA (Personal Care Attendant)) providing lunch meal service to residents on the fourth floor. At 12:38 pm, Staff 12 was observed handling a partially eaten plate of food bare-handed. The thumb of his right hand was visible on the surface of the plate near the partially eaten food. Staff 12 set the plate in a dish bin located on a cart in the dining area. After setting the plate in the dish bin, Staff 12 proceeded to handle a second plate of partially eaten food with his right hand, picking up a used napkin with his left hand, placing the dish in the dish bin and the napkin in the trash can. Staff 12 proceeded to touch the back of a chair occupied by a resident with both hands without performing proper hand hygiene. On 07/15/24 at 12:40 pm, the surveyor spoke with Staff 12 regarding the need to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment. He acknowledged the findings. 2. On 07/16/24 at 11:22 am, the surveyor entered the fourth floor kitchen through an unlocked door. Upon entry to the kitchen, an unsampled resident was observed to be alone in the kitchen, with one bare hand inside a plastic cereal dispenser. The resident took a handful of cereal from the dispenser and proceeded to eat the cereal. At 11:23 am, the incident was brought to the attention of Staff 24 (PCA) who entered the kitchen and attended to the resident. On 07/18/24, the need to ensure the facility consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC), and Witness 1 (Consultant RN). They acknowledged the findings.

1. Scheduled an in-service for all staff regarding infection prevention and control protocols led by RN, infection preventionist with focus on universal precautions when feeding and assisting residents in the dining room. Door to kitchenette on 4th floor to be locked by staff at all times. Maintenance to install automatic lock. Door to kitchenette on 4th floor to be locked by staff at all times. Maintenance to install automatic lock. 2. Education/training will be provided to all nursing staff in regards to infection control and proper procedures for when to change soiled gloves during peri-care/soiled briefs during ADL care. Continued education/training on infection control procedures will be completed to staff annually and as needed. Automatic lock to kitchenette door will prevent residents entering the kitchen unsupervised. 3. Maintenance to assess lock functionality quarterly. Infection control training for staff upon hire and annually. Infection preventionist or designee will audit infection control practices during dining services and ADL care monthly. 4. Executive Director.

Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 4 sampled residents (#s 4 and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 06/2024 with diagnoses including psychotic disturbance, mood disturbance, and anxiety. Physician's orders dated 06/24/24, the 07/01/24 through 07/15/24 MAR, 06/27/24 through 07/15/24 progress notes, and an After Visit Summary electronically signed by a physician revealed the following: * Resident 4 had a physician order s for quetiapine (for mood disturbance) 25 mg 1 tablet daily at bedtime. * The resident was hospitalized 07/09/24 through 07/11/24. On 07/12/24, a progress note indicated, "Reviewed discharge medication list ... Changed quetiapine admin time from PM to AM." The signed physician orders listed on the After Visit Summary, dated 07/11/24, included orders to continue quetiapine 25 mg 1 tablet at bedtime. Additionally, Resident 5 was to take quetiapine 25 mg 0.5 tablets once daily in the morning. The MAR revealed Resident 4 stopped receiving the bedtime dose of quetiapine effective 7/11/24 and on 7/12/24 began receiving the morning dose of quetiapine 25 mg 0.5 tablet daily. In an interview on 07/17/24 at 3:40 pm, Staff 8 (RCC) acknowledged the new orders were interpreted incorrectly and the bedtime dose of quetiapine should not have been discontinued. No further documentation was provided. She confirmed that Resident 4 would be receiving the bedtime dose until the physician provided further orders.   The need to ensure the facility administered all medications per physician orders was discussed with Staff 1 (ED), Staff 2 (RN), Staff 8 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings. The surveyor confirmed with Staff 1 that Resident 4 received the bedtime dose of quetiapine on 07/17/24. 2. Resident 5 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease. Resident 5's 07/01/24 through 07/15/24 MAR and physician orders were reviewed and revealed the following: a. Resident 5 had a physician order dated 06/19/24 for Calcitonin (osteoporosis) nasal spray, "1 spray by nasal route daily." The MAR revealed instructions to the staff were to "instill 1 spray in each nostril every day" and additional instructions "alternate nostrils daily." On 7/08/24 and 7/15/24 the MAR indicated staff administered to both the left and right nostril. On 07/17/24 at 1:45 pm, during an interview with Staff 2 (RN), she indicated Resident 5 should not be receiving the medication in both nostrils daily, and the MTs should be alternating the spray into the left and right nostril daily. She acknowledged the conflicting instructions on the MAR and stated she would update them. b. Resident 5 had a physician order for a multivitamin (supplement) daily. On both 07/08/24 and 07/15/24 the medication was recorded as unavailable. Between those same dates the medication was documented as administered on six occasions. During an interview on 07/17/24 with Staff 13 (MT), she confirmed the medication was available during those dates in a bottle located in the third drawer of the medication cart, separate from the medication in bubble packs. She revealed that sometimes the MT's would report a medication as not available when not found among the bubble packs, despite the medication being in another drawer. Staff 13 showed this surveyor the medication bottle, which was marked as opened on 05/28/24. The need to ensure the facility administered all medications per physician orders was discussed with Staff 1 (ED), Staff 2 (RN), Staff 8 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings.

1. Resident 4 - Quetiapine order was clarified and corrected in the MAR. Resident 5 - RN spoke with pharmacy and nose spray instructions updated in the MAR. Multivitamin located in med cart. 2. RCC, ED, and RN to ensure all orders are accurate with clear instructions for med techs via clinical chart review daily. Med techs to be in-serviced on proper storage of medications, where backups are stored, and re-ordering medications timely, as well as reporting to supervisor if any medications cannot be located so management can properly follow up and investigate. 3. Daily via clinical chart review. 4. RN, RCC, ED.

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 07/18/24, fire and life safety records dated between 01/2024 and 07/2024, were reviewed. Fire drill records lacked documentation of the following required elements: * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * The number of occupants evacuated. The facility provided no documented evidence staff were given fire and life safety training on alternate months. On 07/18/24 at 12:00 pm, the need to ensure fire drills were conducted according to the OFC and to provide fire and life safety instruction to staff on alternating months was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director). They acknowledged the findings.

1. Fire drills and staff trainings have been set on an alternating schedule each month for the remainder of the year. Fire drill documentation form has been updated to include all required elements. 2. ED to audit documentation monthly and correct as needed. 3. Monthly 4. ED, Maintenance Director

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code, fire and life safety instruction was provided to staff on alternate months, and that resident evacuation needs were met. The fourth floor had multiple residents who required assistive devices and assistance of staff for mobility, and no plan was in place on how to assist the residents in the event of a fire. This placed the residents at risk and constituted an immediate threat to the residents' health and safety. This is a repeat citation. Findings include, but are not limited to: a. Fire and life safety records dated 09/2024 through 10/2024 were reviewed. The documentation showed no drills were conducted which simulated fires on the fourth floor, and the escape route was not identified. During an interview on 11/13/24 at 9:35 am, Staff 4 (Maintenance Director), confirmed there was not a plan in place to assist the residents on the fourth floor. He stated he had a phone call with the Fire Authority on how to best assist residents who were the least mobile, and the plan was to move them "as far away from the fire behind a fire door and wait on the fire department for rescue." However, there was no documented evidence of approval for this plan by the Fire Marshal. Staff 4 also confirmed he was unaware of any equipment such as transfers blankets in the facility which would assist staff in evacuating residents from the fourth floor if they were unable to ambulate down the stairs. Staff 4 further confirmed he was not sure when the last full evacuation the facility had been completed. Service plans for Resident 7 and Resident 8, who lived on the fourth floor, were reviewed for assistance level needed to evacuate the facility. Resident 7 moved into the facility in 07/2024 and required use of a walker for ambulation. The resident's service plan, dated, 10/12/24, stated Resident 7 was "unable to exit building without total assistance" and "mobile with a walker/cane" in the mobility section. The emergency evacuation ability stated, "provide cues and direction for [Resident 8] during an emergency evacuation." Resident 8 moved into the facility in 05/2020 and required use of walker for ambulation and was on continuous oxygen. The resident's service plan, dated 10/11/24, stated Resident 8 was "unable to exit building without total assistance" and "unable to use stairs without assistance" in the mobility section. The emergency evacuation ability stated Resident 8 "requires assistance with evacuation, she will use her 2WW [two wheeled walker] but needs cueing and direction from staff." Multiple staff were interviewed on day and swing shifts. All staff indicated they did not know how they would get residents who could not ambulate independently down the stairs from the fourth floor to the main level. Staff identified ten residents who lived on the fourth floor that would not be able to ambulate down the stairs independently in case of a fire and who relied on a walker as an assistive device. During interviews on 11/13/24 at 10:40 am, Staff 1 (ED), Staff  2 (Nurse), Staff 6 (RCC), and Staff 27 (Nurse Consultant) stated they were unaware of a current plan for evacuating residents who were unable to ambulate independently from the fourth floor. In the event of a fire, they had instructed staff to evacuate the most mobile residents first, and any residents who could not be evacuated should be moved behind a fire door until the fire department arrived. On 11/13/24, the survey team reviewed with Staff 1, Staff 2, Staff 6, and Staff 27 that staff must provide fire evacuation assistance to residents from the building to a designated point of safety. When asked how many staff were available on each shift to help evacuate residents, Staff 1 and Staff 5 stated they tried to staff a total of three care staff (one MT and two personal care attendants) on night shift. During the acuity interview on 11/12/24 at 9:45 am, Staff 2 had confirmed there were up to five residents who required a mechanical lift or two staff members to assist them for transfers on the first floor. This constituted a significant risk to resident health and safety and required an immediate plan of correction to ensure residents on the fourth floor could be safely and effectively evacuated to the designated point of safety in case of a fire. The facility submitted a plan of correction to the survey team which included: * Evaluating residents for their ability to evacuate and thereby identifying residents who would require assistance; * Updated the residents' service plans to include the ability, time, and level of assistance required from staff to evacuate; * Immediately obtaining a mechanical stair climber and a fire safety blanket/transfer sling which could be used to evacuate non-ambulatory residents down the stairs and educating staff on all shifts on correct usage; and * Ensuring no less than four staff were available on all shifts, including the  night shift. An immediate plan of correction was requested on 11/13/24 at 11:20 am. The facility provided a plan of correction on 11/13/24 at 1:01 pm, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall system failures associated with the licensing violation. Refer to C 360. b. Fire and life safety records, dated 09/2024 through 10/2024, showed fire drill documentation was lacking in the following areas: * Escape route used; * Problems encountered; * Evidence of alternate routes used; * Evacuation time-period needed; * Staff members on duty and participating; and * The number of occupants evacuated. Additionally, the records reviewed did not show fire and life safety training was provided to staff on alternating months from the fire drills. The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from fire and life safety training was discussed with Staff 1, Staff 2, Staff 6, Staff 26 (Director of Operations), and Staff 27 on 11/13/24 at 1:10 pm. They acknowledged the findings.

1. Fire drills will be conducted every other month with evacuations of all occupied floors and documentation including * Escape route used; * Problems encountered; * Evidence of alternate routes used; * Evacuation time-period needed; * Staff members on duty and participating; and * The number of occupants evacuated. Staff training on fire and life safety will be held on alternating months. All staff including Maintenance Director will be trained on fire procedures and escape routes used. Resident 7 & 8 evacuated via the stairs with assistance from staff in mock evacuation, as well as all other residents willing to participte. Time and level of assistance needed to evacuate has been documented. Facility has fire chair and sling. 2. Maintenance Director has been given a fire and life safety schedule of fire drills and training dates. 3. Monthly 4. Executive Director/Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure all poisons, chemicals, and other toxic materials were secured in locked storage, and failed to ensure facility grounds were free of litter and refuse and garbage was stored in covered refuse containers. Findings include, but are not limited to: The facility was toured on 07/16/24 at 9:30 am and the following was observed: a. First floor: * Disinfectant cleaner, personal care products, boxes of lancets (containing a blade/needle to puncture skin), and a specimen cup with dark-colored contents located in an unlocked storage room; * Peroxide Multi Surface Cleaner and Disinfectant stored in an unlocked cabinet under the sink in the resident dining room; and * Personal care products stored in an unlocked cabinet above the microwave in the resident dining room. b. Fourth floor kitchenette: * Cleaning chemicals stored in an unlocked cabinet under the sink. On 07/16/24 at 11:50 am, the facility was directed to ensure the identified unsecured toxic materials were stored in a secured location. On 7/17/24 at 8:15 am, the first-floor storage room was again observed to be unlocked with the items listed above unsecured. c. Building Exterior: * Two dumpsters containing large garbage bags were observed to be uncovered; and * Litter and refuse was on the ground near the dumpsters. The need to ensure all poisons, chemicals, and other toxic materials were stored in locked storage, and to ensure the grounds were free of litter and refuse and refuse containers were covered, was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 07/17/24. They acknowledged the findings.

1. First floor - all cleaners/chemicals, personal care items removed from dining room and locked in secure location. Install automatic lock for storage room on first floor. Fourth floor kitchenette - Automatic lock to be installed on kitchenette door. All cleaning chemicals relocated to linen closet on fourth floor with automatic lock is already installed. Litter and refuse to be cleared from outdoor dumpster area. Dumpters to be covered at all times when not in use to promote proper pest control. 2. Maintenance Director to audit lock function quarterly. Staff to be in-serviced on the need to ensure all poisons, chemicals, and other toxic materials are locked and stored in appropriate locations and out of reach from residents. Maintenance Director to walk the exterior building daily. 3. Quarterly and as needed. 4. ED, Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure all poisons, chemicals, and other toxic materials were secured in locked storage, and failed to ensure facility grounds were free of litter and refuse and garbage was stored in covered refuse containers. This is a repeat citation. Findings include, but are not limited to: The facility was toured on 11/12/24 at 11:10 am and the following was observed: * Personal care products that contained potentially toxic material stored out on shelves and countertops were not in locked cabinets in resident bathrooms on the first and fourth floors. The need to ensure all poisons, chemicals, and other toxic materials were stored in locked storage, and to ensure all exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways were made of hard, smooth material, were accessible, and maintained in good repair, was discussed with Staff 1 (ED), Staff 4 (Maintenance Director), and Staff 26 (Director of Operations) on 11/14/24. They acknowledged the findings.

1. All chemicals or other toxic materials secured in locked storage rooms on first and fourth floor. Facility will plan to purchase shower caddys for each resident's personal items such as shampoo to be stored in activities office outside of the resident unit. 2. Prevenative maintenance schedule. 3. Daily with environmental walk throughs. 4. Executive Director/Maintenance Director.

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 facility's interior was toured on 07/16/24 at 9:35 am and the following was observed to need cleaning and/or repair: a. First-floor interior: * Walls had gouges and exposed drywall/missing paint; * Ceiling vents had a build-up of dust; * Light fixtures had light bulbs out; * Ceiling light covers were missing in the storage room; * Furniture chair legs in the corridor outside the dining room were gouged and had exposed wood; * Ceiling tiles in the storage room, dining room, and near the exit had staining; and * Exit door had damage to the door and door frame. b. Fourth-floor interior: * Walls had gouges and exposed drywall/missing paint; * Ceiling vents had a build-up of dust; * Light fixtures had light bulbs out; * Flooring in the resident corridor had peeling/missing pieces; * Room number outside of room 409 was missing; * Table in the resident corridor had a worn finish/exposed wood; and * Baseboard at the end of the corridor was pulled away from the wall. The facility was toured with Staff 1 (Executive Director) and Staff 4 (Maintenance Director) on 07/17/24 at 10:05 am. They acknowledged the areas needing cleaning and/or repair.

1. First floor - Maintenance Director will repair/address/clean wall gouges, exposed paint/drywall, ceiling vents, light fixtures, ceiling tiles, damaged doors, and remove damaged furniture. Fourth floor - Maitenance Director will repair corridor, baseboards, replace tables with exposed wood, and refer to #1. 2. Create a preventative maintenance schedule. 3. Daily environmental walk throughs. 4. Maintenance Director, ED.

Based on observations and interviews, it was determined the facility failed to keep all interior materials and surfaces and equipment clean and in good repair, including all equipment related to heating elements necessary for the health, safety, and comfort of the resident. This is a repeat citation. Findings include, but are not limited to: The facility's interior was toured on 11/12/24 at 11:10 am and the following was observed to need cleaning and/or repair: a. First-floor interior: * Walls had gouges and exposed drywall/missing paint; * Ceiling vents had a build-up of dust; * Light fixtures had light bulbs out; * Furniture chair legs in the corridor outside the dining room were gouged and had exposed wood; * Ceiling tiles in the storage room, dining room, and near the exit had staining; * Exit door had damage to the door and door frame; * Room 102 had multiple cracks in the ceiling; and * Room 109 was missing flooring near the wardrobe. b. Fourth-floor interior: * Walls had gouges and exposed drywall/missing paint; * Ceiling vents had a build-up of dust; * Light fixtures had light bulbs out; * Flooring in the resident corridor had peeling/missing pieces; * Room number outside of room 409 was missing; * Table in the resident corridor had a worn finish/exposed wood; * Baseboard at the end of the corridor was pulled away from the wall; * Room 413 had a hole in the bathroom ceiling; and * Room 416 had pieces of flooring missing. c. Several baseboard heaters in resident rooms were damaged, separating from the wall, and exposed inner wires and/or pipes on both floors. On 11/15/24 between 9:52 am and 10:17 am, the baseboard heaters in rooms 105 and 409 were observed to be in disrepair with exposed pipes and/or wires. Observations identified base board heaters in multiple resident units were damaged. The heaters were located where residents could come into incidental contact, and combustible materials were placed against the heating elements that posed a risk to the residents. The facility was toured with Staff 1 (Executive Director), Staff 4 (Maintenance Director), and Staff 26 (Director of Operations) on 11/14/24 at 12:10 pm. They acknowledged the areas needing cleaning and/or repair. Refer to C 540.

1. Maintenance Director will be given a list of building interior areas to be address/cleaned/repaired with timeline of completion such as wall gouges and esposed dry wall on first floor, replacing light bulbs, repairing ceiling in room 102 that has cracks and flooring in room 109 Fourth floor light fixtures will be replaced with working bulbs, repair bathroom ceiling in room 413, and the flooring in room 416. We have contacted several outside providers to obtain quotes to work on the boiler and temperature regulation. Staff have been temping baseboard heaters every hour and adjusting accordingly. Baseboard heaters in room 105 and 409 repaired. 2. Will identify areas needing attention through interior environmental walk throughs as well as initiated work order requests from community team members. 3. Daily. 4. Executive Director/Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant was used when washing soiled linens and soiled clothing. Findings include, but are not limited to: The facility laundry room was observed on 07/16/24. Two commercial washing machines in the laundry room had no indicator of the water temperature. The laundry detergent observed next to the washing machines did not contain a chemical disinfectant. In an interview on 07/17/24 at 8:45 am, Staff 23 (Housekeeper) confirmed the washing machines and laundry detergent were used to wash resident linens and clothing soiled with urine. In an interview on 07/17/24 at 9:00 am, Staff 4 (Maintenance Director) stated the water temperatures of the washing machines were measured at 110 degrees F. Staff 4 acknowledged the water rinse temperature should be at a minimum of 140 degrees F. The need to ensure washing machines had a minimum rinse temperature of 140 degrees or a chemical disinfectant was used when washing soiled linens and soiled clothing was discussed with Staff 4 and Staff 1 (ED) on 07/17/24 and 07/18/24. They acknowledged the findings.

1. Chemical disinfectant purchased for washers that do not reach a minimum temperature of 140 degrees when washing soiled linens. 2. Housekeeping/Laundry staff in-serviced on the requirements and proper use of the chemical disinfectant. Maintenance Director to order chemical disinfectant as needed and ensure supply is always on hand. 3. Quartly. 4. Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to information being accessible in common areas of the facility.  Findings include, but are not limited to: During the survey on 07/15/24 and 07/16/24, resident service plans were observed in a binder on a table in the dining room accessible to anyone in the area on the first and fourth floors.  In addition, resident meal percentage intake was being documented on a white board in the first floor dining room for public viewing.  The accessibility to service plans and meal intake jeopardized residents' rights to privacy and dignity. The observation was reviewed with Staff 1 (ED), Staff 6 (RCC) , Witness 1 (Consultant RN), and Witness 2 (Regional Director of Operations, Consultant) on 07/16/24 at 2:47 pm.  No additional information was provided.

1. Service plan binders were removed from common areas. Fourth floor service plans to be kept in a cabinet in the kitchenette, which will be installed with auto-locking door. Facility will purchase locking file cabinet with key access for service plans on the first floor. Meal monitoring white boards have been removed from both floors. 2. Staff will be in-serviced on the importance of residents' rights to privacy and dignity, as well as instructed on where service plans are located. Facility will create a tool for caregivers to track residents' intake, to be given to the med techs for documentation after each shift. This will be kept in a binder in the same location as the service plans on both floors. 3.Quarterly 4. RCC.

Based on observation, interview, and record review, it was determined the facility failed to provide each individual privacy in his or her own unit for 3 of 3 sampled residents (#s 1, 3, and 5). Findings include, but are not limited to: During the survey on 07/15/24 and 07/16/24, Residents 1, 3, and 5 were observed in their units with doors open, creating a lack of privacy. Interviews with care staff indicated the residents' doors were left open to conduct frequent safety checks. Review of Residents 1, 3, and 5's service plans did not indicate the residents' preference for their doors to be left open. Resident unit doors being open all the time jeopardized residents' rights to privacy and dignity. The observation was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC) , Witness 1 (Consultant RN), and Witness 2 (Regional Director of Operations, Consultant) on 07/18/24.  No additional information was provided.

1. Resident #1, #3, #5 were interviewed regarding their preference of keeping apartment door open/closed. RCC or designee to follow up with all other residents regarding preferences regarding their doors being open/closed. 2. Information gathered from #1 will be indicated in each individual resident's service plan for staff to review and implement based on preferences. 3. Quaterly service plan reviews. 4. RCC.

Based on observation and interview, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple unsampled residents who resided on the fourth floor. Findings include, but are not limited to: During an interview on 07/17/24 at 12:15 pm with Staff 15 Personal Care Attendant (PCA), she indicated there were a small number of residents who had keys to their rooms but she believed the keys could be used on any of the resident unit doors. An observation on 07/17/24 at 2:15 PM revealed the key to Resident 4's unit could unlock the door to an unoccupied unit on the fourth floor, where Resident 4 resided. In an 07/18/24 interview at 10:21 am, Staff 21 (PCA) indicated at least one resident had a master key that could be used on any of the resident unit doors. The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1 (ED), Staff 6 (RCC), and Witness 2 (Regional Director of Operations Consultant) on 07/18/24. No additional information was provided.

1. All of the locks to the units to be replaced with the individual and only appropriate staff having a key to access the unit. 2. Refer to #1. 3. Quarterly and upon new admissions. 4. Executive Director, Maintenance Director.

Based on observation, record review, and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. This is a repeat citation. Findings include, but are not limited to: Review of records for Residents 6, 7, and 8 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms. During the survey on 11/12/24 through 11/15/24, observations and interviews with residents and staff confirmed residents did not have keys to their units. The need to ensure all residents were provided keys to their units was discussed with Staff 1 (Executive Director) on 11/15/24. She acknowledged the findings.

1. It will be documented that every resident was offered a key to their apartment. If they decline, the POA/guardian will be offered a key. If POA/guardian declines, individual keys will be hung in resident's apartment. 2. Assessments have been updated to include this information in service plans and upon new admissions. 3. Quarterly through service plan reviews and/or as needed. 4. Executive Director/Resident Care Coordinator.

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 C420, C510, C513, and C530.

1. Refer to C420, C510, C513, and C530. 2. Audit plan of correction for above tags to ensure tasks are followed through/corrected. 3. Weekly. 4. Executive Director.

Based on observation, 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 C 231, C 360, C 420, C 510, C 513, and C 540.

See POC for C231, C360, C420, C510, C513 & C540.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 16, 17, 18, and 19) completed the required dementia training and demonstrated competencies in all required areas within 30 days of hire. Findings include but are not limited to: Training records were reviewed with Staff 3 (Business Office Manager) on 07/17/24. a. There was no documented evidence Staff 16 Personal Care Attendant (PCA), hired 02/26/24, Staff 17 (MT), hired 03/18/24, Staff 18 (PCA), hired 04/02/24, and Staff 19 (PCA), hired 06/13/24, completed the required additional dementia care pre-service training topics, including: * Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.); * 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's service plan; and * Use of supportive devices with restraining qualities in memory care communities. b. There was no documented evidence Staff 16 and Staff 17 demonstrated competency in their job duties within 30 days of hire in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. c. There was no documented evidence Staff 17 (MT) demonstrated competency in their job duties of medication pass and treatments. On 07/17/24 survey requested medication and treatment administration demonstration for Staff 17 be completed prior to survey exit. On 07/17/24 at 2:10 pm, Staff 17 verified he demonstrated competency with medication pass and treatments within 30 days of his hire date and prior to administering medication and treatments. d. There was no documented evidence Staff 18 demonstrated competency in their job duties within 30 days of hire in the following areas: * Role of service plans in providing individualized care; and * General food safety, serving and sanitation. e. There was no documented evidence Staff 19 demonstrated competency in their job duties within 30 days of hire in the following areas: * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. The need to ensure newly hired staff completed the required pre-service dementia care training and demonstrated competency in all required areas within 30 days of hire was discussed with Staff 1 (Executive Director) and Staff 3 (Business Office Manager) on 07/18/24. They acknowledged the findings.

1. Staff 16, 17, 18, and 19 to complete the required additional dementia care pre-service training topics as well as demonstrated competency. 2. Ensure all newly hired staff complete the required pre-service dementia care training and demonstrated compentency in all required areas within 30 days of hire. Created a training checklist of required trainings to be used as a tracking tool. 3. Quarterly employee file audits and upon all newly hired employees. 4. Business Office Manager and ED.

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 C270, C280, C295, and C303.

1. Refer to C270, C280, C295, and C303. 2. Audit plan of correction for above tags to ensure tasks are followed through/corrected. 3. Weekly. 4. Executive Director.

Based on interview and record review, it was determined the facility failed to ensure all incidents of abuse or suspected abuse were immediately reported to the local Seniors & People with Disabilities (SPD) office and were promptly investigated for 1 of 1 sampled resident (#10) whose record was reviewed. Findings include, but are not limited to: Resident 10 was admitted to the facility in 04/2019 with diagnoses including unspecified dementia. A review of the resident's facility record, including progress notes dated 10/13/24 through 11/13/24, and temporary service plans was completed, and staff were interviewed. The following was identified: * On 10/28/24, Staff  30 (CG) documented the resident ". . .was found in [his/her] bed with another resident." There was no documented evidence this incident was promptly investigated at the time it occurred to rule out abuse, nor that it was reported to the local SPD office if abuse could not be ruled out. On 11/14/24 at 1:40 pm, Staff 1 (ED) confirmed an investigation was not promptly completed. Survey requested the facility report the incident to the local SPD office. On 11/14/24 at 2:32 pm, verification was received of reporting the incident to the local SPD office. The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office and were promptly investigated was discussed with  Staff 1, Staff  2 (Nurse), Staff 6 (RCC), Staff 26 (Director of Operations), and Staff 27 (Nurse Consultant) on 11/14/24. They acknowledged the findings.

1. All community staff are required to complete mandatory education/training on reporting and investigating abuse/suspected abuse through Oregon Care Partners by December 18, 2024. 2. All new team members that are hired moving forward will complete the mandatory education/training for reporting and investigating abuse/suspected abuse through Oregon Care Partners before they are allowed to work in the community.  The clinical team will audit incidents through 24 hour clinical chart review. 3. Daily 4. Executive Director/RN

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to: At the time of the survey, the MCC had 31 residents. The facility was a four-story building, with residents occupying the first and fourth floors. Each floor was a separate, secured unit. Multiple interviews with staff conducted on 11/12/24 revealed the following: * Staff identified five residents on the first floor who required two-person assistance for transfers and/or ADL care, including the use of a mechanical lift; and * Staff identified eight residents who required 1:1 feeding assistance. The facility's posted staffing plan designated one CG on the first and fourth floors and one MT between the first and fourth floors for the NOC shift. Considering resident acuity, facility structural design, and the number of residents requiring two-person transfers, as listed above, this was not an adequate number of floor staff in case of an actual emergency evacuation. In addition, the NOC shift failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. On 11/12/24 at 3:14 pm, the above findings were discussed with Staff 1 (Executive Director) and Staff 6 (Residential Care Coordinator). The survey team requested the facility schedule an additional direct care staff for NOC shift to ensure the facility meets the evacuation level and the minimum of two direct care staff scheduled and available for residents requiring the assistance of two caregivers. On 11/13/24, the facility provided the survey team with a schedule dated 11/13/24 through 11/30/24 that showed two CGs were scheduled on first floor and one CG on the fourth floor and one MT between the floors for NOC shift. On 11/15/24, the need to ensure the facility provided a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2 (Nurse), Staff 6, and Staff 27 (Nurse Consultant).

1. An additional caregiver has been added on the schedule for NOC shift indefinitely. 2. ED, RN, RCC, will audit ABST and adjust staffing accordingly always ensuring that NOC shift has the additional person necessary to assist with any fire/life safety emergencies/evacuations. 3. Monthly and PRN with significant changes, new admissions, etc. 4. Executive Direcctor, RN, Resident Care Coordinator.

Based on observation, interview, and record review, it was determined the facility failed to ensure their change of ownership survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 420, C 510, C 513, and H 1518.

1. A new POC has been written and to be implemented and followed. 2. POC will be addressed in a timely manner. 3. Daily. 4. Executive Director

Based on observations and interviews, it was determined the facility failed to keep all equipment in good repair, and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations subject to incidental contact by residents or with combustible material. The facility was using baseboard heaters in resident rooms. Several baseboard heaters were in disrepair and exceeded 120 degrees F, which constituted an immediate threat to residents' health and safety. Findings include, but are not limited to: During an interview with Staff 4 (Maintenance Director) on 11/15/24 at 9:45 am, Staff 4 reported that to keep the temperature in the building between 67-71 degrees F, the boiler pipes had to be heated between 165-200 degrees F. On 11/15/24 between 9:52 am and 10:17 am, the baseboard heaters in rooms 105 and 409 were observed to be in disrepair with exposed pipes and/or wires. Temperatures measured with the surveyor's digital thermometer showed that both baseboard heaters exceeded 120 degrees F. At 1:19 pm, resident room baseboard heaters were measured with Staff 4 (Maintenance Director) using the facility's infrared thermometer. Baseboard heaters in the following resident rooms: 102 B, 103, 111, 123, and 413 exceeded 120 degrees F. Baseboard heaters in the following resident rooms: 402 A/B, 410, 411, 412, 414 and 415 failed to maintain 110 degrees F. Observations identified base board heaters in resident units were damaged. The heaters were located where residents could come into incidental contact, and combustible materials were placed against the heating elements that posed a risk to the residents. An immediate plan of correction was requested on 11/15/24 at 11:48 am. The facility provided a plan of correction on 11/15/24 at 3:47 pm, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation. On 11/15/24, the findings were reviewed with Staff 1, Staff 2 (Nurse), Staff 6 (Resident Care Coordinator), and Staff 27 (Nurse Consultant). They acknowledged the findings.

1. Will consult with heating specialist to aquire quotes for repairs to boiler/heaters and reccommendations on heat regulation. 2. Repairs will be made to existing system. 3. Monthly temperature audits to be done following repair to ensure working order. 4. Executive Director/Maintenance Director.

The findings of the change of ownership survey, conducted 07/15/24 through 07/18/24, are documented in this report. The survey was conducted to determine compliance with 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. Tag numbers beginning with the letter H refer to the Home and Community Based Services 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 change of ownership survey of 07/18/24, conducted 11/12/24 through 11/15/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for 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. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day Situations were identified where there was a failure of the facility to comply with Department's rules that represented an immediate threat to residents' health and safety and required an immediate plan of correction in the following areas: OAR 411-054-0090 - Fire and Life Safety; and OAR 411-054-0020 (8) - Heating and Ventilation Systems. The facility put immediate plans of correction in place during the survey.

Based on interview and record review, conducted during a site visit on 06/17/24, it was confirmed the facility failed to immediately notify the department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation for 1 of 3 sampled residents (# 6). Findings include, but are not limited to: a. A review of Resident 4's progress notes and Unusual Incident/Injury Reports did not indicate an occurrence of a reportable event on or around 08/25/23. b. A review of Resident 5's progress notes and Unusual Incident/Injury Reports did not indicate an occurrence of a reportable event on or around 08/26/23. c. A review of Resident 6's progress notes and Unusual Incident/Injury Reports indicated the following: · On 10/04/23 Resident 6 had an unwitnessed fall, and there were no indications on how abuse or neglect were ruled out. The report indicated resident slid out of bed. There was no indication that the department was notified of the 10/04/23 incident. · On 10/07/23 an injury of unknown cause was then observed on Resident 6. S/he had a 10-inch scratch on his/her back. · On 10/13/23 there was an Unusual Incident/Injury Report completed for Resident 6 regarding a 'found on floor' incident with observed abrasions on both knees. There was no indication that the department was notified of the 10/13/23 incident. In an interview on 06/17/24, Staff 1 (Executive Director) and Staff 2 (RN) did not know why incidents were not reported due to occurring under previous ownership. The facility had a change of ownership on 01/01/24. The facility failed to immediately notify the department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24.

Based on interview and record review, conducted during a site visit on 06/17/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (# 4). Findings include, but are not limited to: A review of Resident 4's service plan dated 08/24/23 indicated Resident 4 returned to facility on 08/19/23 with an update to service plan of a 1:1 sitter due to impulsivity and high fall risk. A review of Resident 4's progress notes dated 08/01/23 - 09/30/23 indicated the following: · On 09/03/23 at 3:43 am resident was placed on alert charting. Resident 4's 1:1 care staff went to lunch. The other care staff on the floor was looking after the resident. Resident was found by the 2nd floor med tech laying on his/her right side with his/her eyes closed. Blood was on the floor and coming from his/her head. In an interview with Staff 1 (Executive Director) and Staff 2 (RN) no additional information was provided regarding Resident 4 ' s care plan not being following under previous ownership. The facility had a change of ownership on 01/01/24. The facility failed to ensure the implementation of services. The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24.

Based on observation and interview, conducted during a site visit on 06/17/24, it was confirmed the facility failed to coordinate with off-site health services for residents. Findings include, but are not limited to: A call was placed to the facility mainline phone number on 06/21/24 at 8:17 pm. The phone rang, went unanswered for two minutes. At 8:19 pm a Verizon Wireless "Call cannot be completed as dialed please check the number and try again" message played before the phone call was disconnected. On 06/25/24 at 12:11 pm the facility mainline was called. Staff 5 (Reception) answered and stated s/he answers the phone during business hours and at approximately 4:00 pm s/he switched the phones to night mode and the med techs on shift could still answer the phones, but the phone should go to a voice messaging system. The compliance specialist requested Staff 5 turn the phone system to night mode to ensure voice messaging system was enabled. A call was then placed to the facility mainline on 06/25/24 at 12:16 pm after Staff 5 switched the phone system to night mode. The phone rang and went unanswered for two minutes and then the same Verizon Wireless message from 06/21/24 played and the call was disconnected. A call was place to the facility mainline on 06/25/24 at 12:20 pm and spoke to Staff 3 (Business Office Manager). Staff 3 stated s/he had also tried to call facility while phone system was switched to night mode and experienced the same message and call disconnection. The facility failed to coordinate with off-site health services for residents. The findings of the investigation were reviewed with and acknowledged by Staff 3 (Business Office Manager) via phone call on 06/25/24. Verbal Plan of Correction: Business Office Manager was to follow up with Century Link on 06/25/24 to troubleshoot the voicemail system and would have the system operational as soon as possible.

Based on interview and record review, conducted during a site visit on 06/17/24, it was confirmed the facility failed to ensure a safe medication administration system for 1 of 1 sampled resident (# 7). Findings include, but are not limited to: A review of Resident 7's 06/01/23 - 08/31/23 MAR's indicated the following: · 06/01/23 Omeprazole 20mg not available, ordered from pharmacy; · 06/01/23 Polyethylene glycol powder not available, ordered from pharmacy; · 06/01/23 Enoxaparin Sod withheld due to no nurse available to inject medication; and · 07/02/23 - 07/05/23 Lacosamide 150mg seven doses were not administered due to med not received from pharmacy. A review of Resident 7's progress notes from 06/01/23 - 08/31/23 indicated on 07/03/23 Resident 7's PCP was notified the resident was out of Lacosamide and that the pharmacy was faxing an incorrect doctor. In an interview on 06/17/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Business office manager) and Staff 4 (RCC) did not have additional information to provide regarding Resident 7's missed medications. The facility had a change of ownership on 01/01/24. The facility failed to failed to ensure a safe medication administration system. The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24.

Based on observation and interview, conducted during a site visit on 06/17/24, it was confirmed the facility failed to provide a secure outdoor recreation area. Findings include, but are not limited to: At 11:47 am a large gait from the courtyard exiting to the parking lot was observed to be propped open with a cinderblock and no staff or residents were in sight. In an interview on 06/17/24, Staff 10 (Maintenance Director) stated the gait should be closed and locked at all times. At 11:58 am Staff 1 (Executive Director) was notified of the gate being propped open and a head count of all residents was requested. At 12:07 pm Staff 1 confirmed all residents were accounted for. At 1:45 pm the previously propped open gate was observed to be unsecured. During a walkthrough of the remainder of the courtyard a gate to the facility's HVAC system was unlocked and opened. There was a pair of steel double doors in the unsecured HVAC area that were unlocked and opened to the street north of the facility. Staff 1 was immediately alerted to the unsecured courtyard. The facility failed to provide a secure outdoor recreation area. The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24. A written plan of correction was requested and provided by Staff 1.

Based on interview and observation it was confirmed that 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 the following: In separate interviews with Staff #6 and Staff #13 (S6 & S13) and Witness #4 (W4) the following was stated: · There is an endless smell of marijuana in the facility. A resident has complained to staff about how unbearable the smell is, staff have reported to the administrator that marijuana could be smelled on certain staff members and nothing has been done. · Staff smoke weed on their breaks or while they ' re at work. · There are several staff members that smoke marijuana in the building or are high at work. During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) observed Staff #14 (S14) standing in the small copy room by the employee timeclock waiting to clock in from their break. CS observed a pungent skunk like odor emanating from the room upon entering. CS observed odor appeared to be attached to S14 as the odor dissipated after S14 left the copy room. Facility Plan of Correction: The facility will implement random drug testing in alignment with their policy.

Based on interview and record review it was confirmed that the facility failed to develop and implement a policy on smoking. Findings include the following: In separate interviews with Staff #6 and Staff #13 (S6 & S13) and Witness #4 (W4) the following was stated: · There is an endless smell of marijuana in the facility. A resident has complained to staff about how unbearable the smell is, staff have reported to the administrator that marijuana could be smelled on certain staff members and nothing has been done. · Staff smoke weed on their breaks or while they ' re at work. · There are several staff members that smoke marijuana in the building or are high at work. · Multiple staff smoke vape pens on resident floors and blow the smoke down their shirts. A review of facility Separation Form for Staff #11 (S11) indicates that S11 violated facility 5-10 Smoking in the Workplace policy and posted on the social media site Snap Chat images of themselves smoking in the medication room in front of the med cart. Facility Plan of Correction: Facility terminated staff member for violations of facility policies.

Based on record review and interview it was confirmed that the facility failed to develop and implement a written policy that prohibits the falsification of record. Finding include the following: In separate interviews with Witness #4 and Witness #6 (W4 & W6) the following was stated: · The facility has incomplete and falsified training documents. · Several staff received a training document to sign that management had already signed. The document was already signed by an employee and the signature was whited out. Compliance Specialist (CS) requested a copy of the facilities policy that prohibits the falsification of records. No policy was provided. CS reviewed Training documents for Staff #5 - #11 (S5 - S11) which revealed three of seven staff filed reviewed contained a training signature page with what appears to be whited out information and dates removed. CS also reviewed facility incident reports which revealed an Internal Incident Report dated 01/11/2023 for Resident #10 (R10) that was created by staff at the time of the incident, and there are no management signatures or follow-up on the form. CS also reviewed an Unusual Incident/ Injury Report that was created for the same incident and has a time stamp of 03/02/2023 and this document contains management signatures that were back dated for the date of the incident, 01/11/2023.

Based on interview and record review it was confirmed that the facility failed to provide services in a manner that protects privacy and dignity. Findings include the following: During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that Staff #11 (S11) was terminated after they posted a video of themselves smoking in the medication room on Snap Chat and there were resident charts with resident information in the background. CS reviewed facility Separation Form for S11 which indicates that S11 violated facility policy 5-13 Violation on using a Camera Phone on Company property while performing work for Pacifica. Facility Plan of Correction: The facility terminated staff member for violation of company policies.

Based on interview and record review it was confirmed that the facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse. Findings include the following: In an interview with Witness #5 (W5) it was stated that the facility had not sent any facility self-reports to the local Department since August 2022. During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) reviewed facility incident binder and found multiple instances of reportable events that do not indicate that the facility reported to APS for Resident #1, #5 and an unsampled resident (R1, R5). The above findings were shared with Staff #2 and Staff #4 (S2 & S4) who were in agreement. Facility Plan of Correction: Staff will review APS reporting and go through their incident binder to report any instances that should have been reported but were not.

Based on interview, observation, and record review it was confirmed that the facility failed to assist with toileting and bladder management. Findings include the following: In separate interview with Staff #13 and Witness #2 (S13 & W2) the following was stated: · Staff leave residents unchanged all night and it causes skin breakdown because they are left in wet briefs for long periods of time. · Residents sit in soiled incontinence supplies for long periods of times causing urinary tract infections and kidney infections when left untreated. During an unannounced site visit on 04/20/2023 Compliance Specialist (CS) observed Resident #7 (R7) appeared to be completely soiled through all layers of their clothing. During unannounced site visit on 04/20/2023 and 04/25/2023 CS observed a prevalent urine odor near the 2nd floor elevator. A review of R7 care plan that was available for care staff was dated 06/13/2022 and it was updated by hand that resident is currently a total assist for toileting and on safety checks. Staff indicated that resident was a 2-hour safety check.

Based on record review and interview it was confirmed that the facility failed to ensure that resident service plans are made readily available to staff as well as failed to ensure changes and entries made to the service plan are dated and initialed. Findings include the following: During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) reviewed service plan binders that were available to care staff on the first and second floors and found multiple service plan with changes made and not staff initials or dates for changes, including for Resident #7 (R7). Service plans were out of date and the service plan for Resident #5 (R5) was not available or located in the service plan binder. In separate interviews with Staff #6 and Staff #13 the following was stated: · Resident care needs have changed quite a bit. · R7 is on 2-hour safety checks even if care plan doesn't show it.

Based on interview and record review it was confirmed that the facility failed to have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. Findings include the following: According to Witness #2 (W2) it was stated that Resident #2 (R2) had experienced a UTI and staff were not aware of the residents change of condition. It was also stated that R2 experienced a significant weight gain over six months. Compliance Specialist (CS) reviewed service plan and progress notes from January 2023 to current for Resident #1 (R1) and R2. CS identified in the progress notes for R1 a short-term change of condition with a physician request for monitoring and intervention that was not alert charted and no follow-up was charted regarding the physician request for intervention. CS also discovered in R2 ' s Medication Administration Records for January 2023 to current a severe weight gain of 9.8% over three months. Residents weight gain was not alert charted or monitored.

See findings in C-tags C0301, C0303 and C0330

Based on interview and observation it was confirmed that the facility failed to ensure medications are kept secure between set-up and administration. Findings include the following: During an unannounced site visit on 04/20/2023 Compliance Specialist (CS) observed the medication cart in the dining room on the first floor was unattended, upon further review the medication cart was unlocked in an unsecured area with residents nearby and no staff members present. The above was shared with Staff #2 and Staff #4 (S2 & S4) who acknowledged findings and stated they would work on retraining with the staff working on the med cart that evening.

Based on interview and record review it was confirmed that the facility failed to administer medications as ordered by a physician. Findings include the following: According to Witness #4 (W4) the facility does not have an effective method for receiving new medication orders and that sometimes if new orders are received over the weekend the staff can ' t administer the medication until staff with the proper authorizations come in to review and input the information causing long delays for residents to receive their medications. During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) reviewed Medication Administration Records (MARs) for Resident #1- #3 and Resident #5 (R1- R3 & R5) for January 2023 to current which revealed multiple instances of medications not available, conflicting orders entered and several days passing before error is corrected. CS also found eight instances of the incorrect dosage of a PRN medication being given to R1.

Based on interview, record review, and observation it was confirmed that the facility failed to provide sufficient staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include the following: According to Witness #4 (W4) staff consistently no call-no show, come into work late, or leave the floor that they are scheduled to work on leaving the floor unattended or understaffed and no one comes into support. In an interview with Staff #3 (S3) it was stated that the facility was short staffed this evening. During an unannounced site visit on 04/20/2023 Compliance Specialist (CS) reviewed the facility posted staffing plan which was as follows: Day shift - 6 caregivers; 2 medication technicians Evening shift - 6 caregivers; 2 medication technicians Night shift - 4 Caregivers; 1 medication technician CS reviewed posted staff schedule for April 2023 which revealed 38 of the 90 scheduled shifts did not meet the posted staffing plan. CS reviewed the Daily Assignment sheets for 04/19-04/26/2023 which revealed staff are to take staggered lunches and that on the date of the site visit one staff member had called off for swing shift. CS observed two med techs, and three staff identified as caregivers, two of which were on their breaks, upon entering the facility. CS encountered two other staff members working one was identified as the RCC and the other was the facility administrator.

Based on interview and record review it was confirmed that the facility has not fully implemented and updated an Acuity-Based Staffing Tool (ABST). Findings include the following: During an unannounced site visit on 04/20/2023 Staff #1 (S1) provided Compliance Specialist (CS) with a document titled Care Levels and stated that this was their ABST. Document did not address all of the required ABST elements for each resident, nor did it provide an explanation of how the facility determines their staffing plan. CS asked S1 how they get their staffing plan and S1 stated that they use the staffing plan that the State has required them to use. In an interview with Staff #2 (S2) during an unannounced site visit on 04/25/2023 it was stated that they were unsure of what ABST the facility used, but they would do further research and would email what they could find. CS reviewed the ABST that S2 provided via email on 04/26/2023. Last edit date was 12/06/2022, 51 residents were entered into the tool, the current resident census is 46. Newly admitted residents and residents that have experienced a change of condition or an updated service plan were not reflected in the provided ABST.

Based on interview and record review it was confirmed that the facility failed to train direct care staff within the first 30 days. Findings include the following: During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that the facility had a staff member that was hired to train new staff and after approximately a week they quit and disposed of the training documents that they had, but they are working on getting all training documents for staff. Compliance Specialist (CS) reviewed training documents for Staff #5 - #11 (S5 - S11) which revealed one of seven staff members did not have any training documents. Training documents for S9 appear to have the training dates whited out and are illegible and four of the remaining five staff members training documents were completed more than 30 days after staffs hire date.

Based on interview and record review it was confirmed that the facility failed to have a pre-service orientation and training program for all direct care staff. Findings include the following: During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that the facility had a staff member that was hired to train new staff and after approximately a week they quit and disposed of the training documents that they had, but they are working on getting all training documents for staff. Compliance Specialist (CS) reviewed training documents for Staff #5 - #11 (S5 - S11) which revealed four of seven staff members had incomplete pre-service training and/or orientation records.

Based on interview and record review it was confirmed that the facility failed to ensure that they have documented that they have observed and evaluated the individual staff members ability to perform safe medication and treatment administration unsupervised. Findings include the following: During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that the facility had a staff member that was hired to train new staff and after approximately a week they quit and disposed of the training documents that they had, but they are working on getting all training documents for staff. Compliance Specialist (CS) reviewed training documents for Staff #5 - #11 (S5 - S11) three of which staff members were listed as med techs on the Employee Roster. One of three staff members did not have any demonstrated competencies for passing medications. CS also reviewed Medication Administration Records (MARs) for Resident #1 - #3 and Resident #5 (R1 - R3 & R5) for January 2023 to current and discovered two staff members signing off on medication passes that were not listed as med techs on the Employee Roster. CS reviewed both staff members training records which revealed one of those staff members does not have demonstrated competencies for passing medications.

Based on interview and observation it was confirmed that the facility failed to ensure a copy of the most current inspection report and any conditions placed upon the license is posted with the facility ' s license in public view near the main entrance to the facility. Findings include the following: During unannounced site visits on 04/20/2023 and 04/25/2023 Compliance Specialist (CS) did not observe a copy of the facility ' s condition posted anywhere in the front entrance. In an interview with the facility policy analyst, it was stated that the facility does have a restriction of admissions condition that should be posted. In an interview with Staff #2 (S2) it was stated that they were unaware of the facility condition but would look in to locating it to get it posted.

Based on interview, observation, and record review it was confirmed that the facility failed to keep all interior and exterior materials and surfaces clean and in good repair. Findings include the following: According to Witness #4 (W4) it was stated that resident rooms are not being cleaned either daily or even weekly, toilets and handrails are dirty with brown matter. During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) observed a dark brown substance in the shared restroom for Resident #1 (R1), substance was around the toilet, on the floor and around the doorframe near the restroom light switch. CS also observed a yellowish substance that appeared to run down the wall from approximately waist height and collected and dried at the baseboards in Resident #6 (R6) ' s restroom, the floor was sticky with a strong urine odor while the restroom fan was running. A review of the facility housekeeping schedule revealed that on Tuesdays all floors should have been cleaned as well as a deep clean of the fourth floor. A review of service plans for R1 and R6 revealed staff are to ensure R1 ' s shower and bathroom are clean and dry and R6 ' s states that care staff are to go into room daily on day and swing shift to clean along with housekeeping deep cleans once per week.

See findings in C-tags C0360, C0365, C0370 and C0372

Based on interview and observation it was confirmed that the facility failed to have a secured outdoor recreation area with outdoor furniture sufficient in weight, stability, design, and maintained to prevent resident injury or aid in elopement. Findings include the following: During unannounced site visits on 04/20/2023 and 04/25/2023 Compliance Specialist (CS) observed an unlocked gate, on 04/25/2023 there was a bungee cord holding the gate closed. The gate led to an area that contained the facility ' s dumpsters as well as what appeared to be heating and cooling systems. Within this unsecured area there was a door that was held closed with a screw through the door latch. CS was able to lift screw up and push the door open to gain access to the street. CS also observed on 04/25/2023 a lightweight lawn chair in outdoor recreation area. In an interview with Staff #2 (S2) they identified the lawn chair and stated that they would remove it. S2 also acknowledged photographs of the unsecured doors in the recreation area and stated that they would make sure they got the doors/gate secured as soon as possible.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 04/20/2023 and 04/25/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 05/02/22 through 05/04/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations. Refer to deficiencies in the report.

C150 OAR 411-054-0025 (1) Facility Administration Operations Refer to all citations in this report.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. This is a repeat citation. Findings include, but are not limited to: During the first revisit to the re-licensure, conducted 12/12/22 through 12/14/22 administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations. Refer to deficiencies in the report.

C150 OAR 411-054-0025 (1) Facility Administration Operations Refer to all citations in this report.

2. Resident 1 was admitted to the facility in October 2019 with diagnoses including dementia. The clinical record revealed: a. Resident 1 experienced unwitnessed falls on 04/05/22 and 04/19/22. b. Following the fall on 04/05/22, staff observed the resident with "bleeding from forehead and chin" and was sent to the emergency department for evaluation. c. On 04/19/22, Resident 1 was found on the floor in another resident's room with the other resident present. Staff documented observing "redness on forehead and between eyes" and the resident was sent to the emergency department for evaluation. On 05/03/22, incident reports were requested for review. During an interview on 05/04/22, Staff 3 (RCC) stated she was unable to locate the incident reports but recalls reporting both incidents to the local SPD office as the falls were unwitnessed and abuse or neglect could not be ruled out. The need to ensure a timely and thorough investigation of falls and injuries was completed and that those records were maintained was reviewed with Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and falls with injury were promptly and thoroughly investigated to rule out abuse and neglect and reported to the local SPD office as required for 2 of 5 sampled residents (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the MCC in 04/2021 with diagnosis of dementia. A review of Resident 2's incident reports and chart notes from 02/10/22 through 05/02/22 indicated the following injury of unknown cause: * 02/20/22 Skin tear to right wrist. A review of the incident report documented, "Resident has a ST [skin tear] of unknown origin to right wrist, area noticed when giving resident a shower. Zero suspected abuse. Zero neglect." The date of the investigation was 03/28/22 and there was no follow-up action or administrative review of the investigation. There was no documented evidence the facility either reported the injury as suspected abuse to the local APD office or conducted an immediate investigation of the injury which reasonably concluded and documented that the injury was not the result of abuse. The facility's failure to immediately investigate Resident 2's injury and document the investigation to rule out abuse or neglect and report the injury as suspected abuse was reviewed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings. The facility was directed to self-report the incident to the local APD office. Staff 2 provided verification that the incident was self reported to local APS office prior to survey exit.

C231 OAR 411-054-0028 (1-3) Reporting & Investigating Abuse 1. Immediate action taken to correct the rule violation include thoroughly investigating and self reporting incident to APS for Resident #2, and completing incident reports for Resident #1. Interventions have also been put in place to reduce risk for these incidents to happen again. Care plan has been updated with the interventions for staff to know how to assist the residents. Abuse Reporting and Investigation Guide for Providers for Oregon has been reviewed with the department management team, and will be reviewed at next all staff meeting to provide staff training related to reporting requirements at next all staff meeting. 2. The system will be corrected so the violation will not happen again by ensuring all incidents are investigated timely. If abuse and neglect can not be ruled out, or for injuries of unknown cause, community will follow abuse reporting requirements. Incident reports will be reviewed daily at daily stand up meetings. The community will include incident reporting and investigating abuse and neglect as part of the continuous quality improvement plan. Community will verify the correct process for self reporting to APS has taken place for all reportable incidents. 3. This area will be reviewed on a daily basis in stand up upon review of communication log, alert charting and quarterly basis. 4. The Administrator or designee will be responsible to see that the corrections are being completed and monitored.

Based on interview and record review, it was determined the facility failed to report suspected abuse to the local Seniors and People with Disabilities (SPD) office and failed to conduct an investigation of an injury of unknown cause, to rule out possible abuse or report the injury to the local SPD office for 1 of 3 sampled residents (#6) whose record was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease. Review of Resident 6's clinical records during the survey revealed the following: a. 10/21/22 - "Resident on alert charting for [left] skin tear above eyebrow." The investigation of the injury of unknown cause failed to reasonably rule out abuse or neglect as the cause of the injury. The injury was not reported to the local SPD office. b. 11/22/22 - An outside provider reported witnessing another resident push Resident 6. There was no documented evidence the facility notified the local SPD office of the suspected abuse, investigated the suspected abuse or implemented measures necessary to protect residents and prevent the reoccurrence of abuse. The need to investigate injures of unknown cause to rule out abuse and neglect or report the injury to the local SPD office, report suspected abuse to the local SPD office and implement measures to prevent the reoccurrence of abuse was discussed  with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings. The survey team requested the facility submit the reports. Documentation was provided prior to survey exit.

C231 OAR 411-054-0028 (1-3) Reporting & Investigating Abuse 1. Immediate action taken to correct the rule violation include thoroughly investigating and self-reporting incident to APS for Resident. Interventions have also been put in place to reduce risk for these incidents to happen again. Care plan has been updated with the interventions for staff to know how to assist the residents. Abuse Reporting and Investigation Guide for Providers for Oregon has been reviewed with the department management team, On 1/9/2023 at 10:00 am Department heads and Med techs attended a virtual in-service provided by APS on the topic of Abuse and Neglect reporting. Education on Abuse and neglect reporting, will be reviewed at next all staff meeting to provide staff training related to reporting requirements at next all staff meeting. 2.  The system will be corrected so as to reduce the risk of re-occurrence by ensuring all incidents are investigated timely. If abuse and neglect cannot be ruled out, or for injuries of unknown cause, community will follow abuse reporting requirements. Incident reports will be reviewed daily at daily stand up meetings. The community will include incident reporting and investigating abuse and neglect as part of the continuous quality improvement plan. Community will verify the correct process for self-reporting to APS has taken place for all reportable incidents. 3. This area will be reviewed on a daily basis in stand up upon review of communication log, alert charting and quarterly basis. 4. The Administrator or designee will be responsible to see that the corrections are being completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 05/02/22 at 11:00 am, the central kitchen and kitchenettes on each floor were toured. a. The central kitchen on the first floor was observed to need cleaning and repair in the following areas: * Multiple ceiling tiles had holes that allowed for the potential entrance of insects and rodents into the kitchen; * Ceiling light fixtures or light bulbs near the entrance of the kitchen, above the steam table, and in the dry storage room were broken; * Ceiling light fixtures were missing light covers near the ware wash and in the dry storage room; and * Four ceiling vents were covered in brown or black matter. b. Kitchenette's on each floor had food spills, splatters, debris, dust and black matter that was observed on or underneath the following: * Interior of all cupboards and cabinets; * Exterior cupboards and cabinets were gouged and had a sticky residue buildup; * Multiple cabinet hardware (knobs and hinges) were loose or missing; * Interior and exterior surface doors, bottom and sides of refrigerator shelves and freezers; * Refrigerator handles were loose; * Baseboards and walls; and * Interior and exterior surfaces of the microwaves and toaster ovens. c. The kitchenette on the second floor required the following cleaning and repair: * Interior of the cabinet wall underneath the sink had black matter buildup; d. Kitchenette on the fourth floor required the following repairs: * A broken wall soap dispenser; and * Wall paint near the baseboard wall heater was peeling off. The kitchen was toured with Staff 1 (Executive Director) and Staff 5 (Dining Services Director) on 05/03/22 at 9:38 am and the need to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed. They acknowledged the findings.

C240 OAR 411-053-0030 (1)(a) Resident Services Meals, Food Sanitation Rule 1. Actions taken to correct rule violation will include: a. central kitchen on the first floor ceiling tiles that have holes will be replaced, ceiling light fixtures / light bulbs will be fixed / repaired, ceiling light fixtures will missing covers will be replaced and ceiling vents will be cleaned. b. kitchenettes on each floor will have food spills, splatters, debris, dust and black matter cleaned, interior of all cupboards and cabinets will be cleaned. Exterior cupboards and cabinets will be repaired or replaced due to gouges, knobs and hinges will be replaced on cabinets, interior and exterior surfaces bottom and sides of refrigerator shelves and freezers will be cleaned, refrigerator handles will be repaired,baseboards and walls will be cleaned and repaired, interior and exterior surfaces of the microwaves and toasters will be cleaned. c. kitchenette on first second floor will have interior of the cabinet wall underneath sink cleaned. d. kitchenette on fourth floor will have the soap dispenser replaced and wall near baseboard heater repaired and repainted. 2. The system will be corrected so this violation will not happen again by creating daily, weekly, monthly and quarterly cleaning schedules for the kitchen and kitchenette. 3. The cleaning schedule will be reviewed daily, weekly and quarterly with environmental audits. 4. The Administrator or designee will be responsible for reviewing / monitoring the weekly cleaning schedule to ensure the corrections remain in compliance.

3. During the survey, facility staff stated the quarterly evaluation and service plan were combined into the same document. Resident 5's most recent service plan was not dated. When reviewed on 05/03/22, the most recent update was noted as 01/07/22, with no evidence of quarterly evaluation or update in the last 90 days. The need to ensure timely review and updates to the evaluation was reviewed with Staff 27 (Regional Director of Operations) and Staff 3 on 05/04/22. They acknowledged the findings. 2. During the survey, facility staff stated the quarterly evaluation and service plan were combined into the same document. Resident 1's evaluation/service plan was completed on 08/11/21. The next quarterly evaluation would have been due on 11/11/21. There was no documented evidence of any evaluation completed after 08/11/21. During an interview on 05/03/22, Staff 3 (RCC) stated the facility was currently working on some updates for the evaluation/service plan for Resident 1, but it had not been completed. The need to ensure timely review and updates to the evaluation was reviewed with Staff 27 (Regional Director of Operations) and Staff 3 on 05/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements or that a quarterly evaluation was completed timely, for 3 of 5 sampled residents (#s 1, 3 and 5). Findings include, but are not limited to: 1. Resident 3's move-in evaluation lacked information regarding the following required elements: * The new move-in evaluation was not dated and did not indicate who was involved in the evaluation process. In an interview with Staff 2 (RN) on 05/02/22 at 2:30 pm, he stated that he did not complete the new move-in evaluation for Resident 3 and the previous facility RN was in charge of the new move-in evaluations. The move-in evaluation and the need to complete all required components was reviewed with Staff 1 (Executive Director) on 05/03/22. He acknowledged the findings.

C252 OAR 411-054-0034 (1-6) Resident Move-In and Evaluation: Res Evaluation 1.Immediate actions to correct the rule violation include comprehensive review and update to Resident #3 move-in evaluation has been updated to reflect the move-in date and indicate who was involved in the evaluation process. Resident #1 and #5 evaluation has been updated and reflective of Memory Care specific requirements and current needs and preferences per Oregon Administrative Rules. 2. To ensure the system will be corrected so this violation will not happen again, evaluations including all required factors will be completed per company policy and Oregon State Rule prior to move in, updated within 30 days, quarterly thereafter and with any significant change of condition. The document should be signed to indicate who completed the evaluation. 3. The area will need to be reviewed and audited on a quarterly basis via continuous quality improvement system. Completion and accuracy of Evaluation will be reviewed in daily clinical stand up meeting prior to each new move in to ensure all components are reflective and all areas are complete with appropriate information. 4. The Administer, Licensed Nurse or designee will be responsible to ensure the system has been corrected and the system is monitored.

Based on interview and record review, it was determined the facility failed to ensure evaluations included all required elements, for 2 of 4 sampled residents (#s 6 and 8) whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 move into the facility in 11/2022 with diagnoses including dementia. Resident 8's move in evaluation was not dated and did not indicate who was involved in the evaluation process. The move-in evaluation and the need to complete all required components was reviewed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease. The most recent evaluation was dated 10/12/22. The evaluation did not indicate who was involved in the evaluation process. The need to include information on who was involved in the evaluation process was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.

C252 OAR 411-054-0034 (1-6) Resident Move-In and Evaluation: Res Evaluation 1.Immediate actions to correct the rule violation include comprehensive review and update to Resident #3 move-in evaluation has been updated to reflect the move-in date and indicate who was involved in the evaluation process. Resident #6 and #8 evaluation has been updated and reflective of signature of person and date of doing the assessment. per Oregon Administrative Rules. 2. The system will be corrected so as to reduce the risk of re-occurrence, evaluations including all required factors will be completed per company policy and Oregon State Rule prior to move in, updated within 30 days, quarterly thereafter and with any significant change of condition. The document should be signed to indicate who completed the evaluation. 3. The area will need to be reviewed and audited on a quarterly basis via continuous quality improvement system. Completion and accuracy of Evaluation will be reviewed in daily clinical stand up meeting prior to each new move in to ensure all components are reflective and all areas are complete with appropriate information. 4. The Administer, Licensed Nurse or designee will be responsible to ensure the system has been corrected and the system is monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status and failed to provide clear direction to staff for 3 of 5 sampled residents (#s 1, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the service plan, temporary service plans and progress notes, showed the plan was not reflective and did not provide clear direction to staff in the following areas: * Use of a geri-chair; * Directions for catheter care; and * Sitting up 90 degrees to eat meals and remaining at 90 degrees for at least 30 minutes after.   The need to ensure resident service plans were reflective and provided clear directions to staff was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. Staff acknowledged the findings. 3. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia and Diabetes Type II. The most recent service plan was reviewed and was not reflective or lacked clear instruction for staff in the following areas: * No copy of the service plan was available for staff on the 4th floor where Resident 5 lived; * Not updated after bi-lateral fractures that left Resident 5 non-weight bearing; * Listed wheelchair and walker for mobility, however, Resident 5 was bed bound; and * Failed to list hospice home health services. A service plan update was completed on 3/23/22 instructing staff to place braces on both legs when Resident 5 woke up in the morning, and leave them on until sleep in the evening.  Observations on 05/02/22 showed Resident 5 was not wearing the braces, and Staff 16 (Caregiver) stated he was not aware the braces had been added to the service plan. The need to ensure resident service plans were reflective, provided clear directions to staff, and were readily available for staff to review was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. Staff acknowledged the findings. 2. Resident 1 moved into the facility in October 2019 with diagnoses including dementia and depression. The most recent service plan, dated 08/11/21 was reviewed and was not reflective or lacked clear instruction for staff in the following areas: * Walking ability including use of a wheelchair for mobility; * Current, effective fall interventions; * Ability to eat independently and level of meal assistance required; * Interventions to address weight loss; * Sleep pattern and late night waking hours; * Behaviors including agitation and current interventions: * Use of glasses; and * Emergency evacuation needs. The need to ensure service plans were reflective of resident needs, accurate and included clear direction to staff was discussed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

C260 Service Plan: General 1. Immediate actions taken to correct the rule violation was to update Resident #4, #1, and #5 care plans. Resident #4 care plan has been updated and is reflective of the evaluation, person centered with individual preferences and care needs. It reflects the use of a geri chair, directions for catheter care, and sitting up 90 degrees to eat meals and remain at 90 degrees for at least 30 minutes after. Resident #1 care plan has been updated and is reflective of the evaluation, person centered with individual preferences and care needs. It reflects walking ability including use of wheelchair for mobility, current, effective fall interventions, ability to eat independently and level of meal assistance required, interventions to address weight loss, sleep pattern and late night waking hours, behaviors including agitation and current interventions, use of glasses and emergency evacuation needs. Resident #5 care plan has been updated and is reflective of the evaluation, person centered with individual preferences and care needs. It reflects non-bearing status and bed bound status, and hospice services. Service plan has been placed on floor resident resides. 2. This system will be corrected so this violation does not happen again by ensuring that the care plan is updated with any acute or significant change of condition, as well with pre-scheduled updates (initial, 30 day and ongoing quarterly updates) to reflect the residents current status per Oregon State Rule. Clinical services and Administrator participate with this process to ensure accuracy and personalization, as well as the resident and / or their POA / Representative. 3. At time of move in, 30 day review, quarterly and as needed if a change of condition occurs. 4. The administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans included clear direction for staff and were followed for 2 of 4 sampled residents (#s 6 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1.  Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease. The resident's 10/12/22 service plan was reviewed and revealed the resident was at risk for aspiration and noted the following information: * "[The resident] needs nectar thick liquids. S/he needs to avoid foods that melt into thin liquids (ice cream and popsicles."); and * "[The resident] likes all fluids thin. S/he can manage this if you hand him/her a drink while s/he is sitting." There was no documented evidence Resident 6's service plan provided clear direction to staff related to hydration and liquid consistency. The need to ensure service plans included clear direction to staff was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings. 2. Resident 8 moved into the facility on 11/08/22 with diagnoses including dementia. The service plan dated 11/08/22 noted Resident 8 was scheduled for showers twice a week. The shower schedule available to staff at the time of the survey failed to document Resident 8's shower days. During interviews on 12/13/22 and 12/14/22, Staff 28 (Personal Care Assistant), Staff 34 (MT) and Staff 27 (RCC) were unable to verify whether or not Resident 8 was receiving bathing assistance as scheduled in the service plan. During an interview on 12/13/22 at 10:45 am, Witness 1 (Family member) stated s/he was not concerned about the cleanliness of Resident 8. Resident 8 was observed throughout the survey and appeared well groomed. The need to ensure service plans provided clear direction to staff on the delivery of services was reviewed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22 at 11:50 am. They acknowledged the findings.

C260 Service Plan: General 1. Immediate actions taken to correct the rule violation was to update Resident #6, and #8 care plans. Resident #6 care plan has been updated and is reflective for their thicken liquids, person centered with individual preferences and care needs. It reflects the use of nectar thick liquids.  Also retraining staff on Where to find Shower logs for all residents on each floor this was for residents #8. 2. The system will be corrected so as to reduce the risk of re-occurrence by ensuring that the care plan is updated with any acute or significant change of condition, as well with pre-scheduled updates (initial, 30 day and ongoing quarterly updates) to reflect the resident's current status per Oregon State Rule. Clinical services and Administrator participate with this process to ensure accuracy and personalization, as well as the resident and / or their POA / Representative. 3. At time of move in, 30-day review, quarterly and as needed if a change of condition occurs. 4. The administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 5 sampled residents (#s 1, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: Service plans for Resident's 1, 2, 3, 4 and 5 were reviewed and lacked documented evidence that a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Executive Director) and Staff 3 (RCC) 05/03/22. They acknowledged the findings.

C262 OAR 411-054-0036 (5) Service Plan: Service Planning Team 1. Immediate actions taken to correct the rule violation include: Resident #1, #2, #3, #4 and #5 service plan will be updated with evidence that the resident and / or, the resident's legal representative / person of resident's choice, the facility Administrator or designee, and at least one other staff person familiar with their provided services participates. 2. To ensure the system will be corrected so this violation will not happen again; the service plans will be developed by a service planning team. Monthly service plan review schedule has been set up to ensure timely reviews take place consistently. An invitation will be extended to family / person of resident's choice to attend service plan meeting. All those in attendance will review and sign the service plan. Those not able to attend will be sent a copy of the service plan for review and signature. Signature page will then be attached to service plan. 3. The area will need to be evaluated at resident move in, 30 day review and quarterly update and / or as needed if significant change of condition occurs. 4. The Administered, RCC or designee will be responsible to ensure the corrections are completed and monitored.

2. Resident 4 was admitted to the facility in January of 2022 with a diagnosis of dementia and a Foley catheter. Resident 4's narrative chart notes dated 02/01/22 through 05/01/22 were reviewed and revealed there was no documented evidence the facility monitored changes, resolved monitored changes, notified the facility RN of changes and/or updated the service plan for the following changes of condition: a. The following short term changes were not monitored until resolution:  * 01/14/22 New Move-in; * 02/01/22 Blood at catheter insertion site; * 02/02/22 Golf ball size lump on upper left thigh; * 02/03/22 Foot pain; and * 04/19/22 Missed medications. b. The resident experienced that following change of condition related to weight loss: * On 01/14/22 weight upon admission was 194 pounds; * On 02/2022, Resident 4's weight was 188 pounds (six pound loss from previous month); * On 02/23/22, an RN assessment identified Resident 4 ate 100% of meals but had weight loss of 4% since admission; * On 02/24/22, staff documented, "resident has not been eating well in the evenings with an average of 25% of meal intake since RTC [return to community]."; * On 04/01/22, progress notes documented intake of dinner was 45% and on 04/04/22 intake was 10%; and * On 04/2022, Resident 4's weight was 181 pounds, which resulted in a total weight loss of 6.7% total body weight within three months. Although the RN identified the change of condition for weight loss in 02/2022, there was no documented evidence weight loss interventions were implemented and the service plan was not updated with direction to caregivers to ensure the resident did not continue to lose weight. c. The resident experienced the following significant changes of conditions that were not monitored to resolution or referred to the RN: * 02/19/22, Return from hospital; * 02/28/22, Pressure ulcers on bilateral heels; * 03/10/22, Pain from catheter insertion site with mucus draining; * 03/17/22, "purulent drainage" from genitalia and "pus coming from catheter"; * 03/31/22, Return from hospital for UTI and sepsis; * 04/03/22, Open wound on buttocks; * 04/14/22, Return from the hospital; and * 04/16/22, Starting home health for catheter care, wound care and OT. * 05/02/22, Progress notes documented, Resident 4 continued to experience pain from genitalia and a decline in health condition. There was no documented evidence the facility RN was notified of changes of condition when the resident continued to have pain and  decline in health condition and failed to update the service plan following the changes in condition. The need to ensure the facility documented evidence of interventions, monitored changes, resolved changes, notified the facility RN of changes and/or updated the service plan for changes of condition was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings. 4. Resident 5 was admitted to the facility in 2020 with a diagnosis of dementia and Diabetes Type II. Resident 5's narrative chart notes dated 01/01/22 through 05/01/22 were reviewed and revealed: a.  On 01/05/22 Resident 5 was found on the bathroom floor at 4:30 am after an unwitnessed fall. The fall with possible injury constituted a change of condition that required documented evaluation. A med tech note dated 01/05/22 at 9:41 pm stated "facility nurse and nurse consultant assessed during day shift and decided did not need to be sent out". The assessment referenced in the med tech note was not located during the survey and no service plan updates, interventions, monitoring, or instructions to staff were documented or included in the resident record. A progress note dated 01/06/22 at 9:50 am stated "sent out this morning to hospital and admitted for fractures". b.  A progress note dated 11/19/21 documented "will receive scabies treatment as a preventative measure C/O exposure to a resident with active rashes and itching". On 12/02/21, 14 days later, a note documented "will notify pharmacy so resident can start his/her medication". There was no documented monitoring or resolution of the scabies, and the service plan was not updated with any instructions for staff. The need to ensure the facility documented evidence of monitored changes, resolved changes, notified the facility RN of changes and/or updated the service plan for changes of condition was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings. 3. Resident 1 was admitted to the facility in October 2019 with diagnoses including dementia. A review of the clinical record revealed the following: a. In early February 2022, the resident was identified as having a swollen left foot with redness. The facility notified the physician and a video medical appointment was held on 02/04/22. Progress notes documented on 02/04/22 stated "NP [nurse practitioner] will order new medication for leg swelling and redness..." Resident 1 was placed on alert charting. On 02/10/22, Resident 1 went to a scheduled in-person appointment with his/her physician and the provider stated the medication "should have been started". The facility determined the prescription had been sent to another pharmacy. During an interview on 05/04/22, Staff 3 (RCC) acknowledged the facility did not monitor to follow up on the status of the medication order to treat the cellulitis. The order and medication was received and administered starting on 02/12/22 (eight days after the video appointment). In addition, there was no documentation that the facility nurse had been monitoring the swelling at least weekly through resolution. b. Resident 1 experienced two falls in April 2022. There was no documented evidence the facility determined what action or interventions were needed nor was the resident monitored through resolution. The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution and determining what action or interventions were needed was shared with Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift, weekly progress notes until the condition resolved and/or the facility failed to refer significant changes of condition to the facility RN for 4 of 5 sampled residents (#s 1, 2, 4 and 5) who had changes of condition.  Residents 2 and 4 continued to experience an overall health decline and an increase in ADL care needs. Findings include, but are not limited to: 1. Resident 2 was admitted to the memory care facility in 04/2021 with diagnosis of dementia. Resident 2's clinical records, service plans, and temporary service plans were reviewed during the survey and identified the following changes of condition. a. On 04/07/22, Staff 26 (Former RN) documented, Resident 2 was sent to the emergency room for stomach pain and vomiting. The resident returned the same day with hospital orders to monitor bowel movements and after two days, if the resident doesn't have a bowel movement staff were to administer Miralax every 6 hours until the resident had a bowel movement. Additionally, Resident 2 had PRN Miralax orders, from 11/12/21, to give up to four times per day. There was no documented evidence the facility followed the PRN Miralax orders written on 11/12/21 or contacted the health care provider when the resident failed to have a bowel movement prior to being sent to the ER on 04/07/22. During an interview on 05/04/22, Staff 2 (RN) and Staff 3 (RCC) indicated the facility staff were suppose to monitor and track bowel movements on hand written sheets of paper on each shift and give them to the RCC. Staff 2 and 3 were unable to locate documentation that staff monitored Resident 2's bowel movements or administered the Miralax (intervention) as prescribed. On 04/08/22, the resident was sent out to the emergency room for a body temperature of 101.3 degrees F. On 04/11/22, Staff 21 (RCC) documented in chart notes, Resident 2 returned to the facility with a diagnosis of potential UTI, diverticulitis and sepsis. Staff were instructed to administer Cipro (antibiotic) and Culterelle (probiotic) for seven days and hold fortified beverages while on the antibiotic. A review of the April 2022 MAR pass notes indicated the Culturelle was not received and the resident was not administered Culturelle while taking Cipro and the facility failed to hold daily Med Pass 2.0 (fortified beverage). There was no documented evidence the facility monitored the Culturelle (probiotic) and Cipro (antibiotic) medication errors, the effectiveness of the antibiotic, the resident's bowel movements to determine if the intervention (PRN Miralax) was needed and effective, failed to ensure the determined actions or interventions were communicated to staff and failed to refer the change in condition related to multiple ER visits and decline in health status to the facility RN. b. Between 04/12/22 and 04/25/22 multiple facility staff documented the resident continued to decline, won't eat, had nausea, vomiting, stomach pain, won't get up for breakfast, and needed to assist the resident with meals in his/her room. On 04/18/22, Staff 22 (MT) documented in chart notes, unable to obtain BP due to resident had been septic while in the hospital (seven days ago). There was no documented evidence the facility staff referred Resident 2's continued decline in health status and increase in ADL care needs to the facility RN until 04/25/22 (two weeks later) at which time Staff 26 (RN) documented "was notified today that [s/he] is not eating and has not had a bowel movement since [his/her] return from the hospital. There are no bowel tones noted in any quadrant, even after palpation." Resident 2 was sent to the emergency room. c. On 04/26/22, Staff 3 (RCC) documented in chart notes, Resident 2 returned from the emergency room with a diagnosis of dehydration and a referral for hospice services. On 04/28/22 Staff 22 documented in chart notes, Resident 2 was admitted to hospice services. There was no documented evidence the facility determined actions or interventions for the resident, communicated the actions or interventions to staff and failed to refer the change in condition related to return from hospital with admission to hospice services to the facility RN. The need to ensure the facility determined interventions needed for residents with identified changes of condition, monitored the interventions for effectiveness, communicated the interventions and changes to staff and referred changes of condition to the facility RN when appropriate was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

C270 OAR 411-054-0040 Change of Condition and Monitoring 1. Immediate actions take to correct the rule violation include the following: Resident #2 - a comprehensive nursing assessment and appropriate follow up will be completed related to resident multiple ER visits, decline in health status, and admission to hospice services. Resident #4 - a comprehensive nursing assessment and appropriate follow up will be completed related to weight loss, pain, and decline in health condition. Resident #1- a comprehensive nursing assessment and appropriate follow up will be completed related to skin issues, falls and fall interventions. Resident #5 - a comprehensive nursing assessment and appropriate follow up will be completed related to fall, fractures, and skin issues. 2. To ensure the system will be corrected so this violation will not happen again, a 24 hour communication system is in place to include: a. Shift to Shift Communication Log b. Alert Charting Log / Audit Log c. Significant Change of Condition Log d. Weekly Skin Monitoring Log Staff will start short term monitoring / communication system for any resident identified to have an acute change of condition such as UTI, missed medication, return from the hospital, or fall for an example. When change of condition is identified, staff add the resident name to the alert log to ensure they monitor resident and identify when to report concerns to nursing or physician. The staff will be aware of what to report to the nurse / physician per the temporary service plan (TSP) that has been put in place, which correlates with the resident 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 TSP. Staff should monitor resident status until resident condition resolves and they are back to their baseline, 24- hour book / process will be reviewed daily during clinical review as a means of identification of potential significant change that needs to be assessed by the RN. For significant change condition such as 3. The area needed correction will be evaluated daily during stand up with 24 hour audit system compliance. Community will also complete Monthly Continuous Quality Improvement audit to ensure clinical systems follow company policy and Oregon Administrative Rule. 4. The Administrator and Registered Nurse will be responsible to ensure the system has been corrected and is monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure a resident who had short-term changes of condition was evaluated, resident-specific instructions or interventions were developed, communicated to staff on each shift, reviewed for effectiveness and the condition was monitored to resolution at least weekly for 1 of 4 sampled residents (# 6), who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease. Review of the resident's 08/04/22 through 12/12/22 progress notes revealed the resident experienced the following changes of condition: * 09/02/22 - Medication change, decrease rivastgmine tablet (dementia) to 1.5 mg twice daily; * 09/19/22 - Admission to hospice, risk for weight loss; * 09/27/22 - Medication change, levothyroxine (hypothyroidism) discontinued; and * 10/22/22 - Resident-to-resident physical altercation. a. The facility failed to show documented evidence interventions were developed and communicated to staff on all shifts for Resident 6's medication changes and the physical altercation. In addition, the resident was not monitored with progress noted at least weekly through resolution regarding the physical altercation. b. The resident was admitted to hospice on 09/19/22 and was noted to be at risk for weight loss. The resident had a 09/20/22 physician's order for a nutritional supplement, (Two Cal) 90 milliliters three times per day. In an interview on 12/14/22, Staff 34 (MT) confirmed the nutritional supplement had not been administered to the resident between 11/01/22 and 12/13/22. There was no documented evidence the facility routinely monitored the resident's weight, reviewed the intervention for effectiveness or implemented new interventions when found to be ineffective. Short-term changes of condition and monitoring was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.

C270 OAR 411-054-0040 Change of Condition and Monitoring 1. Immediate actions take to correct the rule violation include the following: Retrained and corrected all issues with Residents #6.   2.  The system will be corrected so as to reduce the risk of re-occurrence, a 24-hour communication system is in place to include: a. Shift to Shift Communication Log b. Alert Charting Log / Audit Log c. Significant Change of Condition Log d. Weekly Skin Monitoring Log Staff will start short term monitoring / communication system for any resident identified to have an acute change of condition such as UTI, missed medication, return from the hospital, or fall for an example. When change of condition is identified, staff add the resident name to the alert log to ensure they monitor resident and identify when to report concerns to nursing or physician. The staff will be aware of what to report to the nurse / physician per the temporary service plan (TSP) that has been put in place, which correlates with the resident 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 TSP. Staff should monitor resident status until resident condition resolves and they are back to their baseline, 24- hour book / process will be reviewed daily during clinical review as a means of identification of potential significant change that needs to be assessed by the RN. For significant change condition such as 3. The area needed correction will be evaluated daily during stand up with 24-hour audit system compliance. Community will also complete Monthly Continuous Quality Improvement audit to ensure clinical systems follow company policy and Oregon Administrative Rule. 4. The Administrator and Registered Nurse will be responsible to ensure the system has been corrected and is monitored.

2. Resident 4 was admitted to the facility in 1/2022 with diagnoses including chronic kidney disease and had a catheter. Resident 4's record was reviewed including progress notes dated 02/01/22 through 05/01/22. The progress notes revealed the following: * On 02/01/22 care staff reported the resident had blood coming from the catheter insertion site and leaking into his/her brief. S/he was also experiencing pain. The note included the RN was notified, but there was no documented evidence the RN assessed the resident or updated the service plan. * On 02/02/22 the RN was asked to look at a golf ball sized lump on the Resident's upper left thigh, but there was no documented assessment. * Progress notes on 02/18/22 identified the resident had "greenish white discharge coming from insertion point" of the catheter that had been "ongoing for about a week." The notes also documented there was a foul smell present, and Resident 4 had a decrease in range of motion in his/her legs "over the past few days." The Resident was unable to bend his/her legs, was complaining of hip pain, moaning in pain and was less responsive than normal. Resident 4 was sent out to the hospital. * On 02/19/22 the progress notes identified the resident returned to the facility from the hospital and was still having pain. The progress notes included there was blood around the tubing, brief and blankets. There was no RN assessment of the resident until 02/23/22. The assessment included the resident's pants had pulled on the catheter tubing causing issues and the tubing needed to be secured properly to the resident's leg. There was no documented evidence the RN assessed the drainage or the catheter pain. On 03/10/22 a progress note revealed the resident had pain associated with his/her catheter tubing with what appeared to be mucus draining from it. A subsequent note on 03/17/22 included there was "purulent drainage." Resident 4 was sent out to the hospital on 03/27/22 with "stroke like symptoms."  Antibiotics were started at the hospital and the resident returned to the facility on 03/31/22 with a diagnosis of UTI with sepsis. There was no further assessment by the RN or documented evidence the service plan was updated with direction to caregivers on catheter care, properly securing the catheter tubing or interventions to ensure the resident did not continue to experience pain. In interview on 05/04/22, Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) the need for a timely RN assessment for a significant change of condition and the service plan to be updated by the RN was discussed. They acknowledged the findings. No additional information was provided. 3. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia and Diabetes Type II. Resident 5's clinical record, service plans, and temporary service plans were reviewed during the survey and identified the following: a. On 02/05/22,Resident 5 returned to the facility from a 30 day hospital stay. Resident 5 had not been receiving insulin before the hospitalization, but arrived with orders for insulin.  Additionally, Resident 5 had used a walker for mobility before the hospitalization, and then bed bound and non-weight bearing due to fractures of both knees, requiring a Hoyer lift to transfer. There was no evidence Resident 5's significant changes had been assessed by an RN at return to the facility. b. A progress noted dated 02/10/22 documented "Resident was admitted to hospice this morning" and noted there would be medication changes, bath schedule changes, and a new bed.  The admission to hospice constituted a significant change of condition. There was no evidence the change was reviewed by an RN until 02/16/22 when an RN note incorrectly stated Resident 5 had returned from the hospital on hospice on 02/05/22.  The service plan was not updated to reflect hospice services and no instructions were developed for staff. The significant changes of condition and the need for an RN assessment that included findings, resident status, and interventions developed as a result of the assessment was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct a significant change of condition assessment including findings, resident status and interventions made as a result of the assessment and update the service plan for 3 of 3 sampled residents (#s 2, 4 and 5) who experienced significant changes of condition related to return from hospital, falls, pain and decline in health status. Residents 2 and 4 continued to experience a decline and increased pain. Findings include, but are not limited to: 1. Resident 2 was admitted to the memory care facility in 04/2021 with a diagnosis of dementia. Resident 2's clinical record, service plan, temporary service plans and chart notes reviewed during the survey identified the following: Between 04/07/22 and 04/28/22 the resident was hospitalized on three occasions, had an increase in his/her ADL care needs related to meal assistance, mobility, an overall decline in his/her health condition and an admission to hospice services. These incidents represented a significant change of condition that required an RN assessment and update to the service plan. During an interview on 05/03/22, Staff 8 (CG), reported the resident "used to eat really well and would even try to take other resident's food. Now, s/he will barely eat anything and sometimes won't get up for breakfast. S/he started to decline about three weeks ago and is now on hospice." During an interview on 05/03/22, Staff 2 (RN), reported he was unable to locate an RN assessment for the decline in health status which resulted in multiple ER visits during the month of April 2022 and he was unable to locate an RN assessment for admission to hospice services. There was no documented evidence the facility RN conducted an assessment which documented findings, resident status, and interventions made as a result of this assessment and updated the service plan to reflect hospice admission, meal assistance and ambulation assistance. The lack of an evaluation and RN assessment resulted in the resident experiencing multiple hospitalizations, continued decline in condition and hospice admission. The significant changes of condition and the need for an RN assessment was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings. Refer to C 270, example 1.

C280 OAR 411-054-0045 Resident Health Services 1. Immediate actions taken to correct the rule violation include: a. Resident #2 will have a comprehensive significant change of condition assessment specific to three hospitalizations, increase in ADL care related to meal assistance, mobility and overall decline in health condition and admission to hospice services. Care plan will be updated to reflect current interventions / needs of the resident. Resident #4 will have a comprehensive significant change of condition assessment specific to hospitalization, pain, catheter care and overall decline in health condition. Care plan will be updated to reflect current interventions / needs of the resident. Resident #5 will have a comprehensive significant change of condition assessment specific to hospitalization, fractures, and mobility. Care plan will be updated to reflect current interventions / needs of the resident. 2. This system will be corrected so this violation does not happen again by the following measures: All resident changes are reported and documented via the 24 hour reporting system. The community nurse will assess the resident and condition change in a timely manner to determine any need for further monitoring. A comprehensive assessment should be completed by RN if the change is significant. Comprehensive assessment involves, but is not limited to, the synthesis of the biological, psychological, social, sexual, economic, cultural and spiritual aspects of the resident's condition or needs, within the environment of practice, for the purpose of establishing nursing diagnostic statements, and developing, implementing and evaluating a plan of care. RN will utilize a significant change of condition log to direct who requires a weekly nursing assessment until the resident is back at their baseline health status, or a new baseline can be established. A significant change of condition includes, but is not limited to return from hospital, falls, pain and decline in health status. 3. The area needing correction will be evaluated on a daily basis. Changes of condition are reviewed through the 24 hour process audit in daily standup meeting to provide oversight and follow up by RN when needed. 4. The Administrator and Registered Nurse will be responsible to ensure the system has been corrected and is monitored.

Based on interview and record review, it was determined the facility failed to ensure RN delegation was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules Division 47, for 1 of 1 sampled resident (# 4) reviewed for the delegation of insulin injections by unlicensed staff.  Findings include, but are not limited to: Resident 4 was identified as having insulin-dependent diabetes and was administered insulin injections by non-licensed staff. On 05/02/22, the facility's RN delegation records were requested and revealed the following: * The previous facility delegating RN left the position on 04/30/22; and * There was no transfer of delegation documentation completed. In an interview with Staff 2 (RN), he stated the facility RN was no longer there and he would be filling in until they had one. He said the previous RN had not been in the facility since 04/26/22 even though her last day was to be 04/30/22 and did not do a transfer of delegation. He stated he let staff know he was available for questions or concerns, but had not completed any delegations of his own. Due to the facility not having a delegating RN, there were no MT staff with current delegations in place to administer insulin injections in the facility. Staff 1 (Executive Director) and Staff 2 provided an immediate plan for ensuring delegations were completed. Staff 2 completed delegation for a night shift MT and continued delegating staff the next morning to ensure there was a delegated staff member on each shift until all delegations could be completed. On 05/04/22, the need to ensure RN delegation was completed and maintained as required by rule was discussed with Staff 2, Staff 3 (RCC) and Staff 27 (Regional Director of Operations). They confirmed the findings.

C282 OAR 411-054-0045 RN Delegation and Teaching 1 2. This system will be corrected so this violation does not happen again by the community RN having documented evidence of completing the RN Delegation in Community Based Care self study course, schedule and complete the exam and print the certificate for CEU to be kept in delegation binder 3. A comprehensive delegation audit will take place, and 100% of residents and delegated staff will be assessed to ensure stability and predictability, as well as delegation log updated and a copy kept in the medication room for all med techs to share accountability with schedule / plan to re-delegate. 4. A comprehensive delegation audit will be completed to ensure delegation and supervision of special tasks of nursing care are being done consistently in accordance with OSBN Administrative Rules. 5. The area needing correction will be evaluated on a monthly basis, utilizing the delegation audit tool and updating delegation log monthly and as needed. 6. Delegating RN is responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers and have policies to ensure outside service providers left written information in the facility that addressed the on-site service being provided and any supplemental care needed, for 1 of 3 sampled residents (#4) who received Home Health services. Findings include, but are not limited to: Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia and catheter care. The record indicated Resident 4 received home health services upon admission in 01/2022. Additionally, in 03/2022, weekly home health for wound care was started. The facility was only able to locate seven home heath provider notes since the resident was admitted in 01/2022. The need to ensure the facility had a system for coordinating on-site services with outside providers was discussed with Staff 2 (RN ), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

C290 OAR 411-054-0045 (2) Res Hlth Srvc: On and Off - Site Health Services 1. Immediate actions taken to correct the violation include requesting documentation for Resident #4 from previous visits with outside provider from 01/2022 - 03/2022 to ensure the chart is reflective. A full chart review for Resident #4 will be completed to ensure care is coordinated with outside services. Resident #4 care plan will be reviewed and updated to reflect any reasonable and appropriate recommendations made by outside provider. This will allow staff to be instructed on and follow any recommendations that were previously made if still appropriate. 2. The system will be corrected so the violation will not happen again by coordinating care with all outside providers per coordination of care policy and procedure that complies with Oregon Administrative Rules. 3. The areas needing correction will need to be evaluated on a daily basis with 24 hour process and order checks, as well as quarterly through the continuous quality improvement system. 4. The community Licensed Nurse 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 a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to: During the re-licensure survey, conducted 05/02/22 through 05/04/22, the survey team identified the following concerns: * C 282: RN Delegation and Teaching; * C 303: Medication and Treatment Orders; * C 310: Medication Administration; and * C 330: PRN Psychotropic Medications. During the exit meeting on 05/04/22, Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) were informed the overall medication and treatment administration system was determined to be inadequate based on the number of deficiencies related to the above medication areas.

C300 OAR 411-054-0055 Systems: Medications and Treatments Please refer to the following deficiencies for POC under C300 to ensure a safe medication system and adequate professional oversight: *C282: RN Delegation and Teaching *C303: Medication and Treatment Orders *C310: Medication Administration; and *C330: PRN Psychotropic Medications

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. This is a repeat citation. Findings include, but are not limited to: During the first re-visit to the re-licensure survey, conducted 12/12/22 through 12/14/22, the survey team identified the following concerns: * C 303: Medication and Treatment Orders; and * C 310: Medication Administration. During the exit meeting on 12/14/22, Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) were informed the overall medication and treatment administration system was determined to be inadequate based on the deficiencies related to the above medication areas.

C300 OAR 411-054-0055 Systems: Medications and Treatments Please refer to the following deficiencies for POC under C300 to ensure a safe medication system and adequate professional oversight: *C303: Medication and Treatment Orders *C310: Medication Administration; and

2. Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia. Resident 4's most recent signed physician's orders, 04/01/22 through 04/30/22 MAR, and 02/01/22 through 05/01/22 progress notes were reviewed, and the following deficiencies were identified: * Humulin was documented as not given because it was not available on 04/03/22 and 04/04/22; and * Humulin lacked documentation if it had been given on 04/16/22 at 8:00 pm, 04/17/22 at 8:00 am, 04/19/22 at 8:00 pm and 04/25/22 at 8:00 pm. There was no written, signed orders for the following: * Progress note dated 02/05/22 and 02/06/22 identified staff started a treatment on Resident 4's feet without orders; and * Progress notes dated 02/19/22 revealed Staff 21 (RCC) directed Staff 9 (MT) to administer PRN Tylenol as a routine medication and Staff 9 followed her direction. The need to ensure physician's order were followed and signed physician's orders were documented in the resident's facility record for all medication and treatments the facility was responsible to administer was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia and Diabetes Type II. Review of Resident 5's hospital discharge orders dated 02/05/22, MARs dated 04/01/22 through 05/01/22, and progress notes dated 01/05/22 through 05/02/22 were reviewed during the survey and the following was identified: On 02/05/22 Resident 5 returned from a hospital stay with physician's discharge orders. A Medication Technician note dated 02/05/22 documented "insulin wasn't given tonight... I wasn't able to administer any PRN pain medications as we had to fax over all documents to the pharmacy". Review of the MAR from 02/05/22 to 02/11/22 documented the following hospital discharge orders were not followed: * Insulin Aspart 100 u/ml flexpen - 24 missed doses; * Insulin Glargine 100 u/ml pen - eight missed doses; * Donepezil 5 mg - four missed doses; * Metformin 500 mg one missed dose; and * Mirtazapine 7.5 mg two missed doses. On 02/11/22 the physician orders were clarified and the insulin was discontinued. On 05/05/22 the need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed or immediately clarified with the prescriber was discussed with Staff 2 (RN) and Staff 27 (Regional Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a legally recognized practitioner were documented in resident records and carried out as prescribed for 3 of 5 sampled residents (#s 2, 4 and 5) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 2021 with a diagnosis of dementia. Resident 2's hospital discharge orders dated 04/07/22, physician orders dated 04/09/22 and 04/28/22 and MARs dated 04/01/22 through 05/01/22 were reviewed during the survey and the following was identified: a. The physician orders dated 04/09/22 were not signed and accessible in the resident's chart; b. PRN Miralax 17 gm pack originally prescribed on 11/12/21 for no bowel movement in three days and instructed staff to contact the health care provider if the resident did not have a bowel movement after two doses; and hospital discharge orders dated 04/07/22 prescribed Miralax every six hours if the resident didn't have a bowel movement within two days of returning to the facility. There was no documented evidence the facility followed the PRN Miralax orders written on 11/12/21 or contacted the health care provider when the resident failed to have a bowel movement prior to being sent to the ER on 04/07/22. Additionally, the facility failed to follow the hospital discharge orders for Miralax every six hours until the resident had a bowel movement. During an interview on 05/04/22, Staff 2 (RN) and Staff 3 (RCC) indicated the facility staff were suppose to monitor and track bowel movements on hand written sheets of paper on each shift and give them to the RCC. Staff 2 and 3 were unable to locate documentation staff monitored Resident 2's bowel movements to ensure the PRN bowel medications were administered as prescribed. c. On 04/11/22, Resident 2 returned to the facility with hospital discharge orders that prescribed Culturelle (probiotic) for seven days while on Cipro. Instructions were given to hold fortified beverages while on the antibiotic. The MAR pass notes indicated the culturelle was not received and the resident was not administered culturelle while taking Cipro and the facility failed to hold daily Med Pass 2.0 (fortified beverage). d. On 04/28/22, Resident 2 was prescribed Tylenol, TID and Senna 1 tablet, daily. The medications were not transcribed on the MARs and Resident 2 had not been administered the medications. On 05/05/22 the need to ensure all written, signed orders from a legally recognized practitioner were documented in resident records and carried out as prescribed was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations). They acknowledged the findings.

C303 OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders 1. Immediate actions taken to correct the rule violation include full audit of physician orders for Resident #2, #4 and #5 to ensure physician orders are being carried out per MD order and that all medications are available to be given per order. 2. The system will be corrected so this violation will not happen again by all resident medication and treatment orders will be reconciled to ensure medications and treatments re dispensed as ordered. 3. Medication reconciliations will be completed on a quarterly basis. Additionally, all new orders will be reviewed and approved by a minimum of two staff. Further daily audits to review missing medications, omissions and PRN usage will be completed. 4. The Nurse, Administrator or trained designee will be responsible to ensure 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 2 of 4 sampled residents (#s 8 and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 06/2017. A review of the 11/01/22 through 12/12/22 MARs and current physician's orders revealed the following: Resident 9 had a physician order for lispro (insulin for diabetes) 10 units to be given before meals. The MAR indicated on 11/16/22 at 4:30 pm, only 3 units of lispro had been administered instead of 10 units. On 11/17/22 at 7:30 am, there was no documented evidence lispro was administered as ordered. An Administration History entry of the lispro on 11/16/22 indicated that there were only 3 units of medication left and the ordered dose could not be given at 4:30 pm. A second entry dated 11/17/22 revealed the facility was out of the medication and the 7:30 am dose could not be administered. The physician was notified of both incidents and there was not a documented negative outcome to the resident. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 35 (ED) on 12/14/22. He acknowledged the findings. 2. Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia. Resident 8's 11/08/22 through 12/12/22 MARs and current physician orders were reviewed.  There was a current order for PRN Carboxymethylcellulose (eye drops) noted on the MAR. During an interview on 12/13/22 with Staff 34 (MT) s/he verified the order however stated the medication was not available for the resident to use if requested. The need to ensure that physician's orders were carried out as prescribed was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations). They acknowledged the findings.

C303 OAR 411-054-0055 (1) (f-h) Systems: Treatment Orders 1. Immediate actions taken to correct the rule violation include full audit of physician orders for all residents.  PO were sent out and received to ensure physician orders are being carried out per MD order and that all medications are available to be given per order. 2.   The system will be corrected so as to reduce the risk of re-occurrence by all resident medication and treatment orders will be reconciled to ensure medications and treatments re dispensed as ordered. 3. Medication reconciliations will be completed on a quarterly basis. Additionally, all new orders will be reviewed and approved by a minimum of two staff. Further daily audits to review missing medications, omissions and PRN usage will be completed. 4. The Nurse, Administrator or trained designee will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure that MARs contained reason for use, resident-specific parameters for PRN medications and clear instruction to staff for 4 of 5 sampled residents (#s 2, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3's 04/01/22 through 04/30/22 MARs were reviewed. Resident 3's physician orders and 04/2022 MARs were reviewed and revealed the following: The following medications did not include a reason for use: * Aspirin (heart health); * Donepezil (Alzheimer's disease); * Lisinopril (hypertension); * Mirtazaoine (depression); * Simvastatin (hyperlipidemia); and * Vitamin B 12 (supplement).   In an interview with Staff 2 (RN) at 2:30 pm on 05/03/22, he acknowledged the lack of reasons for use. The need to ensure an accurate MAR was reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC) and Staff 4 (RCC) on 5/03/22. They acknowledged the MARs were not accurate. 2. Resident 4 was admitted to the facility in 01/2022 with diagnoses including diabetes. Resident 4's physician orders and 04/2022 MARs were reviewed and revealed the following: The following medications did not include a reason for use: * Plavix (blood thinner); * Vitamin C (supplement); * Zinc Sulphate (supplement); * Zinc oxide (sealant); * Nystatin (antifungal); * Aspirin; and * Ciprofloxacin (antibiotic). The following medication was given by one MT, but documented by another MT: * Humulin (insulin). The following medications had blanks on the MAR: * Ciprofloxacin; * Humulin; * Memantine (for dementia); * Quetiapine (antipsychotic): * Bedtime snack; * Foot treatment; * Nystatin; * Povidone iodine; and * Pressure area treatment to heels. The need to ensure an accurate MARs was reviewed with Staff 2 (RN), Staff 3 (RCC), and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings. 4. Resident 5's 04/01/22 through 05/02/22 MAR was reviewed during the survey. The following medications lacked a reason for use: * Calcium carbonate (calcium supplement); * Glucerna (sugar free nutrition); * Acetaminophen (analgesic); * Metformin (oral blood sugar; * Mirtazapine (antidepressant); * Polyethylene glycol (laxative); * Senna (laxative); and * Sertraline (antidepressant). The need to ensure MARs were accurate and included reasons for use was discussed with Staff 2 (RN) on 05/04/22. He acknowledged the findings. 3.  Resident 2 was admitted to the MCC in 04/2021 with a diagnosis of dementia. Resident 2's 04/01/22 through 05/02/22 MARs were reviewed and identified the following: a. The following PRN medications prescribed to treat the same condition lacked clear instructions for unlicensed staff regarding the sequence of administration (which one to administer first, second, etc.) * PRN Tylenol 325 mg tablet and PRN Tylenol 625 mg suppository; * PRN Miralax 17 gm pack, twice daily and PRN phosphate/saline enema once daily both had instructions to administer after three days without a bowel movement; and * PRN Miralax 17 gm pack twice daily and PRN bisocodyl suppository once daily lacked instructions for which one to use first. b. The following inaccuracies on the MAR were identified: * PRN Miralax Powder and PRN Miralax 17 gm pack were discontinued on 04/28/22, however the medications were still transcribed on the May 2022 MAR. Resident 2 had not been administered either of the medications. The need to ensure MARs were accurate and included parameters for PRN medications was reviewed with Staff 2 (RN), Staff 3 (RCC), and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

C310 OAR 411-054-0052 (2) Systems: Medication Administration 1. Immediate actions taken to correct the rule violation included completing a comprehensive review of Resident #3, #4 & #5 MAR and adding specific reason for administering medications / treatments. Resident #2 included a comprehensive review of MAR and adding clear instructions for the sequence of administration of PRN medication prescribed for the same use. Review also included ensuring all medications and treatments are being given per MD order. 100% of residents will have med reconciliation completed to ensure all medications and treatments are accurate to signed physician order, reflect reason for use, appropriate directions / parameters for use and when to notify MD or nursing. Once reconciled, quarterly physician orders will be sent out for 100% of residents for MD review and signature. 2. The system will be corrected so this violation will not happen again by ensuring trained community staff perform a daily MAR audit to ensure no holes / missed medications. All new physician orders go through a triple check system where the order is initially processed by the receiving med tech to ensure no delay of treatment. 2nd check is the next oncoming med tech or RCC to verify orders are accurate, and appropriate directions and parameters for staff to follow are in place. Nursing to be final check to verify all components are in place, and to make updates as indicated. Trained staff will complete weekly and monthly MAR audits to ensure any concerns with medication discrepancy, omission PRN effectiveness, and parameters are followed up on timely. Residents who require MD notification for daily weights or vitals out of parameters will be added to the acuity report to self audit and ensure MD notifications take place timely and follow up as indicated. 3. The area needing correction will be to be reviewed on a daily, weekly, and monthly basis with triple check, MAR audits and monthly continuous quality improvement program. All orders will be reconciled quarterly prior to physician orders sent for MD review. 4. The Licensed Nurse, RCC or trained designee will be responsible to ensure the corrections are completed and monitored.

2. Resident 9 was admitted to the facility in 06/2017 with diagnoses including diabetes and dementia. Resident 9's 11/01/22 through 12/12/22 MARs were reviewed and identified the following blanks: * 11/07/22 - 8:00 pm atorvastatin (for cholesterol); * 11/07/22 - 8:00 pm Lantus (for diabetes); * 11/07/22 - 8:00 pm metformin (for diabetes); and * 11/17/22 - 8:00 pm Lantus. On 12/14/22, the need to ensure MARs were accurate and included if a medication was administered and by whom was discussed with Staff 35 (ED). He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure accurate MARs were kept for all medications prescribed by a legally recognized practitioner and administered by the facility for 3 of 4 sampled residents (#s 7, 8 and 9) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was admitted to the memory care community in 02/2021 with diagnoses including dementia and insomnia. Review of Resident 7's MAR, dated 11/01/22 through 12/12/22, identified the following: The MAR contained blanks in dosage administration for the following medications:   * Benztropine (for muscle control/stiffness) - 11/10/22, 11/11/22 and 11/13/22; * Lorazepam (for anxiety) - 11/11/22; and * Mirtazapine (for unspecified dementia) - 11/10/22, 11/11/22 and 11/13/22. On 12/14/22 the need to ensure accurate MARs were kept for all medications prescribed by a legally recognized practitioner and administrated by the facility was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations). They acknowledged the findings. No further information was provided. 3. Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia. Resident 8's MARs dated 11/08/22 through 12/12/22, current physician's orders and interview and observation with Staff 34 (MT) on 12/13/22 at 12:45 pm of Resident 8's available medications were reviewed and revealed the following discrepancies: *Duplicate entries of medications were identified on the MAR for apixaban/Eliquis (blood clots), furosemide (edema), nifedepine (blood pressure) and Carboxymethylcellulose sodium 0.5%/Lubricating Plus 0.5% (dry eyes). *Review of the physician order's for Resident 8 identified the following: nifedepine (for blood pressure) stated one 30 mg tab to be taken by mouth daily and on the MAR it is stated as one 60 mg tab. *Review of the available medications identified there were two medication bottles available for administration for furosemide (for edema). One of the bottles contained 40 mg tabs and the other bottle contained 20 mg tabs. The physician's order and the MAR stated one 20 mg tab was to be taken by mouth every morning. Medication Pass Notes on the reviewed MARs identified dates when 40 mg tab was cut in half prior to administration, but it was uncertain as to which tab was given each time the medication was administered. The need to ensure the accuracy of the MAR was discussed with Staff 35 (ED), Staff 37 (Director of Operations) and Staff 38 (Regional Director of Operations). They acknowledged the findings.

C310 OAR 411-054-0052 (2) Systems: Medication Administration 1. Immediate actions taken to correct the rule violation included completing a comprehensive review of Residents MAR and adding specific reason for administering medications / treatments, included a comprehensive review of MAR and adding clear instructions for the sequence of administration of PRN medication prescribed for the same use. Review also included ensuring all medications and treatments are being given per MD order. 100% of residents will have med reconciliation completed to ensure all medications and treatments are accurate to signed physician order, reflect reason for use, appropriate directions / parameters for use and when to notify MD or nursing. Once reconciled, quarterly physician orders will be sent out for 100% of residents for MD review and signature. 2.  The system will be corrected so as to reduce the risk of re-occurrence by ensuring trained community staff perform a daily MAR audit to ensure no holes / missed medications. All new physician orders go through a triple check system where the order is initially processed by the receiving med tech to ensure no delay of treatment. 2nd check is the next oncoming med tech or RCC to verify orders are accurate, and appropriate directions and parameters for staff to follow are in place. Nursing to be final check to verify all components are in place, and to make updates as indicated. Trained staff will complete weekly and monthly MAR audits to ensure any concerns with medication discrepancy, omission PRN effectiveness, and parameters are followed up on timely. Residents who require MD notification for daily weights or vitals out of parameters will be added to the acuity report to self audit and ensure MD notifications take place timely and follow up as indicated. 3. The area needing correction will be to be reviewed on a daily, weekly, and monthly basis with triple check, MAR audits and monthly continuous quality improvement program. All orders will be reconciled quarterly prior to physician orders sent for MD review. 4. The Licensed Nurse, RCC or trained designee will be responsible to ensure the corrections are completed and monitored.

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 resident-specific parameters, staff documented that non-pharmacological interventions had been tried with ineffective results prior to administering the medications, direct care staff administering the medications had knowledge of common side effects and when to contact a health professional regarding side effects, and all direct care staff had knowledge of non-pharmacological interventions for 2 of 2 sampled residents (#s 1 and 5) who were prescribed PRN psychotropic medications. Findings include, but are not limited to: 1. Resident 5 moved into the facility in 2020 with diagnosis including dementia and Diabetes Type II. Review of the resident's service plan, physician orders, and 04/01/22 through 05/02/22 MAR revealed the following:     Resident 4 was prescribed Lorazepam 0.5 mg (anti-anxiety medication) one tablet every hour PRN for anxiety. The facility failed to ensure the resident's MAR and clinical record included the following required information: * Resident-specific parameters regarding how Resident 5 expressed anxiety; * Common side effects; * When to contact a health professional regarding side effects; and * Non-pharmacological interventions to attempt prior to administration of the medication. The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 2 (RN) on 03/15/22 at 2:30 pm. He acknowledged the findings. No further information was provided. 2. Resident 1 was admitted to the facility in October 2022 with diagnoses including dementia and depression. The resident was prescribed Risperidone PRN for agitation. The clinical record, including the March 1, 2022 through May 3, 2022 MARs, current service plan and temporary service plans failed to include information on resident-specific symptoms of "agitation". The need to ensure the facility included resident-specific parameters for use of psychotropic medications was discussed with Staff 3 (RCC) on 05/04/22. She acknowledged the findings.

C330 OAR 411-054-0055 (6) Systems: Psychoactive Medications 1. Immediate actions taken to correct the rule violation include completing a comprehensive audit of Resident #5 and Resident #1 MAR and adding resident specific parameters for use of PRN psychoactive medications as well as adding a trigger for staff to document the resident specific non-pharm interventions attempted 2. Any new order for PRN psychoactive medication to treat mood or behavior issues will be reviewed by the Licensed Nurse through the triple check process. The Licensed Nurse will ensure appropriate resident specific indicators for use are in place as well as non-pharm interventions staff should offer prior to using. All active PRN psychoactive medications will be reviewed prior to quarterly physician orders sent for signature as well as with scheduled PRN medication audits. 3. This area will be evaluated on a quarterly basis prior to sending quarterly physician orders for signature, on a monthly basis with medication administration record audits and daily with triple check review if a new order is received. 4.The Licensed Nurse, RCC or trained 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 3 of 3 newly hired direct care staff (#s 8, 11 and 14) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 05/04/22 and identified the following: Staff 8 (CG) hired 01/05/22, Staff 11 (CG) hired 02/01/22 and Staff 14 (CG) hired 03/08/22 lacked documentation of demonstrated competency in First Aid/abdominal thrust. The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

C372 OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff 1. Immediate action taken to correct this rule violation includes ensuring Staff #8, #11 and #14 First Aid / Abdominal Thrust. 2. To ensure the system is corrected and staff remain in compliance with all training requirements, at time of hire, the employee will be assigned required trainings, including First Aid / Abdominal Thrust in compliance with the Oregon Administrative Rules. 3. Staff training records will be to be evaluated upon each staff hire as well as on a monthly basis. 4. Business Office Manager, Administrator or designee will be responsible to see that the corrections are completed and monitored.

Based on record review and interview, it was determined the facility failed to ensure 2 of 3 sampled newly hired direct care staff (#s 21, 25) completed First Aid and Abdominal Thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed on 12/13/22 and 12/14/22. The following deficiencies were identified: Staff 25 (MT) was hired 11/18/22 and Staff 21 (MT/CG) was hired 10/20/22. There was no documented evidence Staff 25 or Staff 21 completed First Aid and Abdominal Thrust training within 30 days of hire. The need to ensure staff completed all required training as specified in the OARs was reviewed with Staff 35 (Executive Director), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22 at 12:20 pm. They acknowledged the findings.

C372 OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff 1. Immediate action taken to correct this rule violation includes ensuring all staff have all training requirements. 2. The system will be corrected so as to reduce the risk of re-occurrence, the system is corrected and staff remain in compliance with all training requirements, at time of hire, the employee will be assigned required trainings and these trainings will be monitored by the RCC ongoing. 3. Staff training records will be to be evaluated upon each staff hire as well as on a monthly basis. 4. Staffing and orientation will be responsible for this moving forward; Administrator 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 general fire and life safety requirements were being met. Findings include, but are not limited to: The facility was an endorsed Memory Care Community home to 52 residents at the time of the relicensure survey. During the acuity interview on 05/02/22 the facility was identified to have residents with high ADL care needs, multiple residents that required two staff for transfers, and multiple resident that were bed bound or used wheelchairs for mobility.  The MCC housed residents on four floors, with two stairwells and one elevator. On 05/04/22, the facility's fire and life safety records were requested for review. There was no documented evidence of the following general fire and life safety requirements: * Evidence of fire drills completed on alternate months; * Evidence of life safety instruction other months; * Evidence alternative exit routes were used during fire drills; * Residents ability to participate in an evacuation; * Staff interviewed were not aware of the designated point of safety; * Evidence staff and residents participated in fire drills and training to assess ongoing evacuation capabilities of both residents and staff; and * Documentation of interventions and resolution related to resident evacuation concerns identified during fire drills. The need to ensure all general fire and life safety requirements were implemented and followed was discussed with Staff 6 (Maintenance Director) on 05/04/22. She acknowledged the findings.

C420 OAR 411-054-0090 (1-2) Fire and Life Safety: Safety 1. Actions taken to correct the rule violation will include; a. Facility will conduct unannounced fire drills every other month at different times of the day, evening, and night. b. Fire and life safety instruction to staff will provided on alternate months. c. Written fire drill records will be kept that include but not limited to; alternative exit routes used, staff and residents that participated in fire drill and interventions and resolution related to resident evacuation concerns identified during fire drills. d. Evaluation of each resident will be completed to evaluate their ability and needs to evacuate safely. 2. The system will be corrected so this violation does not happen again by completing a comprehensive review of current fire drill forms to ensure they meet the requirements of the Oregon Administrative Rule and in servicing administration or designee conducting fire and life safety drills and education on process and documentation required. 3. The area needing correction will be evaluated monthly. 4. The Administrator and / or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months, and staff interviewed did not know the designated point of safety. This is a repeat citation. Findings include, but are not limited to: * Fire and life safety records, reviewed between 07/2022 and 12/2022, revealed fire and life safety instruction was not provided to staff on alternate months; and * During interviews on 12/13/22, Staff 28 (CG) and Staff 38 (CG) indicated they were unaware of the location of the designated point of safety for evacuating residents. The need to ensure that staff received fire and life safety instruction on alternate months and that all staff were aware of the designated point of safety was discussed with Staff 35 (Executive Director), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22 at 12:20 pm. They acknowledged the findings.

C420 OAR 411-054-0090 (1-2) Fire and Life Safety: Safety 1. Actions taken to correct the rule violation will include; a. Facility will conduct unannounced fire drills every other month at different times of the day, evening, and night. b. Fire and life safety instruction to staff will provided on alternate months. c. Written fire drill records will be kept that include but not limited to; alternative exit routes used, staff and residents that participated in fire drill and interventions and resolution related to resident evacuation concerns identified during fire drills. d. Evaluation of each resident will be completed to evaluate their ability and needs to evacuate safely. 2. The system will be corrected so as to reduce the risk of re-occurrence by completing a comprehensive review of current fire drill forms to ensure they meet the requirements of the Oregon Administrative Rule and in servicing administration or designee conducting fire and life safety drills and education on process and documentation required. 3. The area needing correction will be evaluated monthly. 4. The Administrator and / or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to: The facility was an endorsed Memory Care Community home to 52 residents at the time of the relicensure survey. During the acuity interview on 05/02/22 the facility was identified to have residents with high ADL care needs, multiple residents that required two staff for transfers, and multiple resident that were bed bound or used wheelchairs for mobility.  The MCC housed residents on four floors, with two stairwells and one elevator. On 05/04/22, the facility's fire and life safety records were requested for review. There was no documented evidence of the following fire and life safety requirements for residents: * No evidence that each resident was 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; and * No written record of fire safety training, including content of the training sessions and the residents attending. There was no documented evidence residents ability to evacuate the building or follow instructions in an emergency had been evaluated or resident training provided and documented. The need to ensure all resident fire and life safety requirements were implemented and documented was discussed with Staff 6 (Maintenance Director) on 05/04/22. She acknowledged the findings.

C422 OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents 1. Immediate action taken to correct this rule violation includes 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 safe, and re-instructed annually. 2.The system will be corrected so this violation will not happen again by ensuring new residents will be instructed within 24 hours of move in and re-instructed annually for 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. 3. The areas needing correction will be audited daily at stand up meeting and clinical meeting with a new resident move in. 4. The Administrator and / or designee will be responsible to ensure corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to provide sufficient numbers of caregiving staff to meet the condition placed on the facility by the Department of Human Services (DHS). Findings include, but are not limited to: On 07/01/21, the facility was placed under a condition to ensure they had six caregivers and 2 Medication Aides on Day and Evening shifts and four caregivers and 1 Medication Aide on NOC shift. The facility was an endorsed Memory Care Community home to 52 residents at the time of the relicensure survey. During the acuity interview on 05/02/22 the facility was identified to have residents with high ADL care needs, multiple residents that required two staff for transfers or during care and dementia diagnoses. Review of the MCC schedule from 04/1/22 to 05/02/22, observations, and interviews confirmed the facility failed to have six caregivers on the Day or Evening shifts 54 times and failed to have four caregivers on the overnight shift 19 times. In an interview with Staff 1 (Executive Director), on 05/03/22, he stated they were waiting for additional staffing through a state assistance program. In the interim, current staff were frequently scheduled for double shifts. The need to ensure sufficient staffing to meet the scheduled and unscheduled resident needs based on the condition that was place on the facility, was discussed with Staff 1 on 05/03/22.  He acknowledged the findings.

C460 OAR 411-054-0110 (1-12) Conditions 1. Immediate action taken to correct this rule violation includes addressing staff ratios that are required to be in place 2.The system will be corrected so this violation will not happen again by ensuring there are six caregivers and two medication aides on day and evening shifts and four caregivers and one medication aide on NOC shift 3. The schedule and any needs will be audited daily at stand up meeting and reviewed prior to weekends with a manager on call in the event of call ins 4. The Administrator and / or designee will be responsible to ensure corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to provide sufficient numbers of caregiving staff to meet the condition placed on the facility by the Department of Human Services (DHS). This is a repeat citation. Findings include, but are not limited to: On 07/01/21, the facility was placed under a condition to ensure they had six caregivers and two Medication Aides on Day and Evening shifts and four caregivers and one Medication Aide on NOC shift. The facility was an endorsed Memory Care Community home to 43 residents at the time of the first re-visit to the relicensure survey. During the acuity interview on 12/12/22 the facility was identified to have residents with high ADL care needs and dementia diagnoses. Review of the MCC schedule from 12/1/22 to 12/14/22, observations, and interviews confirmed the facility failed to have six caregivers on the Day or Evening shifts 16 times and failed to have four caregivers on the overnight shift five times. The need to ensure sufficient staffing to meet the scheduled and unscheduled resident needs based on the condition that was placed on the facility, was discussed with Staff 35, Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.

C460 OAR 411-054-0110 (1-12) Conditions 1. Immediate action taken to correct this rule violation includes addressing staff ratios that are required to be in place 2. The system will be corrected so as to reduce the risk of re-occurrence by ensuring there are six caregivers and two medication aides on day and evening shifts and four caregivers and one medication aide on NOC shift 3. The schedule and any needs will be audited daily at stand-up meeting and reviewed prior to weekends with a manager on call in the event of call ins 4. The Administrator and / or designee will be responsible to ensure corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit. Findings include, but are not limited to: The interior and exterior of the building was toured on 05/03/22 and 05/04/22. The following issues were noted: On 05/03/22, multiple observations were made of bottles with disinfectant cleaner accessible to the residents on the countertops and in unlocked cabinets of the dining room kitchenettes on the first, second and fourth floors of the facility. The need to ensure all toxic materials were maintained in locked storage to avoid access by residents was discussed with Staff 1 (Executive Director) and Staff 5 (Food Service Director) on 05/03/22 and Staff 6 (Maintenance Director) on 05/04/22. They acknowledged the findings.

C510 OAR 411-054-0200 (3) General Building Exterior 1. Actions taken to correct the rule violation will include; all chemicals and toxic materials will be stored in locked cabinets. 2. The system will be corrected so this violation does not happen again; all staff being inserviced on correct storage and use of all chemicals and toxic materials. 3.The area needed corrections will be monitored daily, weekly and monthly via walk throughs of community by administration, and quality improvement process. 4. The Administrator, Maintenance Director or designee will be responsible to see that the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were in a locked storage unit. This is a repeat citation. Findings include, but are not limited to: During a tour of the facility on 12/12/22 at 1:15 pm the following was identified: * The door next to Room 102 that opened to a corridor leading to the kitchen on the ground floor was not closed and secured. Cleaning materials were observed to be in the corridor that connected to the kitchen. The kitchen door was also opened allowing residents full access to the kitchen. A walk through with Staff 35 (Executive Director), Staff 32 (Maintenance Director), and Staff 24 (Maintenance Assistant) was conducted on 12/13/22 at 11:00 am. They acknowledged the findings.

C510 OAR 411-054-0200 (3) General Building Exterior 1. Actions taken to correct the rule violation will include; all chemicals and toxic materials will be stored in locked cabinets, Also Door next to 102 is locked at this time. 2. The system will be corrected so as to reduce the risk of re-occurrence; all staff being in-service on correct storage and use of all chemicals and toxic materials. 3.The area needed corrections will be monitored daily, weekly and monthly via walk throughs of community by administration, and quality improvement process. 4. The Administrator, Maintenance Director or designee will be responsible to see that the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to: Observations of the facility on 05/02/22 through 05/04/22 showed the following areas were in need of cleaning and/or repair: On the first floor: * A door leading to the back kitchen corridor (near Room 102) could not close completely and latch; * A section of flooring in the hallway in front of the elevator was lifting and uneven, with areas peeling away; * Walls, chair rails and door jambs in the dining room were scuffed, gouged and had some areas of chipped paint; and * Walls on the hallway leading to the medication room had patched but unpainted holes. On the second floor: * An area of the wall was damaged leaving exposed drywall next to the "mechanical room"; and * The trim and door jamb around the elevator was scuffed, gouged and had peeling paint. On the third floor (no residents currently resided on this floor): * A section of exposed wiring on the wall next to the medication room; and * The double doors leading to the balcony area were unsecured, leaving access to a stair way. On the fourth floor: * Room 416 door jambs on the bathroom door and apartment door were gouged, scuffed and had missing paint. The need to ensure the environment was kept clean and in good repair was discussed with Staff 6 (Maintenance Director) on 05/04/22. She acknowledged the findings.

C513 OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors 1. Actions taken to correct this rule violation include; a. on the first floor door leading to the back of kitchen corridor will be repaired, flooring in the hallway in front of elevator will be repaired or replaced, walls, chair rails and door jambs will be repaired and repainted, walls on hallway leading to the medication room will be sanded and repainted. b. on the second floor area of wall with exposed drywall next to mechanical room will be repaired and trim and door jamb around the elevator will be repaired and repainted. c. on third floor section of exposed wiring on the wall next to the medication room will be repaired and the double doors leading to balcony will be secured. d. on fourth floor room 416 door jambs on bathroom door and apartment door will be repaired and repainted. 2. The system will be corrected so this violation will not happen again by; staff will be provided with inservicing on reporting damaged, broken facilities or equipment, utilization of maintenance request log as means of communication regarding repair needs that are not urgent, and Maintenance Director will respond to repair needs timely. 3. The area needing corrected will need to be evaluated on a monthly basis as part of the environmental audit. 4. The Administrator, Maintenance Director or designee will be responsible to see that the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained, clean, and in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of the facility on 12/12/22 showed the following areas in need of cleaning and/or repair: a. First floor entrance, hallway, and resident rooms: * Flooring section in front of elevator was damaged and uneven; * Ceiling vent in the main entrance was covered with dust; * The door leading to the back kitchen corridor next to Room 102 was unable to be latched and secured; * Wall corner next to Room 120 was damaged with chipped paint; * Room 120 bathroom was missing a toilet paper holder; and * Room 124 flooring areas in the bathroom and upon entrance had uneven and bulging floor sections. b. Second floor: * Water damage stains and peeling paint on the ceiling arch in the dining room entrance next to the "mechanical room"; and * A section of window was missing and patched with cardboard in the seating area next to Room 219. The areas in need of cleaning and/or repair were shown to and discussed with Staff 35 (Executive Director), Staff 32 (Maintenance Director), and Staff 24 (Maintenance Assistant) on 12/13/22 at 11:00 am. They acknowledged the findings.

C513 OAR 411-054-0200 (4) (d-i) Doors, Walls, Elevators, Odors 1. Actions taken to correct this rule violation include; a. on the first-floor in room 120 and room 124, fixing the flooring and painting.    b. Flooring in front of elevator is being fixed on first floor.  Working on a bid for this project.   c. Ceiling vent has been cleaned. d. Back corridor kitchen door is locked at this time. 2. The system will be corrected so as to reduce the risk of re-occurrence; staff will be provided with in servicing on reporting damaged, broken facilities or equipment, utilization of maintenance request log as means of communication regarding repair needs that are not urgent, and Maintenance Director will respond to repair needs timely. 3. The area needing corrected will need to be evaluated on a monthly basis as part of the environmental audit. 4. The Administrator, Maintenance Director 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 follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 150, C 231, C 240, C 372, C 420, C 422, C 460, C 510 and C 513.

Z142 OAR 411-057-0140 (2) Administration Compliance Refer to C150, C231, C240, C372, C420, C422, C460, C510 and C513 per plan of correction

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C150, C231, C372, C420, C460, C510 and C513.

Z142 OAR 411-057-0140 (2) Administration Compliance Refer to C150, C231, C240, C372, C420, C460, C510 and C513 per plan of correction

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired direct care staff (#s 6, 8, 11 and 14) completed pre-service orientation topics, 1 of 3 newly-hired direct care staff (#11) failed to complete 6 hours of pre-service dementia care training, 3 of 3 newly hired staff failed to complete all required training and demonstration of competency (#s 8, 11 and 14) and 3 of 3 sampled long term direct care staff (#s 7, 12 and 16) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to: Training records were reviewed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. The following were identified: a. Staff 6 (Maintenance Director), was hired 02/02/22, Staff 8 (CG) hired 01/05/22, Staff 11 (CG) hired 02/01/22 and Staff 14 (CG) hired 03/08/22. There was no documented evidence the following orientation topics were completed:   * Resident rights and values of CBC care; * Abuse reporting requirements; * Standard precautions for infection control; and * Fire safety and emergency procedures.   b. There was no documented evidence Staff 11 had completed pre-service dementia care training. c. There was no documented evidence that Staff 8, Staff 11 and Staff 14 completed the required training in: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Changes of condition and changes that require reporting; and * General food safety, serving and sanitation. d. Staff 7 (CG) was hired 01/29/2015, Staff 12 (CG) was hired 03/01/14 and Staff 16 was hired 04/20/15. For the annual period of their respected hire dates, there were no documented hours of the required 16 hours of in-service training on topics related to dementia and provision of care. The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, that newly hired staff demonstrated and documented required 30 day competencies and that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 3 and Staff 27 on 05/04/22. They acknowledged the findings.

Z155 OAR 411-057-0155 (1-6) Staff Training Requirements 1. Immediate actions taken to correct the rule violation include; a. Staff #6, #8, #11, and #14 will receive the required training in resident rights and values of CBC care, abuse reporting requirements, standard precautions for infection control, and fire and life safety and emergency procedures. b. Staff #11 will receive the required pre-service dementia care training. c. Staff #8, #11 and #14 will receive the required training; role of service plans in providing individualized care, providing assistance with ADL's, changes associated with normal aging, change of condition and changes that require reporting and general food safety, serving and sanitation. d. Staff #7, #12, and #16 will receive the required 16 hours of in-service training on topics related to dementia and provision of care. 2. Ongoing, any newly hired staff will receive the required pre-service training prior to beginning their job duties. All new staff will receive Memory Care required training with 30 days of hire, and ongoing inservice training for Memory Care per annual inservice requirements. 3. The areas needing correction will be evaluated prior to any new hire beginning by using new hire checklist as well as with community continuous quality assurance system reviews. 4. The Administrator, Business Office Manager and / 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 2 of 3 newly hired staff (#s 25 and 30) completed all required training and demonstrated competency, 3 of 3 sampled long term direct care staff (#s 12, 29 and 31) completed a total of 16 hours of annual in-service training, including six hours of annual dementia care training, and 2 of 3 sampled newly hired direct care staff (#s 25 and 30) completed orientation and pre-service topics. This is a repeat citation.  Findings include, but are not limited to: Training records were reviewed on 12/13/22 and 12/14/22. The following were identified: a. Staff 25 (MT) hired 11/18/22 and Staff 30 (MT/CG) was hired on 08/05/22. There was no documented evidence the following orientation topics were completed: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Changes of condition and changes that require reporting; and * General food safety, serving and sanitation. b. There was no documented evidence Staff 30 had completed Med Pass training. c. There was no documented evidence that Staff 25 and Staff 30 completed the required training in:   * Resident rights and values of CBC care; * Abuse reporting requirements; * Infectious Disease Prevention; and * Fire safety and emergency procedures.   The need to ensure newly hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, that newly hired staff demonstrated and documented required 30 day competencies and that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 35 (Executive Director), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22 at 12:20 pm. They acknowledged the findings.

Z155 OAR 411-057-0155 (1-6) Staff Training Requirements 1. Immediate actions taken to correct the rule violation include; a. Staff will receive the required training in resident rights and values of CBC care, abuse reporting requirements, standard precautions for infection control, and fire and life safety and emergency procedures. b. Staff will receive the required pre-service dementia care training. c. Staff will receive the required training; role of service plans in providing individualized care, providing assistance with ADL's, changes associated with normal aging, change of condition and changes that require reporting and general food safety, serving and sanitation. d. Staff will receive the required 16 hours of in-service training on topics related to dementia and provision of care. 2. Ongoing, any newly hired staff will receive the required pre-service training prior to beginning their job duties. All new staff will receive Memory Care required training with 30 days of hire, and ongoing in-service training for Memory Care per annual in-service requirements. 3. The areas needing correction will be evaluated prior to any new hire beginning by using new hire checklist as well as with community continuous quality assurance system reviews. 4. The Administrator, Business Office Manager and / 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 provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 252, C 260, C 262, C 270, C 280, C 282, C 290, C 300, C 303, C 310 and C 330.

Z162 OAR 411-057-0160 (2b) Compliance with Rules of Health Care Refer to C252, C260, C262, C270, C280, C282, C290, C300, C303, C310 and C330 for plan of correction.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C270, C300, C303 and C310.

Z162 OAR 411-057-0160 (2b) Compliance with Rules of Health Care Refer to C252, C260,C270,C300, C303,and 310 for plan of correction.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in service plans for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3, 4 and 5's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. On 05/04/22, the need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 2 (RN), Staff 3 (RCC), Staff 27 (Regional Director of Operations). They acknowledged the findings.

Z163 OAR 411-057-0160 (2)(c )(A)(B) Nutrition and Hydration 1. Immediate actions taken to correct the rule violations include resident #1, #2, #3, #4 and #5 and 100% of other residents will be evaluated and individualized nutrition and hydration plans that include resident preferences will be developed and included on their care plan. 2. The following actions will be implemented to ensure the system is corrected so this violation will not happen again, at the time of move in an individualized nutritional and hydration plan will be developed based on residents evaluated needs and included on the new admission care plan. 3. Each resident's nutritional and hydration plan will be reviewed and updated as needed at their quarterly care plan review or as needed when a significant change of condition occurs. 4. The Administrator, Licensed Nurse or designee will be responsible to see the corrections are completed and monitored.

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 and failed to consistently provide meaningful activities for all residents that promoted or helped sustain physical and emotional well-being, for 5 of 5 sampled residents (#s 1, 2 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, 4 and 5's service plans offered some information about the residents' interests, however, the facility had not fully evaluated the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There were no specific activity plans developed from the evaluations that detailed what, when, how and how often staff should offer and assist the resident with individualized activities. Observations and interviews indicated the residents were dependent on staff to initiate activities and scheduled activities did not happen on each floor of the building. On 05/04/22 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations), who acknowledged the findings.

Z164 OAR 411-057-0160 (2d) Activities 1. Immediate actions taken to correct the rule violation include the review and development of residents #1, #2, #3, #4 and #5 individualized activity plans based of activity evaluation. The activity plans will address the following: past and current interest, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate; and / or identification of activities for behavioral interventions. Activity plans will consistently provide meaningful activities for residents #1, #2, #,3, #4 and #5, and will be developed for 100% of residents to promote or help sustain their physical and emotional well-beings. Their personalized activity plan will be included in their care plan for staff reference to engage in meaningful planned and spontaneous activities with the residents throughout the day. 2. This system will be corrected so this violation will not happen again by ensuring that at the time of move in, an individualized activity plan will be developed and included on the new admission care plan. The activity plans will be person directed and meaningful with focus to promote or help sustain physical and emotional wellbeing for the residents. It will take into consideration 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 community will provide daily structured and non-structured / spontaneous activities throughout the day. The activities will be selected based on resident preferences and ability to participate. 3. To ensure the activity plan meets the current needs of each resident, it will be reviewed and updated as needed at their quarterly service plan review. In addition, it will be updated as needed when a significant change of condition occurs. Activity Director will review activity options and scheduled appropriate activities on a monthly basis when updating the activity calendar. 4. The Administrator, RCC, Activity Director or designee will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure individualized activity plans were developed for each resident, based on their activity evaluations, for 1 of  4 sampled memory care residents (#7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 7 was admitted to the MCC in 02/2021 with diagnoses including dementia and insomnia. Residents 7's service plan offered some information about the residents' historical and current interests. However, the facility had not fully evaluated the resident in the following areas: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; and * Adaptations necessary for the resident to participate. There was no specific activity plan developed from the evaluation which detailed what, when, how and how often staff should offer and assist the resident with individualized activities. On 12/14/22 the need to ensure the facility developed individualized activity plans for each resident in the MCC was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations). They acknowledged the findings. No further information was provided.

Z164 OAR 411-057-0160 (2d) Activities 1. Immediate actions taken to correct the rule violation include the review and development of residents individualized activity plans based of activity evaluation. The activity plans will address the following: past and current interest, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate; and / or identification of activities for behavioral interventions. Activity plans will consistently provide meaningful activities for all residents, and will be developed for 100% of residents to promote or help sustain their physical and emotional well-beings. Their personalized activity plan will be included in their care plan for staff reference to engage in meaningful planned and spontaneous activities with the residents throughout the day. 2.  The system will be corrected so as to reduce the risk of re-occurrence by ensuring that at the time of move in, an individualized activity plan will be developed and included on the new admission care plan. The activity plans will be person directed and meaningful with focus to promote or help sustain physical and emotional wellbeing for the residents. It will take into consideration 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 community will provide daily structured and non-structured / spontaneous activities throughout the day. The activities will be selected based on resident preferences and ability to participate. 3. To ensure the activity plan meets the current needs of each resident, it will be reviewed and updated as needed at their quarterly service plan review. In addition, it will be updated as needed when a significant change of condition occurs. Activity Director will review activity options and scheduled appropriate activities on a monthly basis when updating the activity calendar. 4. The Administrator, RCC, Activity Director or designee will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident and others in the community and include information and instructions for staff to follow, for 1 of 1 sampled resident (#1) who exhibited behaviors. Findings include, but are not limited to: Resident 1 resided on the memory care unit since October 2021 and was diagnosed with Alzheimer's dementia. Progress notes indicated the resident became agitated and was involved in a physical altercation with another resident on 02/16/22. Other progress notes, reviewed from 02/01/22 through 04/03/22, indicated the resident would occasionally become agitated and difficult to re-direct, wandered through the unit and occasionally went into other resident's rooms. The resident's current service plan, dated 08/11/21, did not provide any information on agitation, behaviors or interventions for staff to provide when behaviors occurred. The resident had a physician's order for staff to administer a psychotropic medication as needed for agitation. In an interview on 05/02/22, Staff 8 (CG) stated the resident would often require re-direction if s/he got into arguments with other residents or entered other resident's rooms. The facility failed to evaluate Resident 1's behavior, add information about the behavior to the service plan and develop interventions for staff to attempt when the behaviors occurred. The need to evaluate Resident 1's behavior and provide an individualized behavior plan was discussed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

Z165 OAR 411-057-0160 (e ) Behavior 1. Immediate actions taken to correct the rule violations include evaluating resident #1 for behavioral symptoms and ensuring the care is updated to reflect all current and effective interventions identified for staff to utilize to better meet resident needs and minimize behaviors including agitation, resident to resident altercations and wandering. All current residents will be evaluated for behavioral symptoms, which negatively impact the resident or others. Based off of this evaluation, resident specific interventions to reduce, eliminate or de-escalate any identified behaviors that do negatively impact the resident and others will be identified and added to the care plan. 2. The system will be corrected so this violation will not happen again by ensuring that an evaluation of behavioral symptoms will take place as part of the evaluation process at the time of move in. An individualized behavior support plan will be developed based on residents evaluated needs, and included on the new admission care plan. This area will be re-evaluated within 30 days, and quarterly thereafter to ensure the behavioral plan remains effective to support the residents current needs and preferences.   3. Each resident's behavioral support plan will be reviewed and updated as needed at their next scheduled care plan review (30 day or 90 day) or as needed when a significant change of condition occurs. 4. The Administrator, Licensed Nurse or designee will be responsible to see the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C150, C231, C252, C260, C270, C300, C303, C310, C372, C420, C460, C510, C513, Z155 and Z164.

OAR 411-054-0105 (2-4) Rule was not meet refer to tags C150, C231, C252, C260, C270, C300, C303, C310, C372, C420, C460, C510, C513, Z155 and Z 164.

The findings of the re-licensure survey conducted 05/02/22 through 05/04/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first  re-visit to the re-licensure survey of 05/04/22, conducted 12/12/22 through 12/14/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day