Powell Valley Memory Care Community

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 09/25/25, from 9:55 am through 11:30 am, the facility main kitchen was observed.

1. The following areas needed cleaning:

* Walls and floors throughout the kitchen and dry food storage room – build-up of black matter, dust, and/or food spillage;

* Walls and floors in the walk-in refrigerator and freezer – build-up of black matter, dust, and/or food debris;

* Wall and caulking above splash guard throughout the dishwashing area – build-up of black matter;

* All wire storage racks in the main kitchen and dry food storage room – build-up of black and brown matter and dust;

* All floor drains – black matter and food debris;

* The drain under the ice machine - accumulated debris;

* The wall behind the hand sink - spills and dust build-up;

* Ceiling fire sprinklers and vents – build-up of dust and brown matter;

* Magnetic knife holder – brown and black matter;

* The speaker next to the entrance door had dust build-up;

* Commercial can opener – black matter on blade and housing;

* Drains of beverage counter and hot cocoa dispenser - an accumulation of splatters and stains; and

* Microwave – brown matter and rust on interior.

2. The following items were in need of repair:

* Door handle of walk-in refrigerator was broken and did not latch;

* Walk-in refrigerator door – dents and paint chipping on exterior surface, and chips and paint peeling in interior surface;

* Commercial floor mixer – faulty bowl anchor needing a screwdriver and string to lock it in place;

* Door frames around walk-in refrigerator, walk-in freezer, all doors to and from the kitchen area – paint chips, scratches, gouges, and stains;

* Four two-inch diameter holes in the wall above the prep table;

* Cracked and melted work bowl on food processor;

* At the entrance to the dry food storage area, the wall liner was ripped and missing near the walk-in freezer;

* Steam table lip was pulling away from walls and the gap was filled in with a thick, uneven line of caulking, making it uncleanable; and

* Door from kitchen to hallway leading to MCC – scratches, stains, paint chips, and exposed wood.

3. Improper food storage:

* The walk-in refrigerator temperature displayed outside indicated 52 degrees F. It was re-checked after 30 minutes, and the temperature was still 50 degrees F. Staff 1 (ED) and the surveyor measured the temperature of the cottage cheese in the walk-in refrigerator and it was 46.7 degrees F. All dairy and protein items were requested to be removed from the walk-in refrigerator. At 1:07 pm, the walk-in refrigerator exterior thermometer indicated 40 degrees F;

* Uncovered trays of cookies and plated desserts were observed on a metal rack positioned next to trash cans, risking cross contamination - the surveyor requested the trash cans be relocated; and

* Opened items in dry food storage, free-standing refrigerator, and walk-in refrigerator were not dated.

4. Other areas of concern:

* Recycle bins were uncovered and flies were observed around the contents;

* Staff did not have alcohol wipes to disinfect temperature probes between use;

* Staff were not using sanitizer chemicals and test strips properly; and

* Untrained staff were asked to prepare mechanical soft textures.

The areas of concern were reviewed with Staff 1 and Staff 4 (Dining Service Director at Calaroga Terrace) on 09/25/25 at 1:10 pm. They acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to:

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure residents’ right to have medical and other records kept confidential for multiple sampled and unsampled residents and to receive services in a manner that protected privacy and dignity for 2 of 2 sampled residents (#s 2 and 5) whose ADL cares were observed. Findings include, but are not limited to:

1. During an interview with Staff 10 (CG) on 05/22/25 at 10:30 am, a list posted on the side of the refrigerator in the north MCC kitchenette was observed, listing all north wing residents by first names and room numbers and their meal intake and bowel character. Staff 10 stated information was filled out on the list as it happened and then entered into the ADL log at the end of each shift. The posting was visible to any person walking through the kitchenette.

The need to ensure residents’ right to have medical and other records kept confidential was reviewed with Staff 1 (Administrator) on 05/23/25 at 1:50pm. She acknowledged the findings.

2. Resident 5’s door was observed propped open throughout the survey period, 05/21/25 to 05/23/25. His/her service plan did not indicate the resident’s preference to have the door propped open.

In an interview on 05/23/25 at 9:00 am, Staff 1 (Administrator) stated staff sometimes left doors propped open to provide staff clear sight lines into resident rooms to identify when they were getting up to toilet or move about their unit.

The need to ensure each individual had privacy in his or her own unit and preferences were noted in the resident’s service plan was reviewed with Staff 1 on 05/23/25 at 9:00 am. She acknowledged the findings.

3. Resident 2 moved into the MCC in 07/2020 with diagnoses including Alzheimer’s disease. S/he was identified in the acuity interview as residing in a room with another resident and dependent on staff for ADL care.

During an interview at 2:31 pm on 05/21/25, Staff 13 (Resident Assistant) stated she was not aware of any privacy barriers available to provide Resident 2 with privacy during incontinence care while his/her roommate was also in the room.

Observations of incontinence care were completed on 05/21/25 and 05/22/25. At 11:55 am on 05/22/25, Staff 10 (Resident Assistant) was observed providing incontinence care for Resident 2 while the resident was in full view of his/her roommate. During an interview at the same time, Staff 10 stated she did not know if there were privacy barriers available to ensure the resident’s right to privacy and dignity during ADL care.

The need to ensure residents’ right to privacy and dignity in his/her own unit was discussed with Staff 1 (Administrator) and Staff 19 (Regional Director) at 12:32 pm on 05/23/25. They acknowledged the findings.

OAR 411-054-0027 (1) Resident Rights and Protection - General

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to conduct immediate investigations of multiple unwitnessed falls and injuries of unknown cause to rule out abuse or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office for 3 of 4 sampled residents (#s 1, 2, and 3) with documented falls and injuries of unknown cause. Findings include, but are not limited to:

1. Resident 3 moved into the MCC in 04/2024 with diagnoses including vascular dementia and cerebral infarction (stroke). During the acuity interview the resident was identified as having multiple non-injury falls.

The resident’s 02/19/25 to 05/20/25 progress notes and incident reports (the tool used by the facility to investigate incidents) were reviewed.

There was no documented investigation that determined the service-planned fall interventions were in place at the time the resident fell, and therefore, suspected abuse was not ruled out for the following unwitnessed falls:

* 03/04/25;
* 04/09/25; and
* 05/16/25.

Survey requested the facility report the above unwitnessed falls to the local SPD office. The facility provided verification of reporting to the local SPD office on 05/23/25, prior to survey exit.

The need to ensure the facility immediately investigated unwitnessed falls and ruled out suspected abuse was discussed with Staff 1 (Administrator) on 05/23/25 at 11:45 am. She acknowledged the findings.

?2. Resident 2 moved into the MCC in 07/2020 with diagnoses including Alzheimer’s disease.

The resident’s 02/02/25 to 05/21/25 progress notes and incident reports were reviewed, and the following was identified:

A 04/04/25 progress note indicated the resident was on alert charting for a blister on the buttocks.

During an interview at 2:26 pm on 05/22/25, Staff 4 (LPN) confirmed the resident was not able to state what happened. She confirmed no investigation had been completed to rule out abuse or neglect regarding the injury of unknown cause. Survey requested the injury of unknown cause be reported to SPD and confirmation was received at 4:02 pm on 05/23/25.

The need to ensure injuries of unknown cause were immediately investigated to rule out abuse or neglect and/or reported to the local SPD office if abuse or neglect could not be ruled out was discussed with Staff 1 (Administrator) and Staff 19 (Regional Director) at 12:32 pm on 05/23/25. They acknowledged the findings.

3. Resident 1 moved into the MCC in 11/2023 with diagnoses including vascular dementia.

The resident’s 11/01/24 through 05/21/25 progress notes, incident investigations, 04/01/25 service plan, and temporary service plans (TSPs) were reviewed, and the following was noted:

A progress note dated 02/21/25 indicated the resident was found with a bruise to the right arm and a skin tear.

There was no documented evidence the facility conducted an investigation to determine the cause of the skin injury. The incident was not reported to the local SPD office. The surveyor requested Staff 3 (RN) ensure the incident was reported to the local SPD office. Confirmation that the report was sent to the SPD office was provided prior to exit.

The need to ensure injuries of unknown cause were immediately investigated by the facility and, if abuse was not able to be reasonably ruled out, the injury was reported to the local SPD office, was discussed with Staff 1 (Administrator) on 05/23/25 at 1:30 pm. She acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#5) and evaluations were performed quarterly and were relevant to the needs and current condition of the resident for 3 of 4 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the MCC in 04/2025 with diagnoses including Alzheimer’s disease.

The resident’s new move-in evaluation was reviewed and failed to address the following elements:

* Customary routines with sleeping and eating;
* Spiritual and cultural preferences and traditions;
* Cognition, including memory and confusion;
* Non-pharmaceutical interventions for pain;
* Nutrition habits and fluid preferences; and
* Recent losses.

The need to ensure move-in evaluations included all required elements was reviewed with Staff 1 (Administrator) on 05/23/25 at 1:50pm. She acknowledged the findings.

2. Resident 2 moved into the MCC in 07/2020 with diagnoses including Alzheimer’s disease.

The resident’s record, including the most recent quarterly evaluation, was reviewed, and the following was identified:

a. The resident ‘s current quarterly service plan was dated 04/03/25 and the quarterly evaluation was completed on 01/15/25. Therefore, it was not completed to correspond with and used as the basis for the quarterly service plan update.

b. The evaluation was not relevant to the needs and current condition of the resident in the following areas:

* Level of assistance needed for eating and meals; and
* Diet texture and liquid consistency.

The need to ensure evaluations were updated quarterly and were relevant to the needs and current condition of the resident was discussed with Staff 1 (Administrator) and Staff 19 (Regional Director) at 12:32 pm on 05/23/25. They acknowledged the findings.

3. Resident 3 moved into the MCC in 04/2024 with diagnoses including vascular dementia and cerebral infarction (stroke).

Review of the resident's current service plan and quarterly evaluation identified the following:

The resident ‘s current quarterly service plan was dated 04/26/25 and the quarterly evaluation was completed on 05/21/25. Therefore, it was not completed to correspond with and used as the basis for the quarterly service plan update.

The need to ensure quarterly evaluations were updated and corresponded with the quarterly service plan update was discussed with Staff 1 (Administrator) on 05/23/25 at 11:45 am. She acknowledged the findings.

4. Resident 1 moved into the MCC in 11/2023 with diagnoses including vascular dementia.

The resident’s quarterly evaluation dated 10/24/24, service plan dated 04/01/25, temporary service plans (TSP’s), and progress notes dated 11/01/24 through 05/21/25 were reviewed during the survey. The following was identified:

* The resident was noted to have experienced a significant change in condition related to severe weight loss in 11/2024. The evaluation was not updated following the significant change of condition; and
* The evaluation was not updated quarterly.

The lack of documented evidence the service plan was updated when the resident experienced a significant change of condition was confirmed in an interview with Staff 3 (RN) on 05/23/25 at 11:45 am.

On 05/23/25 at 1:30 pm, the need to ensure evaluations were updated at least quarterly and when a resident experienced a significant change in condition was discussed with Staff 1 (Administrator). She acknowledged the findings.

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure residents’ service plans were readily available to staff and provided clear direction regarding the delivery of services for 5 of 5 residents (#s 1, 2, 3, 4, and 5) whose records were reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the MCC in 04/2025 with diagnoses including Alzheimer’s disease.

In the 05/21/25 acuity interview at 9:45 am, Staff 1 (Administrator) indicated staff had access to updated service plans in binders located on each wing of the MCC. Resident 5’s service plan was observed to be missing from the service plan binder. Staff 3 (RN) printed the resident’s service plan upon request.

The need to ensure resident service plans were readily available to staff was reviewed with Staff 1 on 05/23/25 at 1:50pm. She acknowledged the findings.

2. Resident 2 moved into the MCC in 07/2020 with diagnoses including Alzheimer’s disease.

The resident’s service plan, dated 04/03/25, and temporary service plans dated from 02/21/25 to 05/21/25 were reviewed, interviews with staff were conducted, and observations of the resident were made. The resident’s service plan was not reflective or did not provide clear direction to staff in the following areas:

* Diet texture;
* One-on-one meal assistance;
* Weight loss;
* Chronic skin issues, including right ankle pressure sore;
* Shower schedule;
* Nail care; and
* Resident temperature preferences.

The need to ensure the service plan was reflective of the resident’s needs and preferences and provided clear direction regarding the delivery of services was discussed with Staff 1 (Administrator) and Staff 19 (Regional Director) at 12:32 pm on 05/23/25. They acknowledged the findings.

3. Resident 3 moved into the MCC in 04/2024 with diagnoses including vascular dementia and cerebral infarction (stroke).

During the acuity interview on 05/21/25, Staff 1 (Administrator) stated current service plans were located in binders in the unit kitchens. Resident 3’s quarterly service plan could not be located in the service plan binder and was not readily available to staff. Upon request, Staff 2 (MC Administrator) printed a copy of the resident’s current service plan on 05/21/25 at 1:15 pm.

The need to ensure service plans were readily available for staff was discussed with Staff 1 (Administrator) on 05/23/25 at 11:45 am. She acknowledged the findings.

4. Resident 4 moved into the MCC in 02/2025 with diagnoses including dementia and major depressive disorder.

In the 05/21/25 acuity interview at 9:45 am, Staff 1 (Administrator) indicated staff had access to updated service plans in binders located on each wing of the MCC. The service plan readily available to staff in the service plan binder kept on the unit was dated 03/17/25. On 05/23/25, Staff 1 (Administrator) provided a current service plan dated 05/21/25. This service plan was not readily available to staff.

The need to ensure service plans were readily available for staff was discussed with Staff 1 (Administrator) on 05/23/25 at 11:45 am. She acknowledged the findings.

5. Resident 1 moved into the MCC in 11/2023 with diagnoses including vascular dementia.

a. In the 05/21/25 acuity interview at 9:45 am, Staff 1 (Administrator) stated current service plans for MCC residents were made available to staff via service plan binders in the MCC kitchens. At 10:17 am, Resident 1’s service plan could not be located in the service plan binders and was not readily available to staff. Upon request Staff 2 (MC Administrator) printed a copy of the resident’s current service plan.

b. Observations of the resident, interviews with staff, and review of the service plan, dated 04/01/25, and subsequent temporary service plans (TSP’s) identified 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:

* Updated fall interventions;
* Risks and precautions related to use of bilateral side rails; and
* Cueing for repositioning while seated.

The need to ensure resident service plans were available to staff, were reflective of current care needs, and provided clear direction to staff was discussed with Staff 1 (Administrator) on 05/23/25 at 1:30 pm. She acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short-term changes of condition, communicate resident-specific instructions and interventions to staff on each shift, and monitor the change of condition at least weekly until resolution for 3 of 4 sampled residents (#s 1, 2, and 3) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 moved into the MCC in 11/2023 with diagnoses including vascular dementia.

The resident’s clinical record was reviewed, observations were made, and staff were interviewed during the survey.

The resident was noted to have experienced the following short-term changes of condition:

* 02/21/25: Bruise to the right arm with skin tear; and
* 03/14/25: Medication order change, start Breyna 160-4.5 micrograms (for chronic obstructive pulmonary disease), two puffs into lungs twice daily.

The facility lacked documented evidence each short-term change of condition had actions or interventions determined, documented, communicated to staff, and conditions were monitored, with progress noted at least weekly.

The need to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and to monitor the change of condition at least weekly until resolution was reviewed with Staff 1 (Administrator) on 05/23/25 at 1:30 pm. She acknowledged the findings.

?2. Resident 2 moved into the MCC in 07/2020 with diagnoses including Alzheimer’s disease.

The resident’s 02/02/25 to 05/21/25 progress notes and temporary service plans were reviewed. The following was identified:

There was no documented evidence the following changes of condition had actions or interventions determined, documented, or communicated to staff on each shift, with weekly progress noted to resolution:

* Missed Metamucil (for constipation) on 27 occasions from 02/02/25 to 03/22/25;
* Missed doxepin (for depression), on four occasions from 04/25/25 to 05/01/25;
* Missed donepezil (for Alzheimer’s disease), on three occasions from 05/11/25 to 05/19/25; and
* Missed calcium carbonate (a supplement) on 05/12/25.

The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift, with weekly progress noted to resolution for resident short-term changes of condition was discussed with Staff 1 (Administrator) and Staff 19 (Regional Director) at 12:32 pm on 05/23/25. They acknowledged the findings.

3. Resident 3 moved into the MCC in 04/2024 with diagnoses including vascular dementia and cerebral infarction (stroke). During the acuity interview the resident was identified to have had multiple non-injury falls.

Progress notes dated 02/19/25 through 05/20/25, temporary service plans (TSP’s), and the quarterly service plan, dated 04/26/25, were reviewed during the survey.

The resident had the following unwitnessed non-injury falls:

* 02/18/25;
* 03/04/25;
* 04/09/25; and
* 05/16/25.

There was no documented evidence that resident- specific actions or interventions were determined, documented, and communicated to staff on all shifts, or that prior fall interventions were reviewed for effectiveness after each subsequent fall.

The need to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on all shifts and ensure prior fall interventions were reviewed for effectiveness was discussed with Staff 1 (Administrator) on 05/23/25 at 11:45 am. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN performed an assessment, developed interventions based on the condition of the resident, and/or updated the service plan for 2 of 3 sampled residents (#s 1 and 2) who experienced significant changes in condition. Resident 1 experienced ongoing severe weight loss. Findings include, but are not limited to:

1. Resident 1 moved into the MCC in 11/2023 with diagnoses including vascular dementia.

Resident 1 had an order for mechanical soft, moist and minced food textures and thin liquids. The resident was noted in the 05/21/25 acuity interview to require cueing assistance during meals. The resident was provided a dietary supplement with lunch and dinner each day. The resident's 04/01/25 service plan noted the resident was on a finger food diet with thin liquids.

The resident was observed to consume the following foods during the survey:

* On 05/21/25 for lunch, the resident consumed an egg salad sandwich, a piece of cake, and eight ounces of chocolate nutritional supplement; and
* On 05/22/25 for breakfast, the resident consumed a bowl of oatmeal and a serving of scrambled eggs. For lunch the resident consumed a peanut butter and jelly sandwich, a small bowl of chocolate pudding, and eight ounces of chocolate nutritional supplement.

Resident 1’s weight record noted the following:

* 05/05/25 - 141 pounds;
* 04/01/25 - 147.2 pounds;
* 03/03/25 - 152.6 pounds;
* 02/02/25 - 151.6 pounds;
* 01/04/25 - 150.6 pounds;
* 12/03/25 - 162 pounds;
* 11/03/24 - 162 pounds;
* 10/04/24 - 171.4 pounds;
* 09/02/24 - 177.8 pounds; and
* 08/01/24 - 183.6 pounds.

Between 08/01/24 and 11/03/24, the resident was noted to have lost 21.6 pounds, or 11.76% of his/her total body mass in three months. This constituted a severe weight loss and required an RN assessment.

There was no documented evidence an RN completed an assessment after Resident 1’ s severe weight loss was identified.

From 11/03/24 through 05/05/25, the resident continued to lose weight, losing an additional 21 pounds, or an additional 9.5% of his/her total body mass.

A current weight for Resident 1 was requested on 05/23/25. At 12:02 pm the resident was observed to weigh 146.4 pounds.

In an interview with Staff 3 (RN) on 05/22/25 at 12:48 pm, she confirmed the lack of an RN assessment, which included resident status and interventions made as a result of the assessment, for Resident 1's severe and ongoing weight loss between 08/01/2024 and 05/05/25.

The facility's failure to ensure an RN assessment, which included resident status and interventions made as a result of the assessment, was completed for Resident 1's severe and ongoing weight loss put the resident's health and safety at risk.

The need for the facility RN to assess significant changes in condition and document findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (MC Administrator), and Staff 3 on 05/23/25 at 4:15 pm. They acknowledged the findings. ?

2. Resident 2 moved into the MCC in 07/2020 with diagnoses including Alzheimer’s disease and was identified in the acuity interview as requiring verbal meal cues and thickened liquids.

The resident’s 02/02/25 to 05/21/25 progress notes, outside provider notes, and temporary service plans, and 03/03/25 to 05/20/25 weight records were reviewed. The following was identified:

Resident 2 had orders for mechanical soft textures and nectar-thick liquids. The resident was provided with a dietary supplement at 10:00 am and 8:00 pm each day. Progress notes and outside provider notes indicated the resident required one-on-one assistance with meals.

Observations of the resident were conducted during lunch and/or breakfast on 05/21/25 through 05/23/25, and the following was observed:

* The resident would initiate two or three bites of food at each meal, but would not sustain independent eating; and
* With one-on-one assistance from staff, the resident consumed about 40-80% of each meal, including scrambled eggs, soup, lasagna, cream of wheat, and various desserts.

Resident 2’s weight records were as follows:

* 03/03/25 – 120.4 pounds;
* 04/01/25 – 114 pounds;
* 05/20/25 – 116.6 pounds; and
* 05/23/25 – 120.4 pounds (taken during survey).

From 03/03/25 to 04/01/25, the resident lost 6.4 pounds, or 5.3% of his/her body weight in one month. This constituted a severe weight loss and required an RN assessment which included findings, resident status, and interventions made as a result of the assessment.

At 2:46 pm on 05/22/25, Staff 3 (RN) stated no RN assessment had been completed for the severe weight loss.

The need to ensure an RN assessment was completed documenting findings, status, and interventions made as a result of the assessment for significant changes of condition was discussed with Staff 1 (Administrator) and Staff 19 (Regional Director) at 12:32 pm on 05/23/25. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure infection prevention and control protocols were maintained to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 2 and 5) dependent on staff for ADL care and multiple sampled and unsampled residents dependent on staff for meal service. Findings include, but are not limited to:

1. Resident 2 moved into the MCC in 07/2020 with diagnoses including Alzheimer’s disease and was identified in the acuity interview as requiring staff assistance for ADL care, including incontinence care.

Staff 13 (Resident Assistant) was observed providing incontinence care for the resident on 05/21/25. Staff 13 removed the soiled brief wearing single use gloves. She provided peri care and applied a clean brief and pants using the same gloves. She then adjusted the resident’s head, put a pillow under his/her legs, pulled up a blanket, and adjusted the resident’s bed wearing the soiled gloves. Staff 13 then removed the soiled gloves, gathered a garbage bag with the incontinence trash, and left the resident’s room. She disposed of the trash and proceeded to enter an unsampled resident’s room without performing hand hygiene. When surveyor asked, Staff 13 confirmed she intended to provide incontinence care for the resident. Surveyor requested and observed the staff perform hand hygiene prior to completing any other task.

2. Observations of dining services were completed from 05/21/25 to 05/23/25. Direct care staff were observed to provide food service tasks, including serving meals and beverages and providing physical feeding assistance to sampled and unsampled residents, without a protective covering over potentially contaminated clothing.

The need to ensure infection prevention and control protocols were maintained was discussed with Staff 1 (Administrator) and Staff 19 (Regional Director) at 12:32 pm on 05/23/25. They acknowledged the findings.

3. Resident 5 moved into the MCC in 04/2025 with diagnoses including Alzheimer’s disease.

During ADL observations on 05/22/25 at 10:23 am, Staff 10 (CG) assisted the resident with toileting. Staff 10 donned single use gloves in the room to assist Resident 1 with putting on shoes. Without changing gloves or performing hand hygiene, Staff 10 escorted the resident to the bathroom. After toileting, Staff 10 assisted the resident in pulling up his/her briefs and pants and then handed a tissue to the resident with the same gloved hands. The resident blew his/her nose with it. Staff 10 then removed the gloves and put them in her pocket until she reached the trash can in the kitchenette and threw them away. Staff 10 was not observed to perform hand hygiene after removing the gloves.

The need to ensure infection prevention and control protocols were maintained was discussed with Staff 1 on 05/23/25 at 1:50 pm. She acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the MCC in 07/2020 with diagnoses including Alzheimer’s disease and depression. The resident’s 02/02/25 to 05/21/25 progress and medication exception notes and current physician orders were reviewed. The following was identified:

a. Medication exception notes indicated the following medications were not administered due to not being ordered:

* Metamucil (for constipation), on 29 occasions from 2/2/25 to 4/30/25;
* Doxepin (for depression), on four occasions from 4/25/25 to 5/1/25;
* Donepezil (for Alzheimer’s disease), on three occasions from 5/11/25 to 5/19/25; and
* Calcium carbonate (a supplement) on 05/12/25.

b. The resident’s progress notes indicated staff were crushing medications and mixing with a pureed texture to administer. Staff 8 (MA) was observed administering the resident his/her medications crushed in a puree at 8:20 am on 05/22/25. There was no physician order for staff to administer medications crushed.

c. The resident had an order for mechanical soft diet textures. The modified diet was not included on the resident’s service plan or MAR. Meal observations revealed the resident was served regular texture items such as bacon and bread rolls. The resident was not observed eating the regular texture items. Interviews with care staff on 05/21/25 and 05/22/25 revealed they did not know the resident had orders for a modified diet. At the request of survey, the resident’s service plan was updated, and the mechanical soft diet texture order was implemented prior to survey exit.

The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 19 (Regional Director) at 12:32 pm on 05/23/25. They acknowledged the findings.

2. Resident 1 moved into the MCC in 11/2023 with diagnoses including vascular dementia.

The resident’s physicians’ orders were reviewed, observations were made, and staff were interviewed. The following was noted:

Resident 1 had an order for mechanical soft, moist and minced food textures with thin liquids. The resident was noted to require staff assistance with cutting up his/her food. Observations made on 05/22/25 at 11:34 am found the resident was served chicken strips for lunch. The chicken strips were not cut into pieces for the resident. When the resident did not eat any of the chicken strips, staff brought him/her a peanut butter and jelly sandwich and potato chips as an alternative. The chicken strips and the potato chips did not follow the resident’s prescribed diet. This was brought to the attention of Staff 12 (MA) prior to Resident 1 consuming any of the potato chips. Staff 12 asked Resident 1 for permission to remove the potato chips from the plate. The resident agreed.

In a 05/22/25 interview with Staff 21 (Dining Services Director/Recruiter) at 3:34 pm, she relayed she was unaware Resident 1’s diet order for mechanical soft food textures included the food be moist and minced.

The need to ensure physician orders were followed as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (MC Administrator) on 05/23/25 at 4:15 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 1 of 1 sampled resident (# 4), who had documented medication refusals. Findings include, but are not limited to:

Resident 4 moved into the facility in 02/2025 with diagnoses including dementia and major depressive disorder.

The resident's MAR, dated 05/01/25 through 05/21/25, was reviewed and revealed facility staff documented Resident 4 refused the following medications on multiple occasions:

* Haloperidol 1 mg daily for agitation, three occasions;
* Levetiracetam 500 mg twice daily for seizure control, five occasions;
* Lorazepam 0.5 mg twice daily for anxiety, two occasions; and
* Omeprazole 20 mg daily for gastro-esophageal reflux disease, two occasions.

There was no documentation that the physician or other practitioner was notified of the refusals.

On 05/23/25, the need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (Administrator) and Staff 2 (MC Administrator) on 05/23/25 at 4:15 pm. The findings were acknowledged, and no additional documentation was provided.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated prior to a new resident moving in and/or no less than quarterly for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5). Findings include, but are not limited to:

The facility’s ABST data was reviewed at 11:08 am on 05/21/25. The ABST data did not show documented evidence Resident 5’s ABST was entered prior to move-in or that ABST data was updated at least quarterly to correspond with the quarterly service plan updates for Residents 1, 2, 3, and 4.

The need to ensure residents’ ABST was updated prior to move-in and no less than quarterly was discussed with Staff 1 (Administrator) on 05/22/25 at 10:22 am. She acknowledged the findings.

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

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

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

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

This Rule is not met as evidenced by:

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

Fire drill and fire and life safety records dated 10/2024 through 04/2025 were reviewed on 05/21/25. The following was identified:

a. There was no documented evidence the facility conducted a fire drill in the MCC every other month between 10/2024 and 04/2025.

b. Fire drill documentation failed to address the following:

* The escape route used; and
* Comments relating to residents who resisted or failed to participate in the drill.

c. There was no documented evidence the facility was providing staff training on fire and life safety to staff on alternate months of fire drills.

The need to ensure unannounced fire drills were conducted in accordance with the OFC and fire and life safety instruction was provided to staff on alternate months of fire drills was reviewed with Staff 1 (Administrator) on 05/23/25 at 1:50pm. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission and at least annually. Findings include, but are not limited to:

Fire and life safety records dated 10/2024 through 04/2025 were reviewed on 05/21/25.

There was no documented evidence residents were instructed within 24 hours of admission and re-instructed at least annually in the facility’s fire and life safety procedures.

The need to instruct residents on fire and life safety procedures, methods, and responsibilities within 24 hours of admission and to re-instruct residents at least annually was reviewed with Staff 1 (Administrator) at 1:50pm on 05/23/25. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure individual rights of privacy, dignity, and respect for multiple sampled and unsampled residents.

Refer to C 200.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity

(1) Residential and non-residential HCB settings must have all of the following qualities:
(c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure physical accessibility to all residents for 1 of 5 sampled residents (#1) and one unsampled resident. Findings include, but are not limited to:

a. Resident 1 moved into the MCC in 11/2023 and was identified as requiring a walker to ambulate safely.

During an interview with Staff 1 (Administrator) on 05/23/25 at 9:45 am, Resident 1 was observed attempting to walk out of the courtyard door from the activities room. The door was observed to close on the resident, pushing him/her into the courtyard. Assistance was provided for the resident to exit safely.

b. During an observation on 05/21/25 at approximately 1:45 pm, an unsampled resident attempted to enter the north dining room from an exterior courtyard door. S/he struggled to maneuver the door threshold, and the door closed on the resident, hitting him/her several times and knocking him/her off center. This occurred for several minutes before care staff came to assist the resident. The care staff was also observed to struggle with the door closing while trying to assist the resident with maneuvering the four wheeled walker over the door threshold.

On 05/23/25 at 4:15 pm, the need for the facility to ensure the setting was accessible to all individuals was reviewed with Staff 1. She acknowledged the findings.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(b) The setting is physically accessible to an individual.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure residents’ right to privacy in his or her own unit. Findings include, but are not limited to:

Refer to C 200.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) had a key to their unit. Findings include, but are not limited to:

During resident and/or family interviews it was determined Residents 1, 2, 3, 4, and 5 did not have keys to their rooms.

During an interview with Witness 1 (Family Member) and legal representative on 05/23/25, it was reported the resident did not receive a key at move-in, nor did the representative or the resident’s spouse.

The need to ensure the individual and only appropriate staff had a key to access their unit was reviewed with Staff 1 (Administrator) on 05/23/25 at 2:20 pm. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

Refer to: C 200, C 231, C 295, C 363, C 420, and C 422.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure that 2 of 4 newly hired staff (#s 14 and 15) completed all areas of pre-service training prior to beginning job duties, 3 of 4 newly hired staff (#s 8, 15, and 18) demonstrated competency in assigned job duties within 30 days of hire, and 4 of 4 long-term direct care staff (#s 9, 12, 13, and 17) completed a minimum of 16 hours of in-service training annually based on anniversary date of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 20 (Business Office Manager) and Staff 1 (Administrator) at 8:46 am on 05/23/25. The following was identified:

a. There was no documented evidence Staff 14 (Dietary Assistant), hired 02/05/25, completed the following pre-service training prior to beginning job duties:

* Abuse reporting requirements;
* Food handler’s certificate;
* Written job description;
* Approved HCBS course;
* Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms;
* Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses;
* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and
* Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to identify and address pain, provide food and fluids, prevent wandering and elopement, and use a person-centered approach.

b. There was no documented evidence Staff 15 (MA), hired 01/10/25, completed the following pre-service training prior to beginning job duties or providing personal care:

* Resident rights and values of CBC care;
* Abuse reporting requirements;
* Fire safety and emergency procedures;
* Written job description;
* Infectious disease prevention;
* Approved HCBS course;
* Approved LGBTQIA2S+ course;
* Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms;
* Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses;
* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities;
* Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to identify and address pain, provide food and fluids, prevent wandering and elopement, and use a person-centered approach;
* Environmental factors that are important to resident’s well-being;
* Family support and the role the family may have in the care of the resident;
* How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require on-going assessment;
* How to provide personal care to a resident with dementia, including an orientation to the resident and the resident’s service plan; and
* The use of supportive devices with restraining qualities in MCCs.

c. There was no documented evidence Staff 18 (Resident Assistant), hired 04/01/25, demonstrated competency within 30 days of hire in the following areas:

* Providing assistance with ADLs;
* Conditions that require assessment, treatment, observation and reporting; and
* General food safety, serving and sanitation.

d. There was no documented evidence Staff 16 (Resident Assistant), hired 03/17/25, demonstrated competency within 30 days of hire in the following areas:

* Providing assistance with ADLs;
* Conditions that require assessment, treatment, observation and reporting; and
* General food safety, serving and sanitation.

e. There was no documented evidence Staff 8 (MA), hired 03/21/25, and Staff 15 (MA), hired 01/10/25, demonstrated competency within 30 days of hire in the following areas:

* The role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Conditions that require assessment, treatment, observation and reporting; and
* General food safety, serving and sanitation.

f. There was no documented evidence Staff 9 (Resident Assistant), Staff 12 (MA), Staff 13 (Resident Assistant), and Staff 17 (Resident Assistant), all hired 03/01/20, completed a minimum of 16 hours of in-service training annually (based on anniversary date of hire) on topics related to the provision of care for persons in CBC, including six hours of dementia care training, annual infectious disease prevention training, and HCBS training.

The need to ensure documentation of staff completing training requirements was discussed with Staff 1 and Staff 19 (Regional Director) at 12:32 pm on 05/23/25. They acknowledged the findings.

OAR 411-057-0155(1-6) Staff Training Requirements

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review it was determined the facility failed to ensure health care services were provided in accordance with the licensing rules of the facility. Findings include, but are not limited to:

Refer to: C 252, C 260, C 270, C 280, C 303, and C 305.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, and 4’s current service plans were reviewed during the survey. Each service plan lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to ensure an individualized nutrition and hydration plan was developed for each resident and included in the service plan was reviewed with Staff 1 (Administrator) on 05/23/25 at 4:15 pm. She acknowledged the findings.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose records were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, and 4’s records were reviewed. There was no documented evidence the facility evaluated the residents in the following areas:

* Current abilities and skills;
* Emotional and social needs and patterns;
* Physical abilities and limitations;
* Adaptations necessary for the resident to participate; and
* Identification of activities for behavioral interventions.

There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist the residents with individualized activities. Individualized activity plans were not included on the resident's activity service or care plan.

The need to ensure residents were evaluated in all required areas and individualized activity plans were developed was discussed with Staff 1 (Administrator) on 05/23/25 at 4:15 pm. She acknowledged the findings.

OAR 411-057-0160(2d) Activities

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

This Rule is not met as evidenced by:

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 10/29/24 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas:

* Lower shelves throughout the kitchen – drips/spills/debris;

* Ceiling vents, in dishwashing area and near kitchen entrance door – heavy buildup of dust;

* Commercial can opener – black matter on blade and area around the housing attached to the counter;

* Walk in refrigerator, housing holding the fans – dust build up;

* Commercial mixer – food splatters on food guard and finish worn off on area holding mixer gadgets;

* Two door refrigerator at end of service line, exterior of doors and vent below doors – smears/splatters on doors and dust/debris on vent; and

* Lid and exterior of garbage can next to service line – food drips/splatter/spills.

The areas of concern were observed and discussed with Staff 1 (Dietary Services Director) and discussed with Staff 2 (Memory Care Administrator) on 10/29/24. The findings were acknowledged.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities.

Findings include, but are not limited to:

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 08/02/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection of 08/02/23, conducted 11/03/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to: On 08/02/23 at 11:00 am, the following improper practices were observed: * The dishwasher was not displaying the rinse temperature. The display showed a flashing "P2" code. Staff 1 (Maintenance Director) indicated the element in booster may be going out. Staff 2 (Food Service Director) called Ecolab to check immediately; * Three garbage cans were not covered when not in use; * The vents above the stove were greasy/dusty; * Improper glove use included not washing hands between changing from dirty to clean gloves and multiple uses with same pair of gloves, such as leaving service line and conducting other activities and returning to the service line; and* Several staff were not using hair restraints.The areas of concern were observed and discussed with Staff 2 and Staff 3 (Executive Director) on 08/02/23. The findings were acknowledged.

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

The findings of the desk review, conducted 06/15/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

Based on interview and record review, conducted during a desk audit on 06/15/2023, it was determined the facility failed to evaluate the resident's health, medical, behavioral or care needs within a reasonable time after the resident had been deemed ready for discharge for 1 of 1 sampled resident (# 1) whose records was reviewed. Findings include, but are not limited to:In an interview on 06/15/23, Staff 1 (Administrator) stated Resident 1 was sent to the hospital after a resident-to-resident altercation and the family was informed that they would not be able to re-admit the resident to the facility without one-on-one care. Staff 1 further stated no one from the facility evaluated the resident when s/he was ready to discharge from the hospital and that no move-out notice was issued for Resident 1.Resident 1's charting notes dated 09/01/22-10/01/22 were reviewed. *A note entered on 09/30/22 indicated resident was involved in a resident-to-resident altercation, administrator advised staff to have resident sent to hospital to be evaluated, PCP and POA advised of incident.*A note entered on 10/01/22 indicated hospital social worker was informed they would need to admit Resident 1 until the facility could find alternate placement for resident. *A note entered on 10/01/22 indicated Resident 1 was ready for discharge from the hospital and the prospect of a one-on-one caregiver was discussed with family as well as the possibility of alternate placements, taking resident home with family or increasing resident medications. Family was informed without proper safety measures in place they would not be able to re-admit Resident 1 to the facility.*A note entered on 10/01/22 indicated Resident 1's wife was looking for alternate placements for resident.*A note entered on 10/01/22 indicated that a director for another community had an immediate opening and would be going to the hospital to evaluate Resident 1 for placement in their facility.There was no evidence an involuntary move out notice was provided to the resident and no evaluation of the resident's health, medical, behavioral or care needs within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge.The facility failed to evaluate the resident ' s health, medical, behavioral or care needs within a reasonable time after the resident had been deemed ready for discharge.The findings of the investigation were reviewed with and acknowledged by Staff 1 on 06/30/23.Verbal Plan of Correction:Facility owners and administrator have worked with marketing on how to evaluate incoming residents to ensure residents are a correct placement so that they do not end up in a similar situation with a failed placement of a resident.

The findings of the re-licensure survey conducted 04/04/22 through 04/06/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 04/06/22, conducted 08/30/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second revisit to the re-licensure survey of 04/06/22, conducted 12/15/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:The kitchen was toured on 04/04/22 and 04/05/22 with Staff 5 (Dietary Supervisor). The following was observed to be in need of cleaning or repair:* The stove and oven were in need of cleaning due to blackened and dried food debris;* All observed cutting boards had deep gouges which deemed them to be uncleanable;* Brown matter was observed on the ceiling in the food preparation area;* The wall located on the other side of the walk in freezer had holes and chipped paint throughout;* In the walk in refrigerator, the linoleum flooring had approximately one half of an inch gouges that were around a foot in length which deemed it to be uncleanable;* The door going into the walk in refrigerator had built up debris and chipped paint on it;* The wall behind and to the right of the three sink area was in need of cleaning and repair;* There was dark orange debris located around the grease trap located on the floor at the right of the three sink area; and * The black paint on the walls in the warewashing area was chipped throughout which deemed the walls to be uncleanable. The memory care kitchenettes were toured on 04/04/22. The following was observed to be in need of cleaning or repair:* The cabinets in both kitchenettes were gouged and scratched;* The interior of the cabinets were missing laminate and were not cleanable surfaces;* The cabinet interiors were dirty with food debris, spills and splatters; and* Each hood range was scratched and missing paint. The need to ensure the kitchen was clean and in good repair was discussed with Staff 1 (MCC Administrator) on 04/05/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the RN when necessary, for 1 of 3 sampled residents (#2), who experienced a change of condition. Resident 2 experienced a fall which resulted in a dislocation of the left hip. The resident continued to experience uncontrolled pain for several days before being sent to the emergency room. Findings include, but are not limited to:Resident 2 was admitted to the MCC in 01/2011 with diagnoses including dementia.The resident's progress notes, incident reports, temporary service plans (TSPs) and 02/2022 and 03/2022 MARs were reviewed and revealed the following:* A 02/28/22 Fall Incident and Investigation form indicated the resident experienced an unwitnessed fall on the same date;* A 02/28/22 a TSP instructed staff to monitor the resident for pain and discomfort; * Between 02/28/22 and 03/04/22, the resident was noted to call out for help several times daily and to express pain with facial grimacing;*Between 02/16/22 and 02/27/22 one dose of PRN pain medication was administered to the resident. The residents usage of PRN pain medication increased after the fall on 02/28/22 and for the four following days;* 03/04/22 "... PT came to visit resident and noticed a significant length difference between legs ...[technician] said it looked like [s/he] dislocated it."; and* 03/04/22 The resident was seen at the emergency department where the left hip dislocation was confirmed.The facility failed to evaluate and refer the resident's condition to the RN for assessment. As a result, the resident continued to experience uncontrolled pain.The need to ensure Resident 2's change of condition was evaluated and referred to the RN was discussed with Staff 1 (MCC Administrator) and Staff 2 (RN) on 04/06/22. They acknowledged the findings.

Based on interview and record review, It was determined the facility failed to ensure an RN assessment was completed for 1 of 2 sampled residents (# 2), who experienced a significant change of condition. Findings include but are not limited to:Resident 2 was admitted to the MCC in 02/2022. The resident experienced a partial left hip replacement in 01/2022 and was hospitalized on 03/04/22 after a dislocation of the left hip. Progress notes, and interim service plans were reviewed and revealed the following:Upon re-admission to the facility the resident continued to express pain and showed difficulty in motility.The hip dislocation, pain and changes in motility constituted a significant change in condition for which an RN assessment was required.There was no documented evidence the facility RN completed a significant change of condition assessment for the conditions which included documented findings and resident status.The requirement to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (MCC Administrator) and Staff 2 (RN) on 04/06/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 8 and 9) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 04/06/22 and identified the following:Staff 8 (CG) hired on 12/8/20, and Staff 9 (CG) hired 02/02/22 lacked documentation of demonstrated competency in First Aid/abdominal thrust.The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (MCC Administrator) and Staff 14 (Staffing Development Coordinator) on 04/06/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document all required components of fire drills and provide fire and life safety instruction to staff on alternate months of fire drills. Findings include, but are not limited to:Fire drill records from 11/2021 through 04/2022 were reviewed on 04/05/22. The facility lacked documented evidence fire drills were conducted every other month and included the following required components:* The escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;* Evacuation time period needed; and* Number of occupants evacuated.The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills. On 04/06/22, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 1 (MCC Administrator). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document all required components of fire drills. This is a repeat citation. Findings include, but are not limited to:On 8/30/22, fire drill records were reviewed for 07/15/22 through 08/18/22. The facility lacked documented evidence fire drills included the following required components:* The escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;* Evacuation time period needed; and* Number of occupants evacuated.On 08/30/22, the need to ensure all required components of fire drills were documented was discussed with Staff 1 (MCC Administrator) and Staff 14 (Plant Operations Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:Fire and life safety records from 11/2021 through 04/2022 were reviewed on 04/05/22. The facility lacked documentation of the following required elements:* Evidence alternate routes were used during fire drills;* Staff interviewed knew the designated point of safety; and* Evidence residents were being instructed on fire and life safety procedures within 24 hours of admission and annually.The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (MCC Administrator) on 04/06/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to:Refer to C240, C372, C420 and C422.
Based on interview and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to:Refer to C420.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly-hired direct care staff (# 9) completed pre-service dementia care training, 3 of 3 newly hired staff failed to completed all required training and demonstration of competency (#s 8, 9 and 12) and 3 of 3 sampled long term direct care staff (#s 5, 7 and 13) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:Training records were reviewed with Staff 14 (Staffing Development Coordinator) and Staff 1 (MCC Administrator) on 04/06/22. The following deficiencies were identified:a. Staff 9 Care Partner (CP), was hired 02/02/22. There was no documented evidence Staff 9, had completed the 6 hour pre-service dementia care training.There was no documented evidence that Staff 8, Staff 9 and Staff 13 had completed the required training in:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging; * Changes of condition and changes that require reporting; and* General food safety, serving and sanitation; b. Staff 7 (CG) was hired 04/30/2013, Staff 5 (MT) was hired 03/14/2016 and Staff 13 was hired 02/15/2015. For the annual period of their respected hire dates, there were no documented hours of the required 16 hours of in-service training on topics related to dementia and provision of care.The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, that newly hired staff demonstrated and documented required 30 day competencies and that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 1 on 04/06/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to:Refer to C270 and C280.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 1 of 3 sampled residents (# 2), whose activity plans were reviewed. Findings include, but are not limited to:Residents 2 was transferred to the MCC from the assisted living community in 01/2022. The resident's activity evaluation and service plan was reviewed on 04/06/22 and revealed the following:There was no evidence an updated activity evaluation had been completed and the service plan individualized to reflect the following required components:*Residents' current preferences; *Current abilities and skills; *Emotional/social needs and patterns; *Physical abilities and limitations;*Adaptations necessary for the resident to participate; and*Identification of activities for behavioral interventions.There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.On 04/06/22 the need to evaluate and develop individualized activity plans including all required components for Resident 2 was discussed with Staff 1 (MCC Administrator) who acknowledged the findings.