Grove Pointe Senior Living

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

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 sampled resident (# 6) and failed to ensure evaluations were performed at least quarterly, to correspond with the quarterly service plan updates, for 3 of 6 sampled residents (#s 1, 3 and 7) whose evaluations were reviewed. Findings include, but are not limited to: 1. Residents 1, 3, and 7’s most recent quarterly evaluations were requested during the survey. During an interview on 03/31/26 at 11:50 am, Staff 6 (Staffing/MT) confirmed there were no quarterly evaluations for Residents 1 and 7. Staff 6 stated the facility was trying to get quarterly evaluations updated. During an interview on 04/01/26 at 12:10 pm, Staff 4 (RCC) confirmed there was no quarterly evaluation to review for Resident 3. The facility had been working on completing residents’ quarterly evaluations but has not “gotten to all of them yet.” The need to ensure resident evaluations were completed at least quarterly was discussed with Staff 1 (ED), Staff 2 (Health Services Director Specialist/LPN) and Staff 4 at 2:43 pm on 04/01/26. They acknowledged the findings. 2. Resident 6 was admitted to the facility on 02/2026 with diagnoses including chronic obstructive pulmonary disease (COPD). A review of the resident’s move-in evaluation identified the following elements were not addressed: * Pronouns; * Cognition, including memory, orientation, confusion and decision-making abilities; * Complex medication regimen; and * History of dehydration or unexplained weight loss or gain. The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (ED) on 03/31/26 at 1:35 pm. Staff acknowledged the findings.

Resident #6 Evaluation/service plan was updated on 4/13/2026 by the ED to include; pronouns, cognition, basis for complex medication regimin, and any history of dehydration or weight loss/gain. Resident's #1, 3, and 7 evaluation and service plan will be updated to include all required elements including * Pronouns; * Cognition, including memory, orientation, confusion and decision-making abilities; * Complex medication regimen; and * History of dehydration or unexplained weight loss or gain. by the ED/HSD/Designee by 5/1/2026. ED, HSD or Designee will review evaluation tracker in ALIS two times per week for one month, then weekly after that to plan for upcoming evaluation and care plan updates. The Regional Nurse will educated the ED regarding the requirements of the OAR for resident evaluations/service plans. ED/HSD/Designess will audit all resident records to ensure each evaluation/service plan contains the required elements per the OAR. Any identified missing elements will be updated by the ED/HSD/Designee. HSD/Designee will review resident evaluations/CP reports weekly during to ensure care plans are completed & accurate x4 weeks, bi-weekly x 4 weeks then quarterly,ongoing. The results of these audits will be discussed during the monthly Continuous Quality Improvement Committee meeting.

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were completed quarterly, readily available to staff, reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services and were implemented for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2022 with diagnoses including diabetes mellitus and hypotension. Observations of the resident, interviews with staff and resident, review of service plan dated 05/28/25, 12/31/25 through 03/27/26 observation notes and change in plan of communication were completed. The service plan was not reflective, was not implemented and did not provide clear direction for staff in the following areas: * Use of a cushion or a pillow in the wheelchair; * Level of assistance with incontinence care and dressing status; * Conflicting information regarding weight measurements, monthly versus daily; * Sleeping habits and resident preferences; * Using a special boot on the left foot; * Presence of a side rail on the bed; * Use of a sensor to check blood glucose, including care of the sensor; and * Use of hearing aids status. The need to ensure resident service plans were reflective of current care needs, were implemented and provided clear direction to staff was discussed with Staff 1 (ED) on 04/01/26 at 11:59 am. He acknowledged the findings. 2. a. During the acuity interview on 03/30/26, facility staff reported service plans were stored in the service plan binder, located in the MT room for direct care staff to review. Upon observation of the binder at 11:05 am on 03/30/26, the service plans for Residents 1, 3, 4, 5 and 7 were not available to staff at the time of survey entrance. b. There was no documented evidence resident service plans had been updated, at least quarterly, for the following: * Resident 1’s most recent service plan, dated 09/25/25 and Resident 7’s most recent service plan dated 09/05/25, were provided to the survey team on 03/30/26 at 11:33 am; and * Resident 3’s most recent service plan, dated 06/30/25, was provided to the survey team on 03/30/26 at 12:35 pm. During an interview on 03/30/26 at 11:05 am, Staff 6 (Staffing/MT) acknowledged there were multiple service plans in the process of being updated since the change of ownership and were not available to staff. The need to ensure residents’ current service plans were readily available to staff and updated at least quarterly was reviewed with Staff 1 (ED), Staff 2 (Health Services Director Specialist/LPN) and Staff 4 (RCC) at 2:43 pm on 04/01/26. They acknowledged the findings.

ED/HSD/Designees will ensure all residents including residents 1,2,3,4,5, 6 and 7 have a current evaluation and care plans reflective of residents needs within the last quarter by 6/1/26. ED/HSD/Designee will monitor due dates weekly to ensure all evaluations are completed within the time specified. Initial assesments done no more than 30 days prior to admit, move-in assessment done within the first 30 days and quarterly assessments done quarterly. Review EHR and schedule completion of evaluations within required completion days. ED/HSD/ Designee will ensure updated copy of resident evaluation and service plan for all residents will be available in the careplan binder in the med room for all staff to view. The ED/Designee will audit the service plan binder at least monthly x 3 months beginning 6/1/2026 to ensure it is kept up to date. The results of these audits will be reported to the monthly Continuous Quality Improvement Committee. ED, HSD or Designee will review evaluation tracker in ALIS two times per week for one month, then weekly after that to plan for upcoming evaluation and care plan updates. The Regional Nurse will educated the ED regarding the requirements of the OAR for resident evaluations/service plans. ED/HSD/Designess will audit all resident records to ensure each evaluation/service plan contains the required elements per the OAR. Any identified missing elements will be updated by the ED/HSD/Designee. HSD/Designee will review resident evaluations/CP reports weekly during to ensure care plans are completed & accurate x4 weeks, bi-weekly x 4 weeks then quarterly,ongoing. The results of these audits will be discussed during the monthly Continuous Quality Improvement Committee meeting.

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 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that consisted of the resident, the resident's legal representative if applicable, any person of the resident’s choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose records were reviewed. Findings include but are not limited to: Resident 1, 2, 3, 4 and 5’s most recent service plans lacked evidence a service planning team reviewed and participated in the development of the service plans. On 03/31/26 at approximately 1:56 pm, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED). No additional information was provided.

ED/HSD/RCC will provide care conferences to all residents and their legal represenentative at the time of the updated evaluation. Documentation of care plan or attempts to schedule a conference will be kept with resident records. All residents will be offered care conference by 6/1/26. Regional Director of Health services will educated the ED on the requirements of a service planning team, The ED/HSD/designee will discuss care conference schedules at standup at least 4 days/week. The ED/HSD will audit updated evaluations/service plans and care conference schedules/documentation weekly x 4 weeks, bi-weekly x 4 weeks or until compliance with service planning team achieved. The results of these audits will be reported to the monthly Continuous Quality Improvement Committee.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure short term changes of condition were monitored weekly through resolution and significant changes of condition were evaluated, referred to the facility nurse, documented, and the resident’s service plan updated as needed for 3 of 5 sampled residents (#s 2, 3, and 5) who had documented short term and/or significant changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 05/2019 with diagnoses including mild cognitive impairment, type 2 diabetes, and anemia. Resident 5's clinical record, service plan, temporary service plans, incident reports, and observation notes reviewed from 12/30/25 through 03/30/26 revealed the following: On 03/25/26, Resident 5 had three falls out of his/her recliner and was transported to the emergency room for evaluation. On 03/27/26 an RN assessment was completed for a significant change of condition following Resident 5’s falls. Interventions identified from the RN assessment included: * Replace the broken recliner chair in their room; * Place non-skid mat on the seat to prevent slipping; and * “Resident should remain in public areas with line-of-sight supervision during waking hours”. An observation in resident 5’s room on 03/31/26 at 12:05 pm with Staff 1 (ED) revealed the broken recliner chair had not been replaced and the non-skid mat on the seat was covered with a blanket. In interview on 03/31/26 at 1:00 pm, Staff 18 (CG) was not aware of the new interventions or how to implement them. In interview at 2:00 pm on 03/31/26, Staff 4 (RCC) confirmed the service plan had not been updated after the RN assessment was completed. On 4/01/26 at 4:00 pm, the need to update the service plan with the new interventions after a change of condition was reviewed with Staff 1, Staff 2 (Health Services Director Specialist/LPN), and Staff 4. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 12/2022 with diagnoses including diabetes mellitus and hypotension. a. The resident's 03/19/26 service plan, 12/31/25 through 03/27/26 observation notes and 12/18/26 through 03/30/26 outside provider visit notes were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved in the following areas: * 01/06/26 - A new medication, torsemide for fluid retention; * 02/13/26 – A recurrent pressure sore on the coccyx; and * 03/05/26 – Returned from the emergency room for catheter leakage, pain and received antibiotic treatment for urinary tract infection. During an interview on 03/31/26 at 1:35 pm, Staff 1 (ED), confirmed the changes of condition had not been monitored with weekly progress noted until resolved. No additional information was provided. b. The resident’s 03/19/26 service plan, 12/21/25 through 03/05/26 change in plan of care communication and 12/18/26 through 03/30/26 outside provider visit notes were reviewed and indicated the resident developed a stage 2 pressure sore on the coccyx on 01/12/26, which resolved on 01/17/26, and reoccurred on 02/13/26. There was no documented evidence the facility evaluated the resident, referred the resident to the facility nurse and updated the care plan accordingly. During an interview on 03/31/26 at 12:20 pm, Staff 2 (Health Services Director Specialist/ LPN), reported the facility used a triple-checking system to review documentation of outside provider visit notes. This system included checks by MT, RCC staff and nurses. Although there was a note in the record, she was not aware of the pressure sore and was not able to determine whether other nurses were aware of it. On 03/30/26 at 12:41 pm, the resident was observed using a cushion in his/her wheelchair and on the same day at 12:55 pm, Staff 11 (CG) reported the resident used a pillow in the wheelchair to provide pressure relief. There was no service plan documenting the use of the cushion and pillow while the resident was in the wheelchair. During an interview on 04/01/26 at 10:35 am, Staff 15 (CG) and Staff 18 (CG) reported there was no open wound on the coccyx area and a dry scab was at the previous wound site. The need to ensure short-term changes of condition had documentation of weekly progress until resolution, and significant changes of condition were evaluated, referred to the facility nurse, documented and the resident’s service plan updated as needed was discussed with Staff 1 on 03/31/26 at 1:35 pm. Staff acknowledged the findings. 3. Resident 3 was admitted to the facility in 02/2025 with diagnoses including chronic obstructive pulmonary disease. Review of Resident 3's clinical record, service plan, temporary service plans, after visit summaries, and 12/10/25 through 03/24/26 observation notes revealed the following: * 02/01/26 – A missed dose of tramadol for severe pain; * 02/03/26 – Multiple medication changes included hydrochlorothiazide (for reducing fluid retention) was discontinued, and Vitamin D3 (a supplement) and ondansetron PRN (for nausea) were new; * 02/04/26 – Injury fall; and * 03/04/26 – Routine tramadol for severe pain was discontinued. There was no documented evidence these short-term changes of condition were monitored, with progress noted at least weekly, to resolution. On 04/01/26 at 2:43 pm, Staff 2 (Health Services Director Specialist/LPN) and Staff 4 (RCC) confirmed the identified changes of condition for medications and a fall, and they acknowledged the lack of documented monitoring through resolution. The need to ensure the facility monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (ED), Staff 2, and Staff 4 on 04/01/26 at 2:43 pm. They acknowledged the findings.

HSD/Designee/RN Delegation Nurse will evaluate & document all necessary changes & interventions and TSP's in place for residents #2, 3, and 5. ED/HSD/RN will be reeducated by the Regional Director of Health Services on the need to ensure actions and interventions for short term change in condition were documented and communicated to staff, and monitored weekly until resolution. Guidelines for changes of condition and need to ensure all actions& interventions regarding change in condition, and TSP's are completed. All staff will be educated by the ED/Designee on Temporary Service Plans, reading the binder and signing the acknowledgement of the TSPs. HSD/Designee will track on the nursing audit log change of condition weekly to ensure RN change of condition assessment is completed along with service plan updates. Daily clinical meeting will occure with RCC, Nurse and ED where we will review observation notes and incident reports for any potential significan change of conditions. These changes of conditions will be reported to RN oversight nurse immediately .

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 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

Based on interview and record review, it was determined the facility failed to have a system in place for tracking controlled substances administered by the facility, for 1 of 1 sampled resident (# 3) whose MARs and controlled substance drug disposition logs were compared for accuracy. Findings include, but are not limited to: Resident 3 moved into the facility in 02/2025 with diagnoses including chronic obstructive pulmonary disease. Resident 3’s 03/01/26 through 03/30/26 MARs and controlled substance disposition log, dated 03/06/26 to 03/30/26, were reviewed and showed the following: * Physician orders for tramadol 50 mg to give 2 tablets twice a day as needed for severe pain; * A dose was signed out in the disposition log on 03/08/26 at 7:30 pm, and the dose was not reflected on the MAR; * A dose was signed out in the disposition log on 03/11/26 at 7:13 pm, and the dose was not reflected on the MAR; * A dose was signed out in the disposition log on 03/13/26 at 6:20 pm, and the dose was not reflected on the MAR; * A dose was signed out in the disposition log on 03/17/26 at 6:23 am, and the dose was not reflected on the MAR; * A dose was signed out on the MAR on 03/07/26 at 10:07 am, and the dose was not reflected on the disposition log; * A dose was signed out on the MAR on 03/08/26 at 5:14 am and the dose was not reflected on the disposition log; * A dose was signed out on the MAR on 03/12/26 at 7:12 pm, and the dose was not reflected on the disposition log; and * A dose was signed out on the MAR on 03/14/26 at 6:28 pm, and the dose was not reflected on the disposition log. The inconsistencies were reviewed on 04/01/26 at 12:51 pm with Staff 2 (Health Services Director Specialist/LPN). She indicated she was not aware of a process to review the controlled substance drug disposition logs for accuracy. Comparison of the remaining quantities of the medication to the disposition log showed the amount left was accurately reflected on the log. The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (ED), Staff 2 and Staff 4 (RCC) on 04/01/26 at 2:43 pm. They acknowledged the findings.

All medication staff will be re-educated by the ED/Regional Director of Health Services on the requirements of tracking/documenting controlled substances. The Regional Director of Health Services/designee will implement the electronic tracking within the EHR system and train all medication staff on the use of this system. The ED/Designee will audit narcotic dispositions/administrations weekly x 4 weeks, then bi-weekly x 4 weeks to ensure compliance. The ED/HSD/Designee will be responsible for reporting the results of these audits to the Continuous Quality Improvement Committee.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

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

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to orders for 2 of 2 sampled residents (#s 2 and 5) who had documented refusals. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2022 with diagnoses including constipation. Resident 2's MARs, dated 03/01/26 through 03/30/26, were reviewed and showed facility staff documented Resident 2 refused the following orders: * Bacitracin (first-aid antibiotic) ointment on three occasions; * Bisacodyl 5 mg (laxative) on 20 occasions; and * Polyethylene powder (laxative) on 46 occasions. There was no documented evidence the prescriber had been notified of the refusals. The need to ensure the facility notified physicians or practitioners of medication refusals was reviewed with Staff 1 (ED) on 03/30/26 at 1:35 pm and Staff 4 (RCC) on 04/01/26 at 1:15 pm. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 05/2019 with diagnoses including mild cognitive impairment, type 2 diabetes, and anemia. Resident 5's MARs, dated 03/01/26 through 03/30/26, were reviewed and revealed facility staff documented Resident 5 refused the following orders: * Acetaminophen 500 mg (for pain) on four occasions; * Bupropion 150 mg (anti-depressant) on two occasions; * Duloxetine 30 mg (anti-depressant) on two occasions; * Famotidine 200 mg (for gastric reflux) on two occasions; * Lithium 300 mg (for bi-polar depression) on two occasions; * Miconazole nitrate 2% (topical anti-fungal) on one occasion; * Nystatin cream (topical anti-fungal) on one occasion; * Senna 8.6 mg (laxative) on two occasions; and * Trospium Chloride (anti-spasmodic) on three occasions. There was no documented evidence the prescriber had been notified of the refusals. On 04/01/26 at 4:10 pm, the need to notify the prescriber when a resident refused to consent to medication orders was reviewed with Staff 1 (Executive Director), Staff 2 (Health Services Director Specialist/LPN), and Staff 4 (RCC). They acknowledged the findings.

On 4/17/26, The ED notified Resident #2 and #5's physician of the medication refusals. ED/HSD/Designee will conduct training with all med techs on company policy for resident refusals. The med tech will complete the physician communication form and fax to physician for every refused medication. Documentation will be maintained in resident physical charts. ED/HSD/Designee to audit daily for two weeks and then once a week for 2 months to ensure completion. The ED/HSD/Designee will report the results of these audits to the Continuous Quality Improvement Committee.

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

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer medications and had more than one resident in a unit were evaluated for safety and a physician's order was in place for the self-administration for 1 of 1 sampled residents (# 7) who self-administered medications. Findings include, but are not limited to: Resident 7 moved into the facility in 11/2024 with a diagnosis of syncope (fainting). During the acuity interview on 03/30/26, it was identified Resident 7’s medications were administered by Witness 1 (Spouse), who lived in the same apartment with Resident 7. In an interview on 04/01/26 at 2:45 pm, Witness 1 confirmed s/he administered medications to Resident 7. Witness 1 indicated medications were kept in the bathroom, and s/he did not keep medications in a locked container. Review of Witness 1’s physician orders revealed there was no current signed physician's order for Witness 1 to self-administer medications, nor was there a quarterly assessment of Witness 1’s ability to safely self-administer medication, including his/her ability to administer medications to Resident 7. There was no documented evidence the facility had assessed Resident 7's ability to safely have medication in the unit. The need to ensure residents who self-administered their medications and had more than one resident residing in the unit were evaluated quarterly and had a current physician's order for self-administering was reviewed with Staff 1 (ED), Staff 4 (RCC), on 04/02/26 at 9:50 am. They acknowledged the findings.

The ED/HSD/Designee completed a self medication evaluation for resident #7 and Witness #1 on 4/3/26. A written physician order for resident #7 was obtained by the ED on 4/3/26. ED/HSD/Designee will complete self medication assessment and SLUMS for every resident in the community who is designated as a self med and ensure there is a physician order for those resident's to self-medicate. If a physician will not given an order for self-medication, or it is determined through the evaluation that the resident is unable to self administer medications, the community will proceed with administration of those medications. The ED/HSD will be educated by the Regional Director of Health Services on the Self Administration of medication policy. The medication staff will be educated by the ED/HSD/Designee about the self administration of medication policy. The ED/HSD will audit self medication evaluations monthly to ensure they are current per policy.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, other less restrictive alternatives evaluated prior to use of the device were documented, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident's service plan for 1 of 1 sampled resident (#4) who used supportive devices with restraining qualities. Findings include, but are not limited to: Resident 4 was admitted to the facility in 02/2024 with diagnoses including heart failure and chronic kidney disease. Observations of the resident and the resident's room on 03/31/26 at 3:30pm showed a half-length side rail on the side of the bed in the up position that represented a device with restraining qualities. Review of Resident 4's record revealed there was no documented evidence the device with restraining qualities had been assessed by an RN, PT, or OT, no documentation of other less restrictive alternatives evaluated prior to use of the devices, no documentation of instruction to caregivers on correct use of and precautions for the device, and no documentation of the use of the side rails in the resident's service plan. During an interview on 04/01/26 at 4:00 pm, Staff 1 (ED) acknowledged no assessment had been completed for Resident 4's side rail. The need to ensure the use of a supportive device with potentially restraining qualities included documentation of all required elements and the device was included in the resident's service plan was discussed with Staff 1, Staff 2 (Health Services Director Specialist /LPN) and Staff 4 (RCC) on 04/01/26 at 4:05 pm. They acknowledged the findings.

Resident #4 device with restraining qualities supportive device assessment will be completed by the RN. The ED will educate all staff on devices with restraining qualities. The ED/HSD will audit all residents for use of supportive devices with restraining qualities and refer all identified to the RN to complete the assessment and will review all residents to ensure all resident assistive devices are included in evaluations and service plans. The ED/HSD will audit supportive device assessments monthly x 3 months and then quarterly to ensure they are kept up to date.

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

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

Based on interview and record review, it was determined the facility failed to ensure the ABST was updated before a resident moved in, whenever there was a significant change of condition, and no less than quarterly at the same time the resident’s service plan was updated to determine appropriate staffing levels to address activities of daily living and other tasks related to care for 4 of 6 sampled residents (#s 3, 5 and 6) and multiple unsampled residents. Findings include, but are not limited to: Review of clinical records, including service plans and/or evaluations for Residents 3, 5 and 6, revealed the facility's ABST was not updated prior to move in, whenever there was a significant change of condition and at least quarterly to reflect the residents' care needs and ensure the ABST accurately determined the needed staffing level. The ABST evaluation date for multiple unsampled residents, reviewed during the survey, revealed the ABST evaluations had not been reviewed and updated in the last 90 days (quarterly). On 03/31/26 at 2:20 pm, the need to ensure the ABST was updated prior to move-in, following significant changes of condition and at least quarterly was discussed with Staff 1 (ED). He acknowledged the findings.

The ED was educated by the Regional Director of Health Services on the requirements of the ABST to be updated prior to move in, at least quarterly and with a change of condition. ED/HSD/Designee have updated all residents in ABSTcurrently. ED to ensure that as each new assesment is completed in ALIS, the update is entered into ABST and a current staffing plan is updated with the date of implementation and posted. ED will also audit monthly to ensure that all residents have been updated in ABST within the last 90 days. The ED/designee is responsible to ensure the ABST is updated appropriately and reflects accurately the time of care for each resident to ensure adequate staffing levels.

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

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired sampled staff (#s 12 and 14) completed all required pre-service orientation and dementia training prior to beginning their job responsibilities and providing care for residents. Findings include, but are not limited to: Staff training records were reviewed on 04/01/26 and revealed the following: a. There was no documented evidence Staff 12 (CG) and Staff 14 (CG) both hired 02/25/26, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Abuse reporting requirements; and * Fire safety and emergency procedures. b. There was no documented evidence Staff 14 had completed one or more of the following pre-service dementia care training topics: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need for newly hired staff to complete all required pre-service orientation and dementia training prior to starting their job duties and providing care to residents was discussed with Staff 3 (Business Office Manager) on 04/01/26 and Staff 1 (ED) and Staff 4 (RCC) on 04/02/26 at 9:50 am. They acknowledged the findings.

The ED/BOM will be educated by the Regional Director of Operations and the Regional Director of Health Service on preservice training requirements. ED/BOM will develop plan and schedule for structured orientations to occur in community. ED/BOM have developed master copy of new hire documents to be used in future orientations. ED/BOM will audit all employee files for completeness using audit tools. All files will be audited and completed by 6/1/26. Any staff identified that are missing training will be given a timeline of completion and if they are not completed, they will not be on the schedule. ED/BOM will audit one employee file daily during the daily stand-up meetings. To ensure new files are being completed to standards and in a timely manner.The results of these audits will be reported to the monthly Continuous Quality Improvement Committee. As of 4/28/26 Staff 12&14 have completed all missing and required new hire documented trainings.

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

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 sampled staff (#s 8, 12, 13, and 14) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 04/01/26 and revealed the following: There was no documented evidence Staff 8 (MT), Staff 12 (CG), Staff 13 (CG), or Staff 14 (CG) hired 11/01/25, 01/05/26 and 02/25/26 respectively, demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * General food safety, serving and sanitation; and * First aid/abdominal thrust. The need for staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 3 (Business Office Manager) on 04/01/25 and Staff 1 (ED) and Staff 4 (RCC) on 04/02/26 at 9:50 am. They acknowledged the findings.

Staff #8, 12, 13, and 14 will have their competencies completed by the RCC/HSD Specialist/Designee. The ED/BOM will be educated by the Regional Director of Operations and the Regional Director of Health Service on training requirements within 30 days of employment. ED/BOM will audit all employee files for completeness using audit tools. All files will be audited and completed by 6/1/26. ED/BOM will audit one employee file daily during the daily stand-up meetings. To ensure new files are being completed to standards and in a timely manner. These audits will be reported to the monthly Continuous Quality Improvement Committee.

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 staff were provided with fire and life safety training every other month and to document all required fire drill elements per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety documentation from 11/2025 through 03/2026 was reviewed on 03/30/26 and 03/31/26. The following was identified: 1. There was no documented evidence all staff were provided with fire and life safety training every other month. 2. Fire drill documentation did not include one or more of the following required elements: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. In an interview on 03/30/26 at 3:06 pm, Staff 1 (ED) reported having been employed at the facility for about three weeks and he confirmed no fire and life safety training to staff had been completed with the change of ownership in 11/2025. The need to provide fire and life safety training to all staff on opposite months of fire drills, as well as the need to address all required elements in fire drill documentation, was discussed with Staff 1 on 03/31/26 at 1:35 pm. Staff acknowledged the findings.

The ED will educate the Maintenance Director on the requirements of fire drills and training per the OAR. ED & Maintenance Director will conduct monthly fire drills at the community. The fire drills will be rotated monthly to ensure that each quarter there will be fire drill on each shift. The fire drill will be documented on the Oregon Fire Drill form. The form will be uploaded into TELS and hard copy will be maintained in the Emergency Binder. Oregon fire drill form will be used to ensure the following is documented with every fire drill; * Escape Routes Used * Problems Encountered * Number of Occupants Evacuated * Evidence that Alternative Routes were Used Maintenance Director will conduct monthly fire and life safety training at each all staff meeting. Training topic will be noted on the agenda and kept with the sign in sheet for the meeting. The ED/Designee will audit TELS (maintenance tracking system) monthly. Fire Drills and monthly training will be discused monthly at the CQM meeting.

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

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

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission. Findings include, but are not limited to: Fire and life safety documentation from 11/2025 through 03/2026 was reviewed on 03/30/26 and 03/31/26. In an interview on 03/31/26 at 1:34 pm, Staff 1 (ED) was unable to provide documentation that residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the facility within 24 hours of admission for Resident 6. He further stated he reviewed the facility’s admission packet and confirmed it did not include information on general safety procedures. The need to provide fire and life safety instruction to residents within 24 hours of admission was discussed with Staff 1 on 03/31/26 at 1:35 pm. He acknowledged the findings.

The ED will educate the Maintenance Director on the requirements for fire safety training for the residents within 24 hours of move in and annually. Maintenance Director will hold two meetings to train all residents in the community receive proper life safety training. The safety training will include; general safety, evacuation procedures, fire drill responsibilities and designated meeting place in case of a fire. These meetings will take place May 12th and May 28th. Annual training will be scheduled in TELS system for an annual date. The ED/BOM will audit new resident move in files within 24 hours to ensure completion of the fire training.The ED will track the annual training dates and ensure completion.

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

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Based on observation and interview, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple unsampled residents who resided on the first, second, and third floors. Findings include, but are not limited to: On 04/01/26 at 2:55 pm, an unsampled resident indicated all resident keys could be used on any of the resident unit doors. In an 04/01/26 interview at 3:05 pm, Staff 19 (CG) stated the residents all have the same key, it opened all the apartments, and he was provided the same key. Staff 19 stated if a resident wanted a new key and lock for their apartment door, they would have to tell the administrator. On 04/01/26 at 3:15 pm, the unsampled resident allowed the surveyor to use his/her key to trial other resident’s doors with their permission and the following was revealed: * It was observed the unsampled resident’s key unlocked a total of eight occupied units and two unoccupied units on the three floors. During an interview on 04/02/26 at 9:50 am, Staff 1 (ED) stated he was recently made aware of the key situation, and a plan was in place for new locks and keys for all the resident’s units. The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1 and Staff 4 (RCC) on 04/02/26 at 9:50 am. They acknowledged the findings.

The ED and the Maintenance Director will be educated by the Regional Director of Operations on the requirements of residents having access to their own lock and key with appropriate staff having access. Metro Lock Services will be onsite 4/22/26 to rekey all resident rooms and provide the community with keys for all rooms. The ED/MTD will ensure that each resident's key only opens their apartments and that appropriate staff have the key to access the unit. The ED/MTD are responsible to ensure that each apartment is keyed individually.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

OAR 411-054-0034 (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 preferred pronouns for 1 of 1 sampled resident (# 6) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252.

Refer to C 252.

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 411-054-0030 (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).

C240: Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 08/27/25 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * Dishwashing area – caulking and wall above back splash – build up of black matter, walls below dirty side of dishwasher drips of brown/black matter, shelf holding dish racks with dried white matter; * Floor and drain between steamer and flat top grill – food debris/build up of black matter; * Wall behind flat top grill and stove – grease drips; * Top of partial wall behind cooking equipment – dusty/greasy; * Interior of drawer next to stove – loose debris/food particles; * Oven doors and knobs – drips/spills/dried debris; * Commercial can opener – blade finish worn/black matter build up on housing of opener; * Four burner stove – doors with spills/knobs with dried debris/crusty build up; * Upper and lower shelves throughout the kitchen – spills/debris/dried food; * Walk in refrigerator fan cover – dusty; * Convection oven – sides/front drips/grease, top dusty; * Lids on food bins – food debris; * Stand mixer shelves – debris/spills/dusty; * Ecolab MSDS notebook on wall next to stand mixer – dusty; * Stainless steel doors on service line – smears/spills; * Exterior of garbage cans – food drips/spills; * Wall behind ice maker and vents – heavy build up of dust; * Wall above and behind refrigerator near service line – dust build up; * Single door refrigerator near service line – exterior door with smears/drips/spills; and * Three door freezers – bottom shelves with debris/spills, exterior doors with smears/drips/spills, vents above and below doors dusty. Improper food storage included: * Bags of croutons – not dated/labeled; * Multiple open bags of food in refrigerators – not dated/labeled and/or securely closed (bacon, green beans, salad, raw chicken, shredded cheese); * Uncovered container of cornmeal; * Bin with granulated sugar open to air; * Dry storage – boxes sitting directly on floor; * Bags of open frozen foods not securely closed and/or not dated/labeled; * Shelled eggs stored above containers of ready to eat food in refrigerator near service line; and * Walk in refrigerator speed rack – trays of uncovered food items. Other areas of concern: * Colored cutting boards – finish worn and scored; * Ceiling lights above food bins and in dry food storage were uncovered. The areas of concern were observed and discussed with Staff 1 (Lead Cook) on 08/27/25. The findings were acknowledged.

1. Actions Taken to Correct the Violation: All identified areas of concern were cleaned, sanitized, and corrected promptly upon identification. Unsafe food storage practices (open/unlabeled items, improper placement of eggs, uncovered foods) were immediately corrected. Work orders were submitted to Maintenance for needed repairs and equipment issues. New cutting boards were ordered and schedlued to arrive 9/19/25. Maintanice will be painting walls throughout the kitchen between 9/19-9/23 to lighten up the work area. 2. Systemic Correction to Prevent Reoccurrence: A daily cleaning checklist was implemented and must be completed and signed by staff before the end of each shift. A weekly deep cleaning schedule was established. All dietary staff received retraining on 9/16/25 covering sanitation practices, food storage, and cleaning responsibilities. Food storage and cleaning SOPs are posted in the kitchen for ongoing reference. Maintenance staff will complete weekly checks for needed repairs. 3. Monitoring & Frequency: The Executive Director will conduct random weekly audits of kitchen cleanliness, food storage, and sanitation practices, and document the results. Corrective action will be taken immediately if issues are identified. 4. Responsible Staff: • Dining Services Manager – oversees staff retraining, daily cleaning compliance, and weekly audits. • Lead Cook/Cooks – ensures shift cleaning checklists are completed. • Maintenance Supervisor – responsible for kitchen repairs and upkeep.

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

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 09/04/24 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * Microwave oven – interior food splatters; * Hood vents on both sides above stoves/grill – buildup of dust and grease; * Shelves below steamer and one sink counter – drips/splashes/debris; * Front and sides of stoves and oven doors – drips/spills; * Convection oven – sides/top/doors/legs had spills/drips/debris; * Pipes between stove and steamer – significant buildup of black matter; * Wall behind stove across from steam table – grease/drip buildup; * Back of grill top – significant buildup of grease/food splatter; * Front of stainless-steel doors on the steam table – drips/spills/smears; * Commercial mixer – food splatter on base behind the bowl; * Food bins lids on oatmeal and flour – food debris ; * Floor under and behind stove (across from steam table) – buildup of black matter; * Floor under two sink counter – buildup of black matter near the wall and drain had significant buildup of black/brown matter; * Upright refrigerator and freezers – bottom shelves had buildup of food debris/spills; * Ice machine – buildup of dust on intake vent: and * Dishwashing machine – top had buildup of dried debris. The following concerns relate to improper food storage: * Upright refrigerator and walk in refrigerator – contained unlabeled/undated food items; * Upright refrigerator – eggs (in shells) not stored on lowest shelf, creating possible cross contamination if cracked; and * Food bins containing bags of brown and granulated sugar had lid missing, bags were open to the air, creating possible cross contamination. The areas of concern were observed and discussed with Staff 1 (Lead Cook/PIC) and discussed with Staff 2 (Executive Director) on 09/04/24. The findings were acknowledged.

C240 Resident Services Meals, Food Sanitation Rule 1. * Microwave oven- interior will be deep cleaned * Hood vents on both sides above stoves/grill will be deep cleaned to remove dust and grease. * Shelves below steamer and one sink counter will be deep cleaned to remove drips/splashes/debris. * Front and sides of stoves will be deep cleaned to remove drips/spills. * Convection oven sides/top/doors/legs will be cleaned to remove spills/drips/debris. * Pipes between stove and steamer will be cleaned to remove buildup of black matter. * Wall behind stove will be deep cleaned to remove grease/drip build up. * Back of grill top will be cleaned to remove build up of grease/food splatter. * Front of stainless steel doors on steam table will be cleaned to remove drips/spills/smears. * Commercial mixer will be cleaned to remove splatter on base behind bowl. * Food bins lids will be cleaned of food debris. * Floor under and behind stove will be cleaned to remove black matter. * Floor under two sink counter will be cleaned to remove black matter and drain will be cleaned to remove black/brown matter. * Upright refrigerator and freezer will be cleaned to remove build up of food and spills from bottom shelf * Top of dishwahing machine will be cleaned to remove build up of dried debris. * Food in both refrigerator and walk in will be labeled and dated accordingly. * Eggs in refrigerator will be stored on the lowest shelf. * Food bins will be covered with lids ensuring no cross contamination occurs. 2. Sanitation audit form and check list has been created by DSM and be audited weekly for compliance to ensure all areas are being cleaned properly. 3. Audit forms will be reviewed weekly with Executive Director during weekly one on one meeting. 4. DSM or designee will be responsible to ensure compliance.

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, 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 03/21/23 through 03/24/23, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to deficiencies in the report.

Refer to plans of correction for the following citations:  C154, C231, C240, C252, C260, C262, C270, C280, C295, C325, C361, C370, C372, C374, C420, C422, C510, C513, C545

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: A review of Resident Council Board Meeting minutes dated 01/08/23, 01/11/23, 02/05/23, and 03/05/23 identified the following resident concerns: * "Residents have been having wrong medication at wrong time or wrong medication altogether"; * "Out of Meds - still not ordering meds on time and running out for up to 48 hours"; * "Care givers have been seen running meds to the residents for the Med Techs"; * "Many residents have never seen their care plan and do not know what it is"; and * "Sometimes don't see a care giver for days and don't know who they are". There was no documented evidence the above concerns identified during the Resident Council board meetings had been addressed, responded to or resolved.    On 03/21/23, the survey team conducted a group interview with residents. They expressed complaints about cleanliness of the facility, food quality and service, dissatisfaction with caregiving, untimely medication administration, lack of resolution for concerns from resident council meetings, and fear of retaliation from administration if concerns were brought forward. In an interview on 03/23/23, Staff 1 (District Director of Operations) reported residents may make an entry in the facility's "Grievance Log" located at the reception desk when they had concerns. Staff 1 indicated the facility was "addressing" the items in the log; however, no documented evidence existed indicating any items had been resolved. The need to improve the facility's method for responding to and resolving resident complaints was reviewed with Staff 1 and Staff 2 (District Director of Clinical) on 03/24/23 at 11:35 am. They acknowledged the findings.

1. Covering Executive Director was edcuated on grievance log procedure and providing written feeedback to resident concerns to ensure understanding of follow up. All residents will be provided with a copy of the grievance procedure during Town Hall meeting scheduled for 4/19/23. 2. 2.  The Activity Director will collect the monthly Resident Council Meeting Notes and will forward to the Executive Director who will provide notes to department heads for follow up and resolution that will be given back to Resident Council. Executive Director will respond to concerns following grievance procedure which includes actions taken in writing.   3.  Executive Director will review Resident Council notes and grievances submitted every 30 days to montior that concerns have been addressed and resolved. 4.  The Executive Director is responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to assure appropriate responses to incidents of suspected abuse and elopement were investigated and reported to the local SPD office or the local AAA office for 2 of 2 sampled residents (#s 1 and 2) with documented allegations of neglect of care or elopement. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2022 with diagnoses including chronic pain and hypertension. Resident 1's service plan available at the time of the survey, dated 11/10/22, noted the resident was frequently incontinent of bowel and bladder, required assistance from two staff members for tasks that required standing/weight bearing, and received home health services for redness/excoriation on the buttocks. During an interview on 03/22/23 at 10:00 am, Witness 1 (outside provider) stated the resident received outside services for wound care three times a week. Review of outside service provider notes between 02/15/22 and 03/23/23 noted the following: * 02/15/23 "pt [patient] found in soiled brief"; * 02/18/23 "pt [patient] very soiled - 100% saturated brief ....put light on for caregiver assistance ...no response from cg [caregiver] for over an hour ..." * 02/24/23 " ...pt [patient] had no drsg [dressing] in place ...make sure pt [patient] is changed every 2 hours ..." * 02/27/23 "pt [patient] found in 100% saturated 2 briefs, 3 chux [incontinent pads] and urine up [his/her] shirt ...wound dressing placed last Friday still in place with soiled urine/stool ..." Resident 1 received wound care on 03/23/23 at 9:25 am, the dressing was soiled and there was brown matter on the incontinent product. Staff 20 (MT) changed the resident's dressing and provided incontinent care. The statements documented by the outside service provider identified potential neglect of care. There was no documented evidence the facility investigated the allegations of neglect of care or reported the allegations to the local SPD or AAA office as suspected abuse. The lack of investigating and reporting was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/23/23 at 11:00 am. Staff acknowledged the statements should have been investigated. The various allegations pertaining to neglect of care were reported to the local SPD office during survey and verification was received on 03/24/23. 2. Resident 2 was admitted to the facility in 08/2019 with diagnoses including dementia. During the acuity interview on 03/21/23, the facility reported Resident 2 had a recent elopement incident and required an escort back to the facility. Resident 2's progress notes, dated 02/09/23 through 03/20/23, were reviewed and revealed the following documentation on 03/03/23, " ...resident was having wandering issues from the facility today." In an interview on 03/22/23 at 12:54 pm, Resident 2 reported approximately three weeks ago s/he walked to a local store alone and was unable to find his/her way back to the facility. A police officer then escorted the resident back to the community. On 03/23/23, Staff 4 (RN Oversite) and Staff 6 (Resident Services Coordinator) confirmed the resident's need for a police officer escort after getting lost in the community. Documentation of an investigation of the elopement event and/or referral to Seniors and People with Physical Disabilities (SPD) office was requested on 03/23/23. No documentation was provided. The need to promptly investigate and report all reportable incidents to the local SPD office was discussed with Staff 1 (District Director of Operations), and Staff 2 (District Director of Clinical) on 03/24/23. They acknowledged the findings. A report was filed with the local SPD office and documentation provided on 03/24/23 at 2:08 pm.

1. Incident for Resident 1 & 2 was reported to APS prior to surveyors exiting the community. 2. Staff will receive training on abuse & neglect reporting by 5/8/2023.  Incidents will be discussed at daily stand up meeting to ensure investigation is completed timely.  Any incidents without known cause, or otherwise meet reporting criteria will be reported to Adult Protective Services.  Incidents from the past 30 days will be reviewed to assure any incident meeting abuse or neglect reporting criteria are reported to Adult Protective Services. 3. Incidents will be reviewed during routine clinical meeting to monitor effective follow-up, investigation, and/or assure APS reporting has occurred.  Executive Director will regularly review incident reports to determine effective investigation and follow-up information. 4. The Executive Director and/or designee is responsible for this plan of correction.

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 have documented evidence of an administrator review of investigations, for 1 of 1 sampled resident (# 10) who was involved in resident to resident altercations. This is a repeat citation. Findings include, but are not limited to: Resident 10 was admitted to the facility in 04/2022 with diagnoses including dementia. Resident 10's current service plan, dated 06/25/23, progress notes dated 07/07 through 09/12/23, and interviews with care staff between 09/19 and 09/20/23 noted the resident had cognitive impairment, was combative towards staff at times surrounding ADL care, had a history of resident-to-resident altercations, and had been overheard yelling and screaming at spouse and other residents. a. An incident report dated 09/02/23 noted, "...yelling in dining room, no physical, but [resident] threatening to smack..." The residents were separated by staff and removed from the area. Threatening to hit constitutes verbal abuse and required reporting to the local SPD.  There was no documented evidence the facility immediately reported the event to the SPD. Staff 34 (Health and Wellness Director III) reported the verbal abuse to SPD and confirmation of the report was provided prior to survey exit. b. Resident 10 was involved in three resident-to-resident altercations.  The local SPD was notified, actions/interventions were identified and put into place, and investigations completed; however, there was no documented evidence the investigations were reviewed by the Administrator. The need to ensure verbal abuse was reported to SPD and investigations were reviewed by the Administrator was discussed with Staff 33 (Executive Director II), Staff 34, and Staff 2 (District Director of Clinical) on 09/20/23.  Staff acknowledged the findings.

1. Incident of Resident #10 was reported to APS prior to surveyors exiting the community. All incident investigations will be reviewed and signed off by the Executive Director 2. Staff to receive training on abuse and Neglect reporting on Friday Oct 27th. Executive Director will review incident investigations weekly and sign off upon completion. 3. Incidents will be reviewed weekly by executive director to determine effective investigation and follow-up information. 4. The Executive Director and/or designee is responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, kitchen staff did not follow hygienic practices and proper food handling procedures in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 03/21/23 at 10:00 am, the main kitchen, walk-in refrigerator, two reach-in freezers, and dry food storage area were observed to need cleaning in the following areas: a. Kitchen area: * Walls throughout the kitchen had multiple spills, smears, splatters and black streaks; * Pipes behind multiple appliances had grease, dirt, and debris; * Cooktop knobs and handles had sticky matter, built-up grease and dried food debris; * Interior walls of ice-maker machine had unidentified black residue; * Air intake vents of ice-maker machine were covered with dust; * Drains beneath three-compartment sink and on the floor next to the oven were filled with food and other debris; * Floors throughout the kitchen had food debris and grease in the corners, under equipment and around the perimeter of the kitchen; * Ceiling vent above storage shelves across from walk-in refrigerator was covered with dust; * Cooktop backsplash panel was covered with burnt-on grease and other residue; * Range hood filters were covered with grease; * Glass shield in front of serving line chafing dishes were covered with food splatters; * Oven interior, knobs, doors and handles; * Microwave interior, doors and handles; * Air intake vent on front of toast machine was covered with dust and other matter; * Industrial mixer and scale; * Light fixture covers on ceiling in dry storage room had dead insects inside; * Open shelving throughout the kitchen; and * Electrical outlets. b. Walk-in refrigerator: * Refrigerator cooling unit fans had a layer of dust and dirt. Ceiling and walls of walk-in refrigerator had dust build up from fans; and * Light switch junction box covered with rust and dust. c. Reach-in freezers: * Bottom shelves with food debris; and * Exterior surfaces and handles covered with sticky residue. d. Dining room beverage area: * Juice and coffee machines observed with splatters and fluid build-up. On 03/21/23 at 10:00 am, the main kitchen was observed to need the following repairs: * Blade on can opener observed with protective coating removed from wear and rust developing; * Caulking around chafing trays was worn; * Dripping water visible and pooling of water observed under steamer; * Multiple cutting boards were found heavily scored and/or stained and in need of replacement; * Approximately two inch hole in wall surrounding sink drainage pipe next to cutting board rack; * Employee hand-washing station was not functioning; * Two light fixtures above service line area with burnt out bulbs and cracked fixture covers; * Unidentified electrical box next to dish racks were covered with dirty tape; * Water stains on ceiling above warewash machine; * Drywall surface peeling on ceiling above reach-in freezers; and * Industrial mixer was rusted in several places and not covered when not in use as required. On 03/21/23 at 11:30 am, the following improper food handling practices were observed: * Staff 19 (Cook) was observed using single-use gloves for multiple tasks, including food handling, cooking and operating appliances; kitchen staff was observed using sanitation rags to wipe gloved hands during meal service; * Individual portions of dessert were plated on trays in the walk-in refrigerator, left uncovered and open to direct dust and debris contamination from blowing fans; * Frozen condensation drops observed on top of rightmost reach-in freezer; and * Multiple food items in the walk-in refrigerator and reach-in freezers were found removed from their original packaging, not dated and only partially wrapped. Bulk food items were found not dated when opened. Four garbage cans throughout the kitchen were not covered with lids when not in use. Facility did not have a cleaning schedule in place. Staff 18 (Cook) stated the facility had developed a schedule for kitchen cleaning on 03/20/23 but had not implemented it yet. Staff 1 (District Director of Operations) stated the facility had placed a request for bids for deep cleaning of kitchen and ice-making machine, but nothing had been scheduled. Additionally, during a tour of the kitchen on 03/22/23 to share survey findings, Staff 19 was observed not wearing gloves when preparing food. The findings were discussed with Staff 1 and Staff 8 (Maintenance Supervisor) on 03/22/23 at 11:45 am. Both staff acknowledged the findings .

1. On 3/24/23, all dining associates were educated on daily, weekly, and monthly cleaning expectations and checklist containing documentation of cleaning tasks were implemented. Dining associates were educated on glove use and several boxes of gloves in various sizes were brought to kitchen for dinings staff use. Lids were placed on kitchen kitchen garbage cans. Maintenance Director repaired all areas of exposed piping using silicone caulk to ensure cleanable surfaces on 3/25/23/ 2. As bids have been onbtained on deep cleaning of kitchen, we continue to work with vendor on scheduling this service no later than 4/30/23. Dining Service Director or designee will review completion of cleaning checklists daily to ensure tasks are completed and kitchen is kept in clean condition. 3. Executive Director will complete weekly review of kitchen for the next 60 days to ensure all surfaces are clean and in good repair. 4. The Executive Director is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation was dated, contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident's needs, for 1 of 1 sampled resident (# 5) who was recently admitted to the facility. Findings include, but are not limited to: Resident 5 was admitted to the facility in 01/2023 with diagnoses including hypertension, osteoarthritis, and depression. Review of the move-in evaluation revealed the evaluation was not dated and the following required elements were not documented as being addressed: * Customary routine related to eating; * Visits to health practitioners, ER, hospital, or nursing facility in the past year; * Vital signs if indicated by diagnosis, health problems or medications; * Presence of depression, thought disorders, behavioral and mood problems; * History of treatment; * Effective non-drug interventions; * Personality, including how the person copes with change or challenging situations; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Nutritional habits and weight if indicated; and * Recent losses. The need to ensure the initial evaluation was dated, contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident's needs was reviewed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23 at 11:35 am. They acknowledged the findings.

1. The evaluation for Resident 5 was updated during survey to reflect current needs.   2. Resident records will be reviewed to ensure that evaluations are complete and current.  Community Nurses will receive additional education on the move-in evaluation process & form. 3. Residents will be evaluated before move in, quarterly and upon change of condition.  Executive Director or designee will conduct random audits on 4 resident records weekly for the next 60 days to ensure presence and accuracy of evaluation. 4. The Executive Director or designee is responsible for this plan of correction.

2. Resident 1 was admitted to the facility in 06/2022 with diagnoses including chronic pain and hypertension. Observations and an interview with the resident, interviews with staff and a witness, and review of the resident's clinical record during the survey revealed s/he required staff assistance for ADL care needs. a. Resident 1's service plan available at the time of the survey, dated 11/10/22, was not reflective of or in the following areas: * Pain; * Barrier cream applied during ADL care; * Frequency of position changes; * Frequency of home health visits; and * Sleeping preferences. b. The service plan available at the time of the survey was dated 11/10/22 and had not been updated quarterly as required. The need to ensure the service plan was reflective of Resident 1's current needs and completed quarterly was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/23/22 at 11:00 am. The service plan was updated during the survey. 4. Resident 3 was admitted to the facility in 01/2022 with diagnoses including diabetes. a. There was no documented evidence the facility completed a quarterly service plan. The most recent service plan available to staff was completed 11/04/22. b. A Temporary Service Plan (TSP) dated 03/18/23 identified the resident had returned to the facility after a stay in a skilled nursing facility. The TSP directed staff to "Chart on all shifts." A review of the clinical record revealed staff had not consistently charted on all shifts as directed by the plan of care. The need to ensure service plans were updated quarterly and TSPs were implemented was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 08/2019 with diagnoses including dementia. The resident's current service plan, dated 01/15/23, was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 03/21/23 and 03/24/23. Resident 2's service plan was not reflective and/or did not provide clear instruction to staff in the following areas: * Assistance required during laundry tasks; * Incentive spirometer frequency; * Need for increased fluids following 03/09/23 hospitalization; and * Ambulation without adaptive equipment within the community. The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23 at 12:07 pm. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear directions regarding the delivery of services, were not implemented, a copy of the service plan was offered to the resident, and service plans were completed following quarterly evaluations for 4 of 7 sampled residents (#s 1, 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 01/2023 with diagnoses including hypertension, osteoarthritis and depression. Interviews with the resident and staff, and review of the current service plan, dated 02/06/23, revealed Resident 5's service plan was not reflective of current needs and lacked clear instructions to staff for bathing/showering. During an interview on 03/22/23 Resident 5 stated s/he was not offered a copy of service plan.     The need to ensure the service plan reflected residents' current needs, provided clear instructions to staff regarding delivery of services and a copy was offered to residents was reviewed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23 at 11:35 am. They acknowledged the findings.

1. The service plan for Resident 1 & 3 was updated during survey.  The service plans for Residents 2 and 5 will be updated to reflect current status. 2. Remainig resident service plans will be reviewed to confirm that each is reflective of current status.   As part of the routine service plan process, the Licensed Nurse or designee will conduct a record review and obtain feedback from caregivers working directly with the resident prior to updating the service plan. Clinical team and/or operations team will utilize a service plan calendar to ensure timely completion.  Residents will be offered a copy of their service plan with routine updates.   3. The Executive Director and/or designee will randomly audit 4 resident service plans weekly for 60 days to assure ongoing compliance.   4. The Executive Director and/ or designee is responsible for this plan of correction

2. Resident 10 was admitted to the facility in 04/2022 with diagnoses including dementia. The current service plan dated 06/25/23 noted the resident needed stand-by assistance with dressing, using the restroom, escorts to the dining room, and had a wound on his/her heel.  The service plan also noted the resident refused care at times and had verbal altercations with other residents in public areas. Interviews with caregiving staff and a medication aide on 09/19/23 and 09/20/23 noted the following: *Resident 10 was often overheard yelling at his/her spouse; *Resistive to care and would cuss and yell at staff; *Would scream and fight with spouse; *There was no wound on the resident's heel; *When the yelling started, the spouses would be separated; *Resident 10 enjoyed sitting in the lobby area near the fire place; *Staff would re-approach the resident when resistant to care or ask for another staff member to assist; *Holding the resident's hand while explaining care; *Using a calm voice when offering assistance and when escalated; and *Changing physical location at the onset of yelling. Progress notes dated between 07/07/23 and 09/12/23 were reviewed and noted two resident to resident altercations.  One altercation was physical and the other was verbal.  Both incidents occurred between the spouses. Resident 10 was observed during the survey to self propel him/herself to the dining room and the lobby area near the fire place or residing in the apartment.  There was no yelling or screaming overheard between the spouses. Resident 10 had a history of resident-to-resident altercations, was overheard yelling and screaming at spouse, and was resistant to care. The current service plan was not reflective of the resident's status and did not provide clear instruction to staff related to intervening or de-escalating tense situations. The service plan was discussed with Staff 34 (Health and Wellness Director III), Staff 33 (Executive Director II), and Staff 2 (District Director of Clinical) on 09/20/23 at 11:03 am.  Staff 34 updated the resident's service plan. 3. Resident 8 moved into the facility in 11/2020 with diagnoses including congestive heart failure and type II diabetes.   Observations and interviews with the resident, staff interviews and review of the service plan dated 07/03/23 showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Use of a ROHO cushion (to decrease the amount of pressure on the sitting area) while in a wheelchair; and * Behaviors including inappropriate comments. The need to ensure Resident 8's service plan was reflective of current care needs and provided clear direction to staff was discussed with Staff 33 (ED) on 09/20/23 at 10:50 am. Staff reviewed the service plan and acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 3 of 4 sampled residents (#s 8, 10 and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 12 was admitted to the facility in 08/2021 with diagnoses including cerebral palsy, spinal stenosis, asthma, and dysphagia. Observations were made of the resident's care on 09/20/23. Interviews with facility staff and the resident were conducted. The current service plan dated 08/09/23 was reviewed. Resident 12's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Nutrition habits, fluid preferences and diet texture; * Instructions for aspiration precautions and interventions while choking; and * Electric mobility equipment precautions and instructions for proper maintenance. The need to ensure the service plan reflected the resident's current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 2 (District Director of Clinical), Staff 33 (Executive Director II), and Staff 34 (Health and Wellness Director III) on 09/20/23 at 2:40 pm. They acknowledged the findings. No further information was provided.

1. Resident #12 service plan will be updated to reflect nutrition habits, fluid preferences and diet texture; instructions for aspiration precautions and interventions while choking; and electric mobility equipment precautions and instructions for proper maintenance. Resident #10 service plan will be updated to provide clear instruction to staff related to intervening or de-escalating tense situation. Resident #8 service plan will be updated to provide clear direction to staff with regards to use of a ROHO cushion while in wheelchair and how to respond to behaviors including inapprpriate comments. 2. Remaining resident service plans will be reviewed to confirm that each is reflective of current status. As part of the the routine service plan process, the Licensed Nurse or designee will conduct a record review and obtain feedback from caregivers working directly with the resident prior to updating the service plan. 3. The Executive Director and/or designee will randomly audit 4 resident service plans weekly for 60 days to ensure ongoing compliance. 4. The Executive Director and/or designee is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident, for 3 of 7 sampled residents (#s 1, 2 and 5) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2 and 5's most recent service plans lacked documentation 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 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/23/23 and 03/24/23. Staff acknowledged the findings.

1. The service plans for residents 1, 2 & 5 will be reviewed with the resident. 2. Service plans will be developed with a service planning team which may include Executive Director, dining staff, care staff, other associates of the community, resident and family as applicable. If resident or family declines a care conference they will be provided with a paper copy of their service plan. 3. Executive Director and/or designee will conduct random audits of 4 resident service plans weekly for the next 30 days to ensure there is evidence of a service planning team. 4. The Executive Director is responsible for this plan of correction.

2. Resident 1 was admitted to the facility in 06/2022 with diagnoses including chronic pain and hypertension. Resident 1's service plan available at the time of the survey, dated 11/10/22, noted the resident was frequently incontinent of bowel and bladder, required assistance from two staff members for tasks that required standing/weight bearing, received home health services for redness/excoriation on the buttocks, and required both frequent position changes and brief changes. Resident 1's progress notes, skin management and open area flowsheets for 12/16/22 through 03/09/23 were reviewed and noted the resident was being monitored related to a pressure injury on his/her left buttock. There was no documented evidence the resident's skin was monitored consistent with evaluated needs after 03/09/23. Resident 1 was observed during the survey between 03/21/22 and 03/23/23 to be seated in various positions in a recliner chair. Resident 1 was observed to stand for wound care treatment, had a catheter, and was able to re-position in the chair multiple times during observations and interviews. The surveyor requested Staff 4 (RN Oversite) to provide an update regarding Resident 1's skin. On 03/24/23 Staff 4 noted, resident with pressure wound "...left buttock...followed by HH...there is noticeable improvement in the wound as there is no depth to the wound and granulation has taken place to surrounding areas..." Resident 1 was noted to have a change of condition related to skin breakdown, was dependent on staff for ADL care and received HH for wound care. There was no documented evidence the resident's skin was monitored weekly between 03/09/23 and the time of the survey 03/21/23. Monitoring changes of condition weekly through resolution was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/23/23 at 11:00 am. Staff acknowledged the finding and evaluated Resident 1's skin on 03/24/23. 3. Resident 3 was admitted to the facility in 01/2022 with diagnoses including diabetes and anxiety disorder. Resident 3's records were reviewed during the survey and revealed the following: On 02/26/23, Resident 3 had a fall and was sent out to the hospital where s/he was diagnosed with a left hip fracture and admitted to a skilled nursing facility. Resident 3 was readmitted to the facility from the skilled nursing facility on 03/18/23 after rehabilitation related to the hip fracture. There was no documented evidence that upon the resident's return, the facility evaluated the resident for a change of condition, monitored the resident, or referred to the RN to determine if further actions or interventions were needed. The need to ensure residents were evaluated, monitored and referred to the RN for changes of condition upon return to the facility was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23. They acknowledged the findings. 5. Resident 7 was admitted to the facility in 02/2022 with diagnoses including dementia and hypertension. The resident's progress notes, dated from 12/29/22 through 02/07/23, service plan, Temporary Service Plans and outside provider notes were reviewed. Resident 7's Power of Attorney (POA) and facility staff were interviewed. The following changes of condition were identified: a. On 01/16/23, staff reported in a progress note the resident "wasn't feeling well" and had a blood pressure of "153 over 101." Staff called the facility RN who advised them to have the resident lay down and "continue to monitor [his/her] blood pressure." There was no documented evidence the facility communicated the interventions to staff on each shift or monitored Resident 7 through resolution. b. On 02/03/23, a Nurse Practitioner went to the facility to "follow up on a fall." Documentation of the resident's outside provider note revealed, "Patient was in the parking lot of a store and tripped." The store called 911 and after the Emergency Medical Team evaluated Resident 7, they "let [him/her] go home." An interview with the resident's POA on 03/22/23 at 2:11 pm confirmed the incident. There was no documented evidence the facility determined and documented what action or intervention was needed for the resident, communicated the action or intervention to staff on each shift or monitored the resident through resolution. The need to ensure the monitoring of short-term changes of condition included determining and documenting what action or intervention was needed for the resident, communicating the determined action or intervention to staff on each shift, and documenting at least weekly until the condition resolved was reviewed with Staff 1 (District Director of Operations), Staff 2 (District Director of Clinical) and Staff 4 (RN Oversite) on 03/24/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and communicated to staff, and the condition was monitored, at least weekly, through resolution for 5 of 5 sampled residents (#s 1, 2, 3, 6 and 7) who had documented changes of condition. Resident 2 was struck multiple times by another resident which caused undue distress and fear. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2019 with diagnoses including dementia. a. During the acuity interview, Resident 2 was reported to have been involved in a resident-to-resident altercation where an unsampled resident hit Resident 2 multiple times with a walking device. According to a progress note dated 03/09/23, "Resident reported to the MT at 10:37 am, a resident 'jabbed' there [sic] walking stick 6 times below [his/her] left breast area. Resident stated that [unsampled resident] did it because [s/he] thought it was funny. Resident also stated incident happened because [Resident 2] touched [his/her] walking stick and that [s/he] stated 'I'll teach not to touch my cane' and proceeded to 'jab' resident." Resident 2 was sent to the emergency department on 03/09/23 and returned with diagnoses including blunt trauma to chest. In an interview on 03/22/23, Resident 2 summarized what occurred during the resident-to-resident altercation and was then asked about whether s/he felt safe in the community. S/he reported, "I don't like passing [him/her]. I'm scared to death. [S/he] has a cane that [s/he] uses, what if [s/he] hits me with it again?" The resident's progress notes dated 02/09/23 through 03/20/23, Temporary Service Plan (TSP) dated 03/09/23, incident report dated 03/09/23, and investigation (no date documented) were reviewed. A TSP was created on 03/09/23 which instructed care associates to report to the licensed nurse or designee the following: * "Pain in front torso"; and * "Must be monitored and kept away from [unsampled resident] at all times. Protect [Resident 2] from being hit by [unsampled resident]. [Resident 2] loves to touch people and [the unsampled resident] does not like to be touched." Although a TSP was created on 03/09/23, there was no documentation by the caregiving staff the TSP was reviewed until 03/12/23. The TSP did not instruct staff to monitor the resident for fear or other emotional trauma related to the incident. Progress notes dated 03/09/23 through 03/20/23 revealed Resident 2 was monitored for pain following return from the emergency department from 03/10/23 through 03/15/23. The first documented monitoring around whether the two residents were kept separate occurred on 03/18/23 or nine days following the resident-to-resident altercation. There was no documentation on the resident's emotional state in relation to the altercation. Multiple observations were made of Resident 2 during the re-licensure survey. Resident 2 attended activities, assisted other residents with simple tasks during activities, stood very closely to this surveyor and others during conversation, and spent time on the first and second floors. The unsampled resident, who was involved in the resident-to-resident altercation, was not observed in communal areas during the re-licensure survey. Resident 2 was interviewed on 03/22/23 and 03/24/23. During both interviews, s/he reported to have seen the unsampled resident on the first floor during the week of the re-licensure survey and wanted to kick the resident with his/her foot. On 03/23/23, Staff 5 (Health and Wellness Coordinator) was asked about whether the facility monitored the resident's fear associated with the resident-to-resident altercation. She said monitoring occurred around pain and separating the two residents. No additional documents were provided. The facility failed to evaluate Resident 2's fear and/or emotional trauma, develop interventions to mitigate the resident's continued emotional distress and communicate those interventions to staff on all shifts following a resident-to-resident physical altercation that resulted in pain, bruising and swelling for the resident. These failures resulted in ongoing fear and emotional turmoil for Resident 2. In an interview on 03/24/23 with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical), the facility's failure to evaluate the resident's emotional state, develop and communicate interventions to staff, and the resulting continued emotional distress for Resident 2 was discussed. They acknowledged the findings, and no additional information was provided. b. Resident 2's progress notes, dated 02/09/23 through 03/20/23 were reviewed. The following changes of condition lacked documented evidence monitoring instructions and/or interventions were communicated to staff with progress noted, at least weekly, through resolution: * 02/09/23 - New atorvastatin prescription for hyperlipidemia initiated; * 03/03/23 - Wandering/elopement event; * 03/09/23 - Left torso bruising/swelling; and * 03/09/23 - New PRN oxycodone prescription that had been administered for pain. The need to ensure the facility communicated changes of condition including monitoring instructions and interventions to staff and documented progress, at least weekly, until the conditions resolved was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23. They acknowledged the findings. 4. Resident 6 was admitted to the facility in 08/2017 with diagnoses including schizophrenia with intermittent suicidal ideations. Observations of the resident, interviews with staff, review of the resident's service plan dated 03/17/23, Temporary Service Plans and progress notes dated 12/20/22 through 03/21/23 were reviewed. The following short-term changes of condition lacked documentation of monitoring, at least weekly, through resolution for Resident 6's return from ER visits or hospitalizations to the facility after suicidal ideations on the following dates: * 12/20/22; * 01/05/23; * 01/12/23; and * 02/08/23. During an interview on 03/22/23 at 11:19 am, Staff 5 (Health and Wellness Coordinator) acknowledged the short term changes of condition were not monitored weekly until resolution. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/22/23 at 2:45 pm. They acknowledged the findings.

1. The apartment for Resident 1 was cleaned during survey. 2. Staff will be educated on daily tidy procedures and infection control measures related to residents with catheters by 5/8/2023.  Remaining resident apartments will be checked for cleanliness and work orders placed for any area in need of deep cleaning. 3. The Executive Director and/or designee will randomly audit 4 resident apartments weekly for 60 days to assure ongoing compliance. 4. The Executive Director is responsible for this plan of correction.1. A temporary service plan was created to monitor resident for emotional distress and alert charting started for Resident 2 prior to surveyors exiting the community.  Resident 2 did not verbalize any emotional distress or fear related to the other resident through the course of alert charting.  Records for Resident 1, 2, 3, 6 and 7 will be reviewed in terms of those items mentioned in the deficiency report and records updated accordingly. 2. Resident records for those with a known pattern of falls, behaviors, or skin issues will be reviewed to assure proper evaluation, preventative measures and documentation included in the resident record.  Associates will be educated on proper reporting of changes in condition and related documentation by 5/8/2023.   Med Tech associates and Community Nurse will be educated on change of condition documentation to reflect weekly monitoring until resolved.  Resident changes in condition will be discussed during routine staff stand up meeting and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed, documentation is reflected in the resident record and updates are made to the service plan as appropriate.   3. The Executive Director and/or designee will randomly audit 4 resident records weekly for 60 days to assure ongoing compliance. 4. The Executive Director, nursing team and/or designee is responsible for this plan of correction.

2. Resident 1 was admitted to the facility in 06/2022 with diagnoses including chronic pain and hypertension. Resident 1's service plan available at the time of the survey, dated 11/10/22, noted the resident was dependent on staff for ADL care requiring one to two person assist at times. Resident 1 was noted to be independent with food and meal choices. Review of Resident 1's weight record noted the following: * 06/2022 - 244 pounds; * 07/2022 - 260 pounds (an increase of 16 pounds in one month); * 08/2022 - no weight; and * 09/2022 - 268 pounds (an additional eight pound weight gain). Between 06/2022 and 09/2022 Resident 1 gained 24 pounds or 8.9% of his/her body weight resulting in a significant change of condition. Additional weights were documented: * 10/2022 - 271 pounds; * 11/2022 - no weight; * 12/2022 - no weight; and * 01/2023 - 250.4 pounds. Between 10/2022 and 01/2023 Resident 1 lost 20.6 pounds or 7.6% of his/her body weight resulting in a significant change of condition. Resident 1 experienced significant weight fluctuations between 06/2022 and 01/2023. There was no documented evidence the facility RN assessed Resident 1's weight fluctuations to include findings, resident status and interventions made as a result of the assessment. Resident 1 was observed during the survey on 03/22/23 and 03/23/23 to eat independently and ate 100% of a breakfast and lunch meal. Resident 1's weight at the time of the survey was 260.8 pounds. The lack of RN assessment was discussed with Staff 1 (District Director of Operations), Staff 2 (District Director of Clinical) and Staff 4 (RN Oversite) on 03/23/23 at 11:00 am. Staff 4 completed an assessment of Resident 1 on 03/24/23. 3. Resident 3 was admitted to the facility in 01/2022 with diagnoses including diabetes and anxiety disorder. A progress note dated 03/18/23 noted return from a skilled nursing facility for rehabilitation after a hip fracture. There was no documented evidence the facility RN was notified or had completed a significant change of condition assessment that included documented findings, resident status and interventions made as a result of the assessment. The need to ensure the RN was notified and an assessment was completed following a significant change of condition was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/22/23. They acknowledged the findings. Staff 4 (RN Oversite) completed an assessment of Resident 3 on 03/22/23.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely for 3 of 3 sampled residents (#s 1, 3 and 6) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 08/2017 with diagnoses including blindness. Resident 6's service plan available at the time of the survey, dated 03/16/23, noted the resident required assistance to open food containers and to orient resident to location of food on plate. Resident 6 was noted to be independent with food and meal choices but required assistance to fill out the menu. Resident 6 was observed during lunch meals on 03/21/23 and 03/23/23 to eat independently and ate 75% of meals. During an interview on 03/22/23 at 10:55 am, Staff 15 (CG) reported Resident 6 was independent with his/her food choices, demonstrated no issues with nutrition and ate well. She reported Resident 6 had lost weight. Resident 6's weight records were reviewed and revealed the following: * 10/27/22 - 196 pounds; * 11/15/23 - 192.6 pounds (a decrease of 3.6 pounds); * 12/2023 - no weight; * 01/15/23 - 176.4 pounds (an additional decrease of 16.2 pounds); * 02/2023 - no weight; and * 03/2023 - no weight. During the survey, Staff 4 weighed Resident 1 on 03/21/23, which was 178.2 pounds. From 10/27/23 to 01/15/23, Resident 6 had a weight loss of 19.6 pounds or 10% of his/her body weight. This weight loss indicated a significant change of condition and required an RN assessment. There was no documented evidence the facility RN completed an assessment of Resident 6's significant weight loss to include findings, resident status and interventions made as a result of the assessment. On 03/22/23 at 11:45 am, Staff 4 (RN Oversite) confirmed there was no nursing assessment for the weight loss. The need to ensure all significant changes of condition were assessed by an RN and were completed in a timely manner was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/22/23 at 2:40 pm. They acknowledged the findings.

1. A change of condition assessment for Resident 1 & 3 was completed by the RN during survey.  Resident 6 weights will be reviewed by the RN and documentation of the assessment entered into the resident record. 2. Resident records for those with a known pattern of significant weight changes will be reviewed to assure proper evaluation, preventative measures as appropriate and documentation is reflected in the resident record.  Associates will be educated on proper reporting of changes in condition and related documentation by 5/8/2023.  Resident changes in condition will be discussed during routine staff stand up meeting and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed, documentation is reflected in the resident record and updates are made to the service plan as appropriate.   3. The Executive Director and/or designee will randomly audit 4 resident records weekly for 60 days to assure ongoing compliance. 4. The Executive Director and Registered Nurse are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control for 1 of 1 sampled resident (# 1) who had a catheter. Findings include, but are not limited to: Observations were made during the survey to determine adherence to universal precautions for infection control. During observations of the resident's apartment on 03/21/23, 03/22/23 and 03/23/23 the following was noted: * On 03/21/23 and 03/22/23 multiple observations of Resident 1's catheter bag lying directly on the floor; * On 03/21/23 through 03/23/23, Resident 1's apartment had a urine odor; * The floor was sticky/tacky; and * Commode had brown matter in and around the perimeter. Infection control and the condition of the resident's apartment was discussed with Staff 1 (District Director of Operations), Staff 2 (District Director of Clinical) and Staff 4 (RN Oversite) at 11:00 am on 03/23/23.  Resident 1's apartment was cleaned on 03/23/23.

1. The apartment for Resident 1 was cleaned during survey. 2. Staff will be educated on daily tidy procedures and infection control measures related to residents with catheters by 5/8/2023.  Remaining resident apartments will be checked for cleanliness and work orders placed for any area in need of deep cleaning. 3. The Executive Director and/or designee will randomly audit 4 resident apartments weekly for 60 days to assure ongoing compliance. 4. The Executive Director is responsible for this plan of correction.

2. Resident 1 was admitted to the facility in 06/2022 with diagnoses including chronic pain and hypertension. During an interview and observation on 03/21/23, Resident 1 stated his/her family filled up a medication set weekly for the resident to administer his/her own medications. Bottles of prescription medications and the medication weekly organizer was observed in the resident's apartment. The self-administration of medication evaluation was completed on 11/01/22 and noted family was filling the medication organizer and the resident was unable to identify medications, doses or indications for use. The recommendation included having the facility take over medication administration. There was no documented evidence the self medication evaluation had been completed quarterly since 11/01/2022 addressing recommendations from the previous evaluation. Quarterly evaluations of self-administration of medications was discussed with Staff 1 (District Director of Operations), Staff 2 (District Director of Clinical) and Staff 4 (RN Oversite) on 03/23/23 at 11:00 am. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications and had more than one resident residing in the apartment, were evaluated upon move-in and quarterly to assure the residents' ability to safely self-administer medications and to safely have medications in the unit for 2 of 2 sampled residents (#s 1 and 5) who were reviewed for self-administration. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 01/2023 with diagnoses including hypertension, osteoarthritis and depression. During the acuity interview on 03/21/23, Resident 5 was identified as self-administering all his/her medications and lived in the same apartment with his/her spouse. In an interview on 03/22/23, Resident 5 confirmed s/he self-administered his/her medications, did not keep medications in a locked storage and facility staff administered medications to the spouse. Review of Resident 5's records revealed there was no documented evidence the resident was evaluated upon move-in for his/her ability to safely self-administer medications and the resident's spouse was not evaluated for the ability to safely have medications in the unit. The need to ensure residents who chose to self-administer their medications and had more than one resident residing in the unit were evaluated upon move-in was reviewed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23 at 11:35 am. They acknowledged the findings.

1. Resident 1 & 5 have been evaluated for ability to safely self-administer their medications. 2. An audit of residents who self-administer medications will be completed by 5/19/2023 to assure self-administration evaluations are on file.  Self-medication reviews will be updated as part of the routine service planning & evaluation process. 3. The Executive Director and/or designee will randomly audit 4 resident records weekly for 60 days to assure ongoing compliance.    4. The Executive Director and Community Nurses are responsible for this plan of correction

Based on interview and record review it was determined the facility failed to ensure updated information was added to their Acuity Based Staffing Tool (ABST). Findings include: In an interview on 03/24/23, Staff 1 (District Director of Operations) stated the company's ABST was driven by the same information used to create the service plans. During the relicensure survey, multiple sampled residents were found to have service plans that were not updated quarterly and/or were not reflective of the resident's status. The need to implement an ABST based on accurate and updated information was discussed with Staff 1 and Staff 2 (District Director of Clinical) on 03/24/23. They acknowledged the findings.

1. Community is in process of working through updates to resident service plans. Will continue to staff according to mandated staffing as outlined in current condition. 2.  Resident service plans will be reviewed to confirm that each is reflective of current status, thus transferring to the community acuity based staffing tool.   As part of the routine service plan process, the Licensed Nurse or designee will conduct a record review and obtain feedback from caregivers working directly with the resident prior to updating the service plan. Clinical team and/or operations team will utilize a service plan calendar to ensure timely completion.   3. The Executive Director and/or designee will randomly audit  5 resident service plans weekly for 60 days to assure ongoing compliance.   4. The Executive Director  and/ or designee is responsible for this plan of correction

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to: The facility's ABST was reviewed on 09/19/23 and discussed with Staff 1 (District Director of Operations) on 09/19/23 at 4:00 pm. She reported the ABST was populated by the Resident Assessment, which was driven by the service plan for each resident. There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using. The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 2 (District Director of Clinical) and Staff 33 (Executive Director II) on 09/20/23. They acknowledged the findings. No further information was provided.

1. Report showing acuity based staffing minutes were provided during survey including locations and titles of where to find 22 elements. 2. Brookdale continues to work with the Department to review and evaluate the Acuity Based Staffing Tool including where to find all required 22 elements in the ABST generated report and tool. 3. In the interim, Executive Director will continue to send staffing hours to Acuity based staffing correction coordinator. 4. The Executive Director and/or designee is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to: The facility's ABST was reviewed and discussed with Staff 33 (Executive Director II) on 12/06/23. He reported the ABST was populated by the Resident Assessment, which was driven by the service plan for each resident. There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using. The need to have all required ADLs on the ABST was discussed with Staff 33 and Staff 34 (Health and Wellness Director III) on 12/06/23. They acknowledged the findings. No further information was provided.

1. Report showing acuity based staffing minutes were provided during survey including locations and titles of where to find 22 elements. 2. Brookdale continues to work with Department to review and evaluate the Acuity Based Staffing Tool including where to find all required 22 elements in the ABST generated report and tool. 3. In the interim, Executive Director will continue to send staffing hours to Acuity based staffing correction coordinator. 4. The Executive Director and/or designee is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 10, 23, 24 and 31) completed all elements of pre-service orientation and dementia training prior to providing care to residents. Findings include, but are not limited to: Staff training records were reviewed on 03/22/23 and 03/23/23. a. Staff 10 (CG), hired 01/06/23, Staff 23 (CG), hired 01/06/23, Staff 24 (MT), hired 01/31/23, and Staff 31 (Server), hired 01/25/23, lacked written job descriptions. b. Staff 10 lacked documented evidence of being trained in the dementia disease process including progression, memory loss, psychiatric and behavioral symptoms. c. Staff 31 lacked documented evidence of training in the following elements: * Resident rights and values of CBC care; and * Infectious disease prevention. The need for all newly hired staff to complete all required elements of pre-service orientation and dementia training in the specified time frame was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical). No additional information was received.

1. Staff were provided with written job descriptions and associates identified during survey who were found to have missing pre-hire components were assigned these courses via online learning portal 2. Business Office Coordinator will conduct an audit of current employee files for documentation of training in pre-service topics. Any associates found to be missing pre-service training will be scheduled for online or classroom training to complete all pre-service training. Any associates found to be missing will be provided with their job descriptionsfor review and signature. 3. Business Office Manager has revised the orientation process to include ensuring that classroom and online coursework is completed prior to an associate being scheduled for on the floor training. Business Office Coordinator will monitor training records and staff will not be released for on the floor training until all pre-service topics are complete and certificates are present in their training file. The Executive Director will review new hire training files for completion for the next 60 days and then conduct random audits thereafter as part of ongong quality assurance. 4. The Executive Director and Business Office Coordinator are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff (#24) completed all required training and demonstrated competency in all assigned job duties. The facility failed to ensure 2 of 3 staff (#s 25 and 16) had documented evidence of demonstrated competency in all assigned job duties. Findings include, but are not limited to: Training records were reviewed on 03/22/23 and 03/23/23. a. Staff 24 (MT), hired 01/31/23, lacked documentation of training in the following elements: * General food safety, serving and sanitation; * Demonstration of satisfactory performance relating to all assigned job duties (including medication administration); and * Abdominal thrust and First Aid. Survey requested Staff 24 to be removed from the schedule as an MT until she had documentation of demonstrated satisfactory performance in all assigned job duties. Staff 24 was removed from the schedule. b. Staff 16 (MT/CG), hired 04/25/22, and Staff 25 (MT), hired 03/22/22, lacked documentation of demonstrated satisfactory performance in all assigned job duties including medication administration. Staff 1 (District Director of Operations) reported Staff 25 had completed all required training prior to her job duties, but they were unable to locate the documents. Survey requested Staff 16 and Staff 25 obtain the documentation of demonstrated satisfactory performance in all assigned job duties prior to working their next shift. Documentation was completed on 03/23/23. The need to ensure direct care staff completed all required training and had documentation of demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 and Staff 2 (District Director of Clinical) on 03/23/23. They acknowledged the findings.

1. All staff indentified to be lacking in return demonstration were offered training and records were updated prior to survey exit 2. Business Office Manager will conduct an audit of current associate files to determine if skill competency documentation is present as required. All associates found to be missing competency documentation will be retrained with return demonstration observation. New hire staff will receive training with return demonstration by Business Office Coordinator, Resident Care Coordinator or designee. Staff will not be scheduled for independent work until competency training has been completed. 3. Business Office Managerr will monitor competencies for compliance and will communicate with clinical leadership when staff are able to be scheduled for independent work after validation that all required competency trainings have been completed. Executive Director will review new employee training files for completion for the next 60 days and then will conduct random audits thereafter as part of ongoing quality assurance. 4. The Executive Director and Business Office Manager are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to verify 2 of 4 newly hired direct care staff (#s 39 and 40) had demonstrated satisfactory performance in any duty they were assigned. This is a repeat citation. Findings include, but are not limited to: Training records were reviewed on 09/19/23 and 09/20/23. Staff 39 (MT), hired 08/18/23 and Staff 40 (CG) hired 08/04/23, lacked documentation of training in the following elements: * Providing assistance with ADLs; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * Medication administration duties. On 09/20/23 at 10:35 am, the surveyor shared the above findings with Staff 38 (Business Office Manager). Staff acknowledged the findings. The need to ensure direct care staff completed required training's and had documentation of demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 33 (Executive Director II) on 09/20/23. Staff acknowledged the findings.

1. All newly hired staff will complete the required trainings's and have documentation of demonstrated competencies in all assigned job duties within their first 30 days of hire. 2. Business office manager will make binder for all new hires with check sheet of all required trainings and competencies. Staff will be required to complete all tasks within 30 days of hire and not be allowed to start working independently without completion of all tasks. 3. Staff binders will be audited monthly at first of month to ensure completion. 4. Business Office manager and/or designee is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 12, 27 and 28) completed the required minimum 12 hours of in-service training annually which included six hours of dementia care training. Findings include, but are not limited to: Staff training records were reviewed on 03/22/23 and 03/23/23. There was no documented evidence Staff 12 (CG), Staff 27 (MT) and Staff 28 (MT), hired 06/28/10, 08/28/17, and 01/09/19, respectively, had completed the required minimum 12 hours of in-service training annually related to the provision of care which also included six hours of dementia care training. The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/24/23. No additional information was provided.

1 An annual inservice calendar is in place to assure scheduling of 12 hours of annual inservicing for direct care staff to include 6 hours specific to dementia training topics. 2.  Executive Director & Business Office Manager will be provided education as it relates to requirements in rule.  The Business Office Manager will routinely monitor completion of on-line training courses as well as track inservice hours provided during all associate meetings. 3.  Executive Director and/or designee to audit training files monthly for 3 months then quarterly thereafter to assure compliance. 4.  The Executive Director and Business Office Manager are responsible for plan of correction and monitoring.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and to provide fire and life safety instruction to staff on alternate months, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 03/22/23 at 8:45 am. The facility provided documentation of two fire drills in the last six months, which occurred on 02/01/23 and 02/27/23. There was no documented evidence fire drills were conducted every other month. On 02/01/23, staff were instructed on Fire Drill Policy. There was no documented evidence staff were instructed on fire and life safety on alternating months from fire drills. During an interview on 03/22/23 Staff 8 (Maintenance Supervisor) indicated the fire drills and fire and life safety instruction to staff only occurred in 02/2023 over the last six months. The need to ensure fire drills were conducted and staff instruction was provided according to the OFC was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/22/23 at 2:30 pm. They acknowledged the findings and no further information was provided.

1. Fire drills will continue to be held monthly on alternating shifts. Staff instruction on other life safety topics will be scheduled for every other month via online building maintenance platform. 2. Moving forward fire and safety drills will be conducted according to company policy, with each shift receiving drill and instruction quarterly. Additional life safety topics will be completed on alternating monthsl 3.  The Executive Director will review all fire and safety drills and Life topic instruction. 4.  The Executive Director and Maintenance Supervisor are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually thereafter. Findings include, but are not limited to: Fire and life safety records were reviewed on 03/22/23 at 8:45 am and revealed a lack of documented evidence related to the following required elements: * Instructions to residents on fire and life safety procedures within 24 hours of admission; and * A written record, including content and residents attending, of annual re-instruction for residents on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places inside or outside the building in the event of an actual fire. The need to provide training to residents on fire and life safety as required by the Oregon Fire Code was discussed with Staff 1 (District Director of Operations) and Staff 2 (District Director of Clinical) on 03/22/23 at 2:30 pm. They acknowledged the findings and no further information was provided.

1. New move in process has been revised to include review of fire and life safety instruction to residents on or before day of move in. Fire and life safety instruction for current residents is scheduled during next Town Hall meeting on April 19, 2023. 2. Maps with highlighted evacuation routes will be provided to every resident and they will indicate training and understanding via signature on the map. This will be hung on the back of their apartment door for easy visibility. 3. Maintenance Director or designee will make random audits weekly of resident apartments to ensure that maps are still posted for residents to access. This will continue weekly for 60 days and bi-monthly thereafter as part of ongoing community operational process. 4. Executive Director and Maintenance Director are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the facility's common use areas were made of smooth material and maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 03/21/23 at 10:13 am. The following issues were noted: * The facility's common use pathways had multiple expansion joints which measured approximately one inch wide. This constituted a tripping hazard; * The outside perimeter of the pathway surrounding the building had multiple areas where sod and pavement did not meet. This created an approximate one inch wide and one to two inch deep drop-off; and * Large and uneven cracks in pathway concrete on north side of the building. The need to ensure common use areas were free from drop-offs was discussed with Staff 1 (District Director of Operations), Staff 8 (Maintenance Supervisor) and Staff 32 (Housekeeping Supervisor) on 03/24/23. They acknowledged the findings.

1. A punch list of areas in need of repair and/or additional sod was created during walk through with surveyor and provided to Regional Maintenance and landscape vendor to obtain bids and schedule repairs. 2. Work with these vendors will be scheduled to complete no later than May 15, 2024. 3. Maintenance Director will conduct twice weekly walk throughs of building exterior to identify areas in need of repair and/or areas that represent a fall or trip hazard. Areas identified will be routed to appropriate vendor for repair. These audits will continue twice weekly for the next 60 days and then weekly ongoing as part of community operations. 4. The Executive Director and Maintenance Director is responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure interior and exterior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The interior of the building was toured on 03/21/23 at 11:05 am. The following areas were observed to need cleaning and/or repair: * Baseboards in dining room had brown drips, stains and dust; * Walls throughout the dining room had drips, gouges, chipped paint, cracks and holes; * Dining room tables had worn sealant around edges with bare wood exposed; * Chairs throughout the dining room were stained and had scrapes and/or gouges in the wood; * Drywall below resident mailboxes was gouged; * Women's public bathroom on the first floor had lifted baseboard and gouges in the drywall; * Resident laundry room was missing an electric outlet cover; * Ceiling tiles above the first floor shower room were stained brown; * Multiple resident rooms had white drips and were scraped or gouged doors with bare wood exposed; * Multiple resident metal door frames were dented and/or broken; * Walls throughout the facility had chipped paint, scrapes and gouges; * Handrail near room 100 was split which created potential for skin tears; * Interior elevator paneling was gouged; * Chairs throughout the second floor activity room had scrapes and gouges in the wood; * Cabinet door under the sink in the activity room was broken; * Handrails and the door frame surrounding room 200 were coated in tan stains; * Furniture throughout all resident hallways was stained and the legs of the furniture were scraped with bare wood exposed; * Windowsills near third floor seating area had cobwebs, debris and dust; and * Chandelier above staircase had multiple burned out and flickering lightbulbs. The exterior of the building was toured on 03/21/23 at 10:13 am. The following areas were observed to need repair: * Siding throughout the property was damaged with corner pieces missing or not fully attached; * Siding near second and third floor patios was lifted with rusted metal exposed; * Exterior security door near room 119 had rips and holes;   * Multiple exterior patio doors were faded, had gouges, scrapes and/or chipped paint; * Multiple exterior patio door frames were faded, had gouges, scrapes and/or chipped paint; and * Window screens for multiple resident rooms were threadbare and/or had large holes. The surveyor toured the environment with Staff 1 (District Director of Operations), Staff 8 (Maintenance Supervisor) and Staff 32 (Housekeeping Supervisor) on 03 / 24 / 23. They acknowledged the above areas needed to be cleaned and repaired.

1. A punch list of areas in need of cleaning and/or repair was created by Maintenance Director during facility walk through with survey team. All areas identified in need of cleaning and/or repair that could be compelted in house was corrected on or before April 17,2023. Areas requiring outside vendor services were referred to Regional Maintenance to obtain bids and schedule repair. 2. Areas in need of outside vendor support will be repaired or replaced on or before May 23,2023. 3. Maintenance Director or designee will complete interior and exterior community walk throughs twice weekly for the next 60 days to identify areas in need of repair or cleaning. Areas identified will be placed into electronic work order system to ensure follow up and documentation. 4. The Executive Director and Maintenance Director are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' apartments were maintained within a range of 110 - 120 degrees Fahrenheit. Findings include, but are not limited to: On 03/22/23 and 03/23/23, resident apartments were toured and water temperatures were taken throughout the building. Water temperatures were higher than 120 degrees Fahrenheit in the following apartments: * Room 204 - 124.6 degrees Fahrenheit; * Room 223 - 123.6 degrees Fahrenheit; * Room 303 - 123.4 degrees Fahrenheit; and * Room 331 - 130.0 degrees Fahrenheit. The need to adjust the water temperatures between 110 degrees and 120 degrees Fahrenheit was discussed with Staff 1 (District Director of Operations) on 03/22/23 at 3:47 pm. Water temperatures were taken again with Staff 8 (Maintenance Supervisor) on 03/23/23 throughout the course of the day. All temperatures obtained were between 110 and 120 degrees Fahrenheit. The need to ensure water temperatures in residents' apartments were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 1 and Staff 8 on 03/24/23. They acknowledged the findings.

1.All resident apartments found to have water temperatures exceeding 120 degrees during survey were reivewed and corrected prior to survey exit. 2. Water temperatures in all occupied apartments will be reviewed to ensure they do not exceed 120 degrees on or before April 21, 2023. 3. Maintenance Director or designee will conduct a random sampling of 5 resident apartments weekly for to ensure that water temperatures remain between 110 and 120 degrees. This will continue as part of ongoing community operations. 4. Executive Director and Maintenance Director are responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 231, C 260, C 361 and C 372.

1. Plan of correction will be implemented and monitored to ensure that all open citations C231, C260, C361, C372, and C455 will meet standards and satisfy the Department. 2. Audits tools will be created to ensure all citations meet standard. 3. Audit tools will be evaluated weekly to ensure progress of completed tasks to ensure compliance. 4. Executive director and/or designee will be repsonsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C361.

v1. Plan of correction will be inplemented and monitored to ensure that all open citations C361 and C455 will meet standards and satisfy the Department. 2. Executive Director and/or designee will be responsible for this plan of correction.

The findings of the re-licensure survey conducted 03/21/23 through 03/24/23 are documented in this report. The survey was conducted to determine compliance with the OAR 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OAR 411 Division 004. 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 03/24/23, conducted 09/19/23 through 09/20/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second revisit to the re-licensure survey of 03/24/23, conducted 12/06/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 03/24/23, conducted 03/24/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

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 3/7/2023.  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

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 01/17/2023.  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

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 01/17/2023.  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

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 01/17/2023.  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

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 01/17/2023.  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

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 01/17/2023.  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

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 12/13/2022.  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

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 12/13/2022.  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

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 12/13/2022.  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

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 12/13/2022.  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

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 12/13/2022.  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

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 12/13/2022.  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

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 12/13/2022.  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

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 12/13/2022.  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 interview, observation and record review, it has been confirmed that the facility failed to provide household services. Findings include: During an unannounced site visit on 08/29/2022, Compliance Specialist (CS) interviewed Staff #1 (S1). It was stated that the facility had 3 housekeepers, but that 2 left without any notice. The facility administrator and other staff attempted to assist with housekeeping in the meantime. CS completed a walkthrough of the facility, and the following was found: -Extensive stains throughout the facility common areas and in R4 ' s apartment. -Debris found in living room of Resident #4 ' s (R4s) apartment. -Urine residue found in commode in R4 ' s apartment. -Brown substance that appeared to be feces in R4 ' s bathroom and toothbrush. -Sticky floors found in Resident #3 ' s (R3s) apartment. CS reviewed care plans for sampled residents, which revealed residents are signed up weekly for housekeeping with scheduled dates as required by rule. The above information was shared with Staff #2. Facility Plan of Correction: CS consulted with Safety,Oversight and Quality (SOQ) central office and an agreement has been made between facility and Policy Analyst to rectify areas of non-compliance

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 8/29/2022.  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

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 8/29/2022.  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

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 8/29/2022.  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

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 8/29/2022.  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

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 8/29/2022.  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