Quail Crest Memory Care

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals served were palatable and appropriate textures, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the 5 cottage kitchens as well as the main kitchen meal preparation and food storage area on 10/22/25 at 09/30 am through 1:45 pm revealed the following deficiencies:

1) Main Kitchen

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Hood vents and sprinkler areas in industrial hood over stove;
* Exterior of range;
* Flooring between/behind range and oven;
* Flooring in main kitchen entry way;
* Flooring in dry storage;
* Industrial mixer;
* Stainless steal shelves storing spices and cutting boards;
* Metal drawers storing cooking and serving utensils;
* Exterior of trash can;
* Wall behind range top/counter tops;
* Walk in cooler fan cages; and
* Janitor closet sink.

b. Dry storage area with large garage door open with visible debris from outside on the floor. Food storage area shared with facility maintenance that has access to and opens door frequently causing potential access to pests. Multiple dry goods stored in area that are not in sealed containers that could lend to easy penetrable access to potential pests.

c. Multiple potentially hazardous foods were found past seven days from preparation and should have been discarded.

d. Multiple potentially hazardous foods observed without dates opened or prepared.

e. Container of recyclables stored without lid in dishwashing area.

f. Dishes in dishrack were overlapping and overloaded so that sanitizing agent could not effectively reach/touch all surfaces of equipment.

2) Clover Cottage

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Interior/exterior of cupboards/cabinets/drawers storing clean dishes and/or food;
* Walls;
* Fan cage/blades;
* Blender base;
* Window screen next to clean/sanitized dishes;
* Exterior of trash can;
* Wall behind range top/counter tops;
* Toaster; and
* Interior of reach in refrigerator.

b. Flooring beside and underneath of dishwasher with damage/staining. Counter top with area of damage/bubble/discolored and not a smooth surface.

c. Multiple items observed in the reach in refrigerator that did not have open dates. One item found past manufactures use by date and had signs of decay/potential bacterial growth.

d. Multiple employee drink containers were found that were not of the approved style and were not covered, did not have a handle or a straw.

e. Multiple meat and cheese items were stored in same drawer as fresh vegetables.

f. One resident had a diet texture order of puree. During lunch service staff were observed to prepare a plate for this resident. The puree soup and puree sloppy joe had visible chunks and pieces/particles and was not smooth as required. Surveyors intervened prior to incorrectly processed food texture was served to the residents. Staff 2 (Dining Services Director) was also present and acknowledged the food items were not of the correct texture for puree. Staff continued processing the food until the correct texture was achieved.

g. Clean and sanitized dishes were stored directly next to the sink where handwashing or washing of dirty dishes was done. No splash guard was in place to protect the clean/sanitized dishes from potential splash contamination.

3) Acorn Cottage

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Interior/exterior of cupboards/cabinets/drawers storing clean dishes and/or food;
* Fan cage/blades;
* Blender base;
* Exterior of trash can;
* Wall behind range top/counter tops;
* Window screen next to clean/sanitized dishes; and
* Interior of reach in refrigerator;

b. Reach in refrigerator did not have a thermometer located to accurately monitor cold food temperatures. Facility had a log posted on the exterior of fridge that had multiple missing days.

c. Multiple food items stored in reach in refrigerator were noted to be opened without open dates.

d. Clean and sanitized dishes were stored directly next to the sink where handwashing or washing of dirty dishes was done. No splash guard was in place to protect the clean/sanitized dishes from potential splash contamination.

4) Sunflower Cottage

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Interior/exterior of cupboards/cabinets/drawers storing clean dishes and/or food;
* Fan cage/blades;
* Exterior of trash can;
* Wall behind range top/counter tops;
* Window screen next to clean/sanitized dishes; and
* Interior of reach in refrigerator;

b. Section of counter edge missing exposing porous wood. Multiple cabinets with shelving and/or interiors scratched/damaged.

c. Multiple items found stored in reach in refrigerator without dates opened.

d. Clean and sanitized dishes were stored directly next to the sink where handwashing or washing of dirty dishes was done. No splash guard was in place to protect the clean/sanitized dishes from potential splash contamination.
e. Clean and sanitized cutting boards stored next to coffee maker sitting in free standing liquid potentially contaminating the sanitized equipment.

5) Blackberry Cottage

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Interior/exterior of cupboards/cabinets/drawers storing clean dishes and/or food;
* Exterior of trash can;
* Wall behind range top/counter tops;
* Fan cage/blades; and
* Window screen next to clean/sanitized dishes;

b. Chemical dishwasher tested and did not register any parts per million (PPM) of sanitizer. Staff 2 primed the machine multiple times and still was not able to get test strips to register any ppm. Facility indicated they would sanitize resident dishes at another cottage until the dish machine could be serviced and operating correctly.

c. Multiple items found stored in reach in refrigerator without open dates. A jar of homemade/canned salsa was noted in the fridge. Facilities must use/store only foods from approved sources.

d. Clean and sanitized dishes were stored directly next to the sink where handwashing or washing of dirty dishes was done. No splash guard was in place to protect the clean/sanitized dishes from potential splash contamination.

e. Multiple empty/used soda cans and bottles were noted stored on a shelf in the kitchenette area not in approved containers to prevent the attraction of pests.

6) Dandelion Cottage

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Interior/exterior of cupboards/cabinets/drawers storing clean dishes and/or food;
* Window screen next to clean/sanitized dishes;
* Reach in refrigerator base;
* Interior of reach in freezer;
* Exterior of trash can;
* Wall behind range top/counter tops;
* Flooring between dishwasher and cabinets: and
* Fan blades and cage.

b. Chemical dishwasher tested and did not register any parts per million (PPM) of sanitizer. Staff 2 primed the machine multiple times and still was not able to get test strips to register any ppm. Facility indicated they would sanitize resident dishes at another cottage until the dish machine could be serviced and operating correctly.

c. Multiple items found stored in reach in refrigerator without open dates. A jar of homemade/canned pears was noted in the fridge. Facilities must use/store only foods from approved sources.

d. Clean and sanitized dishes were stored directly next to the sink where handwashing or washing of dirty dishes was done. No splash guard was in place to protect the clean/sanitized dishes from potential splash contamination.

e. Multiple packages of food items were found stored in reach in refrigerator and freezer that were open and exposed to potential contamination.

f. A staff drink container was found stored in the freezer next to resident foods.

g. At 11:40 am, the reach in refrigerator thermometer was found at 54 degrees. Food item inside was tested and found at 48 degrees. Refrigerator temperature monitoring log for October was reviewed and documented 14 times where the temperature of the fridge was greater than 41 degrees. Staff 2 acknowledged the refrigerator temperature was too high and discarded the food item that temped greater than 41 degrees. Staff 2 verified the facility would check the temperature of all potentially hazardous food items in that fridge and discard what was not at the correct cold food storage temperature. Staff 2 stated that they had not been made aware of any temperature concerns with that refrigerator.

Staff 2 toured all areas with Surveyors and acknowledged the findings. At 1:15 pm the surveyors reviewed the areas in need of cleaning, repair and practices with Staff 1 (Executive Director) who acknowledged the areas in need of correction.

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

Refer to C240.

Based on observation, interview, and record review, conducted during a site visit on 05/20/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the ABST indicated the following:· Day shift: Clover 2.06 staff, Acorn 2.20 staff, Sunflower 2.01 staff, Blackberry 2.53, and Dandelion 1.86 staff required;· Swing Shift: Clover 1.75 staff, Acorn 2.02 staff, Sunflower 1.78 staff, Blackberry 2.62 staff, and Dandelion 1.69 staff required; and· Night Shift: Clover 0.47 staff, Acorn 0.43 staff, Sunflower 0.37 staff, Blackberry 0.61 staff, and Dandelion 0.29 staff required.A review of the posted staffing plan and staffing schedules for 05/14/25 through 05/20/25 indicated the following:· Day shift: two caregivers and one med tech in each cottage;· Swing shift: two caregivers and one med tech in each cottage; and· Night shift: one caregiver in each cottage and two shared med techs.· The posted staffing plan did not account for multi-person transfer or care needs.· The facility had eleven residents (in four out of five cottages) requiring two-person transfers or care needs and was not consistently scheduling two care staff in each segregated area on the night shift. In an interview on 05/20/25, Staff 1 (Executive Director) stated the following:· Staff 1 was unaware they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance.· Staff 1 included the shared med techs as the second staff member available for two-person transfers on the night shift.Findings were reviewed with and acknowledged by Staff 1.The facility's failure to have a fully implemented and updated ABST; and to have enough staff to meet the scheduled and unscheduled needs of the residents was substantiated.

Based on observation, interview, and record review, conducted during a site visit on 05/20/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the ABST indicated the following:· Day shift: Clover 2.06 staff, Acorn 2.20 staff, Sunflower 2.01 staff, Blackberry 2.53, and Dandelion 1.86 staff required;· Swing Shift: Clover 1.75 staff, Acorn 2.02 staff, Sunflower 1.78 staff, Blackberry 2.62 staff, and Dandelion 1.69 staff required; and· Night Shift: Clover 0.47 staff, Acorn 0.43 staff, Sunflower 0.37 staff, Blackberry 0.61 staff, and Dandelion 0.29 staff required.A review of the posted staffing plan and staffing schedules for 05/14/25 through 05/20/25 indicated the following:· Day shift: two caregivers and one med tech in each cottage;· Swing shift: two caregivers and one med tech in each cottage; and· Night shift: one caregiver in each cottage and two shared med techs.· The posted staffing plan did not account for multi-person transfer or care needs.· The facility had eleven residents (in four out of five cottages) requiring two-person transfers or care needs and was not consistently scheduling two care staff in each segregated area on the night shift. In an interview on 05/20/25, Staff 1 (Executive Director) stated the following:· Staff 1 was unaware they needed two staff in each segregated area, at all times, for residents with two-person transfers or assistance.· Staff 1 included the shared med techs as the second staff member available for two-person transfers on the night shift.Findings were reviewed with and acknowledged by Staff 1.The facility's failure to have a fully implemented and updated ABST; and to have enough staff to meet the scheduled and unscheduled needs of the residents was substantiated.

Based on interview and record review, it was determined the facility failed to notify the local Senior and People with Disabilities (SPD) office when an incident of abuse, or suspected abuse, occurred and failed to report physical injuries of unknown cause to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, for 1 of 4 sampled residents with reportable incidents (# 5). Findings include, but are not limited to:

Resident 5 moved into the facility 12/2024 with diagnoses including Alzheimer’s disease.

The resident's 12/01/24 to 03/02/25 Observation notes, Temporary Service Plans, incident reports, and Incident Investigations were reviewed, and interviews with staff were conducted. The following was identified:

a. Injuries of unknown cause were identified by staff on the following dates:

* 12/14/25 – Right big toe; and
* 01/01/25 – Left knee.

During an interview at 12:50 pm on 03/04/25, Staff 2 (Wellness Director) confirmed there was no documentation that an investigation occurred to rule out suspected abuse and the injuries of unknown cause were not reported to the local SPD office.

b. On 01/31/25, Resident 5 was struck in the face by another resident. There was no documented evidence that the incident was reported to the local SPD office.

The survey team requested the above incidents be reported to the local SPD office, and confirmation was provided at 8:40 am on 03/06/25.

The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office, and that injuries of unknown cause were immediately reported to the local SPD unless an immediate investigation reasonably concluded that the injury was not the result of abuse, was reviewed with Staff 1 (ED), Staff 2 and Staff 4 (Administrative Assistant) on 03/06/25 at 12:40 pm. They 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 that the facility failed to investigate incidents of abuse or suspected abuse promptly or immediately report to the local Seniors and People with Disability (SPD) office for 1 of 2 sampled residents (# 11) who had a fall with a fracture. This is a repeat citation. Findings include, but are not limited to:

Resident 11 was admitted to the facility in 10/2024 with diagnoses including dementia.

Interviews with staff and review of the resident's 09/04/25 service plan and 06/11/25 through 09/16/25 interim service plans, progress notes, and incident investigations were completed. The following was identified:

On 09/16/2025, during an acuity interview, Staff 2 (Wellness Director/LPN) and Staff 3 (RN) reported that Resident 11 had sustained a fall with a sacral fracture.

On 08/22/25, an incident report was completed, indicating that Resident 11 had an unwitnessed fall at 1:30 pm in a common area of the cottage. The resident was unable to state what had happened. After the fall, Resident 11 complained of back and hip pain.

On 08/27/25, the resident was sent to the hospital for severe back and hip pain and returned with a diagnosis of a sacral fracture.

Staff 3 completed an investigation of the fall with injury on 08/27/25, which was five days after the fall, and had not reported the incident to the local SPD.

The facility was instructed to report the injury of unknown cause to the local SPD office on 09/16/25 at 12:31 pm. Proof of reporting was received from the facility on 09/16/25 at 2:49 pm.

The need to ensure all incidents and injuries were investigated immediately and, if not, were reported to the local SPD office was discussed with Staff 1 (ED), Staff 2 (Wellness Director/LPN), and Staff 3 (RN) on 09/17/25. They 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 observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 6 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 11/2024 with diagnoses including Alzheimer’s disease and type 2 diabetes.

Observations of the resident, interviews with staff, review of the resident's most recent service plan, dated 02/25/25, and Temporary Service Plans showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Hospice services, including frequency and the tasks they were responsible for providing;
* Current ability to express needs;
* Bed bath instructions;
* Use and assistance with a tilt-in-space chair;
* Alternating pressure mattress instructions;
* Meal assistance instructions, including aspiration precautions;
* Frequency of offering fluids and snacks;
* Level of assistance needed for teeth brushing and oral care;
* Frequency of safety checks;
* Non-pharmacological interventions for pain; and
* Current skin condition and treatment.

The need to ensure service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Wellness Director) and Staff 4 (Administrative Assistant) on 03/06/25. They acknowledged the findings.

2. Resident 4 moved into the facility in 03/2024 with diagnoses including Alzheimer’s disease.

Observations of the resident, interviews with staff, review of the resident's service plan, dated 01/08/25, and Temporary Service Plans showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Weight gain;
* Pain and medication available;
* Falls within the past 90 days;
* Interventions for refusals relating to ADLs;
* Sleeping attire;
* How Resident 4 reacts during showers and getting his/her hair wet;
* Staff announcing intent to let the resident know when they need to go into his/her unit to negate behaviors;
* Triggers that cause Resident 4's agitation towards other residents; and
* Person centered behavior interventions.

The need to ensure service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 4 (Administrative Assistant) on 03/06/25. They 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 observation, interview, and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated, referred to the RN for assessment and the service plan was updated as needed, and/or failed to ensure residents who experienced a short-term change of condition had actions or interventions determined and documented, communicate the determined action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 4 of 7 sampled residents (#s 2, 4, 5, and 7) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 03/2024 with diagnoses including Alzheimer’s disease.

The resident's service plan, dated 01/08/25, Observation notes, dated 12/01/24 through 03/04/25, Temporary Service Plans, Task Administration Record (alert charting documentation) for 12/2024, and weight records, dated 07/2024 through 02/2025, were reviewed. Staff were interviewed and Resident 4 was observed.

a. Resident 4’s weight records were reviewed and revealed the following:

* 01/15/25: 131 pounds;
* 01/22/25: 133 pounds;
* 01/29/25: 137 pounds;
* 02/05/25: 140 pounds; and
* 02/19/25: 142. 8 pounds.

The surveyor requested the resident be weighed during the survey. On 03/04/25 at 10:44 am, Resident 4 weighed 144.4 pounds.

Between 01/15/25 and 02/19/25, Resident 4 had a weight gain of 11.8 pounds or 8.26% of his/her total body weight in one month. The weight represented a significant change of condition, and the facility was required to evaluate, to refer to the facility RN, to document the change, and to update the service plan as needed.

There was no documented evidence the resident was evaluated, the significant change of condition was referred to the facility nurse, or the service plan was updated as needed.

b. The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution:

* 12/13/24: Resident 4 reported being in extreme pain;
* 12/16/24: The resident reported continued extreme pain;
* 12/22/24: Resident to resident altercation; and
* 12/24/24: An increase in Depakote (to treat psychiatric conditions) and Zyprexa (an antipsychotic).

The need to ensure the facility evaluated residents who experienced significant changes of condition, referred the resident to the facility nurse, documented the change and updated the service plan as needed; and determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 4 (Administrative Assistant) on 03/04/25 and 03/06/25. They acknowledged the findings.

2. Resident 7 moved into the facility in 11/2024 with diagnoses including vascular dementia.

The resident's service plan, dated 12/31/24, Observation notes, dated 12/02/24 through 03/03/25, Temporary Service Plans, and Task Administration Record (alert charting documentation) were reviewed and staff were interviewed. The following was identified:

Resident 7 was involved in a resident to resident altercation on 12/22/24. There was no documented evidence the facility determined actions or interventions, communicated those actions or interventions to staff on all shifts, and monitored the resident through resolution relating to the resident to resident altercation.

The need to ensure the facility determined and documented what action or intervention was needed for a short-term change of condition, communicated the action or intervention to staff on all shifts, and monitored the short-term change of condition at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 4 (Administrative Assistant) on 03/06/25. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 10/2021 with diagnoses including dementia.

Resident 2's clinical record was reviewed for changes of condition and identified the following:

* A progress note on 12/14/24 indicated the resident was experiencing pain near their buttocks. Staff observed Resident 2’s skin and indicated the right buttock was reddening and beginning to form a pressure wound. “The wound did not appear to be deep or break the skin.”

There was no documented evidence of ongoing monitoring or resolution of the resident skin condition.

During an interview on 03/04/25, Staff 24 (CG) indicated Resident 2’s current skin condition was stable and intact.

On 03/06/25, the need to ensure residents who experienced short-term changes of condition were monitored weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 4 (Administrative Assistant). They acknowledged the findings.

4. Resident 5 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease.

The resident's current service plan available to staff, dated 02/25/25, and 12/01/24 through 03/02/25 Observation notes and Temporary Service Plans were reviewed, interviews with staff were conducted, and observations of the resident were completed.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or monitoring at least weekly through resolution:

* 12/14/24 – “[Right] big toe is open and bleeding”;
* 12/17/24 – Groin “bright red in color and painful”;
* 12/29/24 – Weeping yellow discharge in groin with odor;
* 01/01/25 – Skin abrasion to left elbow and left knee;
* 02/07/25 – Witnessed non-injury fall;
* 02/19/25 – Increased transfer assistance required, use of hoyer mechanical lift; and
* 02/21/25 – New type of hoyer sling being utilized.

The need to ensure the facility determined and documented actions or interventions needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (ED), Staff 2 (Wellness Director) and Staff 4 (Administrative Assistant) on 03/06/25 at 12:40 pm. They 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 residents who had a significant change of condition were referred to the RN for assessment, and/or failed to ensure residents who experienced a short-term change of condition had actions or interventions determined and documented, communicate the determined action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 4 of 4 sampled residents (#s 8, 9, 10, and 11) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the community in 12/2024 with diagnoses including Alzheimer's disease and Pick's disease.

The resident’s Observation notes dated 06/01/25 through 09/12/25, service plan dated 06/12/25, and Temporary Service Plans (TSPs) and Change in Service Plans dated 06/21/25 through 09/08/25 were reviewed, and interviews with staff were conducted. The following was identified:

a. On 07/02/25 the resident experienced a severe weight gain of 10.1% in 90 days, which constituted a significant change in condition.

The RN assessment determined the following interventions:

* Intake monitoring;
* Staff to offer and encourage lower carb/low sugar foods – more protein, vegetables, fruits as tolerated; and
* Sugar free snacks and drinks as tolerated.

There was no documented evidence interventions had been communicated to staff on all shifts, or that the facility had monitored the resident according to their evaluated needs.

On 09/17/25, Staff 3 (RN) reported that although intake monitoring had been communicated and implemented electronically, she was unable to find the TSP that instructed staff to encourage lower carb foods, more protein, vegetables, fruits, and sugar free snacks and drinks, and did not know if these interventions had been implemented.

The need to ensure the facility communicated determined interventions for changes of condition to staff on all shifts, and monitored the resident according to their evaluated needs, was discussed with Staff 1 (ED), Staff 2 (Wellness Director/LPN), and Staff 3 on 09/17/25 at 3:15 pm. They acknowledged the findings.

b. On 6/21/25 Observation notes reported the resident returned from urgent care with confirmation of a urinary tract infection (UTI). There was no documented evidence the facility determined interventions, communicated interventions to staff, and monitored the resident at least weekly through resolution.

In an interview on 09/17/25, Staff 2 (Wellness Director/LPN) reported that he did not know UTIs required documented monitoring.

The need to ensure the facility determined interventions for changes of condition, communicated interventions to staff, and monitored the resident according to their evaluated needs, was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RN) on 09/17/25 at 3:15 pm. They acknowledged the findings.

2. Resident 9 moved into the community in 03/2024 with diagnoses including dementia and type 2 diabetes.

The resident’s Observation notes dated 06/01/25 through 09/16/25, service plan dated 08/19/25, and Temporary Service Plans (TSPs) and Change in Service Plans dated 05/27/25 through 09/12/25 were reviewed, and interviews with staff were conducted. The following was identified:

a. An Observation note dated 06/15/25 documented that the resident complained of pain while urinating and reported having difficulty urinating. On 07/01/25, an Observation note stated, “Course of Cefpodoxime is complete — staff report [resident] is continuing to manifest altered mentation and dysuria [discomfort when urinating].” There was no documented evidence that the facility had determined interventions for the change of condition and monitored the resident according to their evaluated needs.

In an interview on 09/16/25 Staff 2 (Wellness Director/LPN) stated there was no TSP for this UTI, and no documentation of monitoring of the resident according to their evaluated needs.

b. An Observation note dated 08/27/95 documented a rash on the resident’s chest. There was no documented evidence the rash was monitored at least weekly through resolution.

The need to ensure the facility monitored changes of condition at least weekly through resolution was discussed with Staff1 (ED), Staff 2, and Staff 3 (RN) on 09/17/25 at 3:15 pm. They acknowledged the findings.

3. Resident 10 was admitted to the facility in 02/2022 with diagnoses including dementia and diabetes.

The resident's 06/20/25 service plan and progress notes, interim service plans, and incident reports dated 06/05/25 through 09/16/25 were reviewed.

The following short-term changes of condition lacked actions/interventions determined and communicated to staff on all shifts, and/or RN notification of a significant change of condition:

* 07/25/25 – Progress notes indicated an open area to the left buttocks. There were no actions or interventions determined and communicated to staff on all shifts. This area was resolved on 08/25/25.

In an interview on 09/17/25, Staff 3 (RN) reported that there were already interventions in place on the MAR for staff, and no additional interventions determined at that time.

* 09/08/25 – A transcribed hospice visit note identified open wounds to the right buttocks (3x3x0 cm) and left buttocks (2x1x0 cm).

On 09/15/25, the right buttock wound measured 8 x 3 cm, and the left buttock wound measured 4 x 3 cm.

There were no actions or interventions determined and communicated to staff on all shifts.

On 09/17/25, Staff 2 reported that the resident had a history of recurrent pressure ulcers to the buttocks, but that she had not been notified of the wounds, which opened on 09/08/25, and there were already interventions in place on the MAR for staff, and no additional interventions were determined at that time.

The need to ensure changes of condition had actions/interventions determined, and the RN was notified of significant changes of condition was discussed with Staff 1 (ED), Staff 2 (Wellness Director/LPN), and Staff 3 on 09/17/25. They acknowledged the findings.

4. Resident 11 was admitted to the facility in 10/2024 with diagnoses including dementia.

The resident's 09/04/25 service plan and progress notes, interim service plans, and incident reports dated 06/05/25 through 09/16/25 were reviewed.

The following short-term changes of condition lacked actions/interventions determined and communicated to staff on all shifts, and monitoring of progress at least weekly through resolution:

* On 07/23/25, Resident 11 was reported as stating, “someone ran my foot over and it hurts”. There was no follow-up with actions/interventions determined, and no documented monitoring of progress through resolution.

Staff 2 (Wellness Director/LPN) stated that the daughter had told staff that the resident had a history of something running over his/her foot so thought it was not a change of condition.

* On 07/09/25, progress notes indicated the resident’s eyes were red, itchy, and puffy, with a complaint of stabbing pain in the right eye. There was no follow-up with actions/interventions determined, and no documented monitoring of progress through resolution.

Staff 2 and Staff 3 (RN) reported on 09/17/25 that there were no instructions provided for staff or monitoring of the symptoms.

* On 07/11/25, Resident 11 was started on Flonase 50 mcg, two sprays in each nostril daily for allergy symptoms. There was no follow-up with actions/interventions determined, and no documented monitoring for adverse effects of the new medication.

The need to ensure changes of condition had actions/interventions determined and communicated to staff on all shifts, and were monitored through resolution, was discussed with Staff 1 (ED), Staff 2, and Staff 3 on 09/17/25. They 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 interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely for 1 of 1 sampled resident (# 4) who experienced significant weight gain. Findings include, but are not limited to:

Resident 4 moved into the facility in 03/2024 with diagnoses including Alzheimer’s disease.

The resident’s Observation notes, dated 12/01/24 through 03/04/25, Temporary Service Plans, and weight records, dated 07/2024 through 02/2025, were reviewed. Staff were interviewed and Resident 4 was observed.

The following weights were recorded by the facility:

* 01/15/25: 131 pounds;
* 01/22/25: 133 pounds;
* 01/29/25: 137 pounds;
* 02/05/25: 140 pounds; and
* 02/19/25: 142. 8 pounds.

The surveyor requested the resident be weighed during the survey. On 03/04/25 at 10:44 am, Resident 4 weighed 144.4 pounds.

Between 01/15/25 and 02/19/25, Resident 4 had a weight gain of 11.8 pounds or 8.26% of his/her total body weight in one month. The weight represented a significant change of condition.

There was no documented evidence the facility RN conducted a timely assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.

The need to ensure a timely RN assessment was completed for residents who experienced a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Wellness Director), Staff 3 (RN), and Staff 4 (Administrative Assistant) on 03/04/25 and 03/06/25. 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 interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 1 of 3 sampled residents (# 3) who received outside services. Findings include, but are not limited to:

Resident 3 moved into the memory care community in 11/2024 with diagnoses including Alzheimer’s disease and type 2 diabetes and was identified during the acuity interview as receiving Hospice services.

Resident 3's hospice provider notes, 01/03/25 through 02/25/25, observation notes, 12/01/24 through 03/02/25, service plan dated 02/25/25, and temporary services plans dated 01/23/25 through 02/18/25 were reviewed during the survey. The following concerns or recommendations had been documented:

* 01/03/25: "Speech ability is reducing, non-verbal assessments for care needs and comfort should be done”;

* 01/27/25: “MD order processing error noted, left upper extremity wrist wound care order from 01/23/25 were not processed, I provided a copy, but orders will be changed for the forehead wound, and orders will include routine hand cleansing.” “Please correct error”;

* 02/03/25: “Patient was served a meal in bed and voiced being done, no one to one staff intake assist noted please follow up.” “Please pre-medicate [resident] with PRN lorazepam 30 minutes before bathing, [Resident 3] apparently refused bathing yesterday, but no PRN lorazepam was given”; and

* 02/21/25: “Maintenance needs to address placement of cable box / modem and power strip.” “Current placement is a fire hazard.” “General pressure relief measures and general barrier cream applications (in place [with] wound) should continue.”

Hospice provider notes were documented in the resident’s observation notes; however, there was no documented follow-up to the information left by the provider, or that the resident’s service plan was adjusted to ensure continuity of care.

The need to ensure the facility coordinated care with outside providers to ensure continuity of care was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc

(2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (# 3) whose ADL care was observed, and for multiple unsampled residents who received meal service and assistance. Findings include, but are not limited to:

1. Observations of meal service were conducted from 03/04/25 to 03/06/25. Caregiving staff were observed serving food and feeding residents without wearing a protective covering over potentially contaminated clothing.

2. On 03/04/25 at 11:00 am, Staff 17 (MT) and Staff 21 (CG) were observed providing incontinence care for Resident 3. During the observation, both staff donned gloves without performing hand hygiene, transferred the resident to their bed, and removed their soiled brief. Staff 21 failed to doff soiled gloves, perform hand hygiene, and don clean gloves before touching the resident's body and applying a clean brief for the resident. After incontinence care, Staff 21 touched multiple surfaces and resident personal items in the room with the soiled gloves still on.

The need to establish and maintain effective infection control protocols was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They 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 interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident including fire evacuation standards. Findings include, but are not limited to the following:

The following was identified during the entrance conference on 03/03/25 at approximately 11:00 am with Staff 1 (ED) and Staff 2 (Wellness Director):

* The MCC consisted of five distinct cottages – Acorn, Blackberry, Clover, Dandelion, and Sunflower. Sixteen residents were living in Acorn, 16 residents were living in Blackberry, 16 residents were living in Clover, 14 residents were living in Dandelion, and 16 residents were living in Sunflower; and

* Twelve residents required two-person assist for transfers at all times – two residents resided in Acorn, three residents resided in Blackberry, three residents resided in Clover, two residents resided in Dandelion, and two residents resided in Sunflower.

The facility's posted staffing plan and the staffing schedule from 02/23/25 through 03/01/25 were reviewed. The facility's posted staffing plan indicated five CGs and two MTs were scheduled to work the 10:00 pm to 6:15 am shift daily. This equated to one CG in each cottage and two MTs that floated between the five cottages who administered medications and assisted with caregiving duties as needed.

Interviews with staff in two of the five cottages reported that it was difficult to meet the scheduled and unscheduled needs of residents when they were the only staff person in the cottage from 10:00 pm to 6:15 am when residents were exhibiting behaviors.

The facility lacked a sufficient number of overnight staff to meet the scheduled and unscheduled needs and fire evacuation standards of the multiple residents who required the assist of two care staff for transfers, had behaviors (including resident-to-resident altercations), and resided in five distinct cottages.

The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents and fire evacuation standards on the overnight shift was discussed with Staff 1 (ED) during the survey. She acknowledged the findings.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time that the staff were providing to each resident as outlined in each individual service plan for 3 of 6 sampled residents (#s 3, 4, and 5) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the facility in 12/2024 with diagnoses including Alzheimer’s disease.

The resident's service plan, Interim Service Plans, and ABST were reviewed. Staff were interviewed and Resident 5 was observed. The resident's ABST did not accurately capture care time in the following areas:

* Medication administration;
* Assisting with communication, assistive devices for hearing;
* Escorting to and from meals;
* Frequency of safety checks;
* Transferring in or out of bed or chair; and
* Bowel and bladder management.

The need to ensure the ABST accurately captured care time was reviewed with Staff 1 (ED), Staff 2 (Wellness Director) and Staff 4 (Administrative Assistant) on 03/06/25 at 12:40 pm. They acknowledged the findings.

2. Resident 3 moved into the facility in 11/2024 with diagnoses including Alzheimer’s disease and type 2 diabetes.

Observations of the resident, interviews with staff, and review of the resident’s records revealed Resident 3's ABST minutes and/or frequencies were not reflective in the following areas:

* Assisting with communication, assistive devices for hearing, vision and speech;
* Providing treatments (e.g. skin care, wound care, antibiotic treatment);
* Repositioning in bed or chair; and
* Transferring in or out of bed or chair.

The need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They acknowledged the findings.

3. Resident 4 moved into the facility in 03/2024 with diagnoses including Alzheimer’s disease.

Observations of the resident, interviews with staff, and review of the resident’s records revealed Resident 4's ABST minutes and/or frequencies were not reflective in the following areas:

* Monitoring behavioral conditions;
* Dressing and undressing;
* Bathing; and
* Cueing or supporting while eating.

The need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They acknowledged the findings.

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time

(1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING
(b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average.
(c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents.
(d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1).
(e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule.
(f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.
(g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

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) evaluation was updated and reviewed before a resident moved in, no less than quarterly at the same time of service plan update, and/or with a significant change of condition for 3 of 4 sampled residents (#s 2, 5, and 6) and an unsampled resident, and failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. Findings include, but are not limited to:

The facility was a licensed MCC with five distinct cottages.

1. The facility’s ABST was reviewed with Staff 1 (ED) during the survey. The following was identified:

a. Resident 2’s and Resident 6’s ABST evaluation did not have evidence it was updated quarterly at the same time as the service plan update.

b. Resident 5 experienced a significant change of condition relating to a decrease in mobility on 02/19/25. There was no documented evidence the ABST was updated with the significant change of condition.

c. An unsampled resident moved into the facility on 02/25/25 and did not have an ABST evaluation completed as of 03/04/25.

2. The facility’s posted staffing plan and staffing schedule from 02/23/25 to 03/01/25 were reviewed. The following was identified:

The posted staffing plan for the facility was as follows:

* Day shift: 10 CGs, 5 MTs;
* Evening shift: 10 CGs, 5 MTs; and
* Night shift: 5 CGs, 2 MTs.

Review of the facility schedule and corresponding timecards from 02/23/25 to 03/01/25 revealed the facility failed to staff per the posted staffing plan on three shifts, or 14.28% of the total shifts reviewed.

The need to ensure residents’ ABST evaluations were updated before move-in, with significant changes of condition, and no less than quarterly with the service plan, and the need to ensure consistent staffing to meet or exceed the posted staffing plan was discussed with Staff 1. 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 with all required elements documented and failed to provide fire and life safety training to staff on alternate months per the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records, reviewed between 09/2024 and 02/2025, revealed the following:

a. The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas:

* The escape route used;
* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;
* The number of occupants evacuated; and
* Evidence alternate routes were used during fire drills.

Multiple staff interviews conducted between 03/04/25 and 03/06/25 indicated residents were not relocated or evacuated during fire drills.

b. There was no documented evidence fire and life safety instruction was provided to staff on alternating months from fire drills.

The need to ensure fire drills and fire and life safety training was provided and documented as required was reviewed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 5 (Facility Services) on 03/06/25. They 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 re-instructed on fire and life safety procedures at least annually in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 03/05/25.

There was no documented evidence of a written record of annual re-instruction to residents including content and residents attending, general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.

The need to ensure residents were provided instruction as required by the OFC was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They 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 interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C231 and C270.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to provide a call system that connected resident units to the care staff center or staff pagers, and to provide exit door alarms or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

On 03/03/25 at 1:20 pm, a tour of the facility identified the following:

a. There were multiple resident rooms which lacked any device or system to allow residents to communicate needs to staff. A few residents were observed wearing necklace call pendants, and safety checks were performed regularly. However, there were still many residents in apartments with no means of calling for assistance.; and

b. The doors to the outside courtyard area had no alarm or other system in place to alert staff when residents exited the building.

On 03/04/25, the need to provide a call system that connected resident units to staff center or pagers, and to provide exit door alarms or another acceptable system to alert staff when residents exited was discussed with Staff 1 (ED) and Staff 5 (Facility Services). They acknowledged the findings.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable

(11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to maintain a setting which ensured individual rights of privacy, dignity, and respect. Findings include, but are not limited to:

The memory care community included a mix of single units and shared (two person) apartments. During the survey, there were multiple observations of shared units which lacked any method for maintaining privacy for residents during personal care. This constituted a violation of individual rights to privacy and dignity for residents.

On 03/06/25, the need to ensure individual rights of privacy, dignity, and respect were discussed with Staff 1 (ED) and Staff 2 (Wellness Director). They acknowledged the findings.

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 interview and record review, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple sampled and unsampled residents. Findings include, but are not limited to:

During an interview on 03/06/25, Staff 7 (Resident Care Manager) confirmed the majority of the residents in each cottage did not have keys to their units and keys were located in the MT area of each cottage.

On 03/06/25, the need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 4 (Administrative Assistant). They 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 231, C 360, C 420, C 422, and C 555.

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 follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 231.

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 provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to: C 260, C 270, C 280, C 290, C 295, C 362, and C 363.

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

Refer to C 270.

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 an individualized nutrition and hydration plan was developed, and included in the service plan for 3 of 6 sampled residents (#s 1, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

Review of the current service plans for Residents 1, 3 and 4 revealed the records lacked daily programs for nutrition and hydration, based on each individual resident’s preferences and needs.

On 03/06/25, the need to develop individualized nutrition and hydration plans for each resident, and to include these in the residents’ service plans was discussed with Staff 1 (ED) and Staff 2 (Wellness Director). They 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 activity evaluations addressed all required components and individualized activity plans were developed for 4 of 6 sampled residents (#s 3, 4, 5 and 6) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 3, 4, 5 and 6's most recent evaluations and service plans were reviewed. The records did not address one or more of the required components:

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

There was no individualized activity plan developed based on the evaluation that reflected the resident's activity preferences and needs for Residents 3, 4, 5, and 6.

The need to ensure the facility evaluated each resident for activities and developed an individualized activity plan based on the evaluation was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 03/06/25. They 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 furniture in the outdoor recreation area was of sufficient weight, stability and design to prevent resident injury or aid in elopement. Findings include, but are not limited to:

On 03/04/25 at 9:50 am, the facility’s outdoor recreation area was observed, which included five lightweight tables and 19 lightweight chairs.

During an interview at 12:05 pm on 03/04/25, Staff 28 (CG) stated that five minutes prior she had witnessed an unsampled resident standing on one of the lightweight chairs near the courtyard gate. She stated the resident had been exit-seeking recently and appeared to have moved the chair to the gate in an attempt to elope. As of 03/05/25 at 9:30 am, all lightweight furniture had been removed from the courtyard.

On 03/04/25 at 1:30 pm, the need to ensure all outdoor furniture was sufficient in weight, stability, and design to prevent resident injury or aid in elopement was reviewed with Staff 1 (ED). She acknowledged the findings.

OAR 411-057-0170(6) Secure Outdoor Recreation Area

(6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 7/24/23, 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 revisit to the kitchen inspection of 07/24/23, conducted 10/12/23, 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 revisit to the kitchen inspection of 07/24/23, conducted 12/27/23, 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, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to:Observation of the 5 cottage kitchens as well as the main kitchen meal preparation and food storage area on 7/24/23 at 11:45 am through 3:00 pm revealed the following deficiencies:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:* Interior of cabinets and drawers for all cottages;* Interior of reach freezers in all cottages;* Fan blades and external cages with heavy dust accumulation in all cottages;* Bottom oven drawer in Clover;* Cabinets under sinks in all cottages with splatter and black debris;* Oven door in Blackberry with large accumulation of food debris; and* Walk in cooler with large dust accumulation on fan cages and ceiling.b. The following areas were found in need of repair:* Cabinets below sinks in all cottages with water damage;* Holes in walls of lower cabinets under sinks;* Cabinets and drawers in all cottages with damage, heavily scored, chipped paint or exposed porous wood on the interiors;* Flooring in Dandelion pealing up, water damage to cabinets and flooring by sink;* Counter top in Dandelion near sink with damage;* Oven door in Blackberry with damage (crack) on top of door* Main kitchen floor found with multiple deep ridges/cuts/holes or splitting seams along with areas of dirt/debris build up and staining. * Shelving above ware washing area in main kitchen splitting and pealing from moisture penetration.* Walk in cooler with large cracks throughout the concrete floor making it not a smooth and cleanable surface.c. Multiple cutting boards in each cottage were found damaged with heavy scoring and/or staining.d. Food items not clearly separated when stored as required. e. Evidence noted with dishes being put away wet with stagnate water found. Facility noted to be storing clean dishes on towels with no defined practice on cleaning or rotating towel to ensure they were clean.f. Multiple divider plates and plastic mugs found with protective glaze missing and heavily scored. Cooking pans with visible paint chipping and scratches. g. Multiple food and/or beverage items stored on the floor in the cottage dry storage pantries. h. Scoops were found stored in bulk food item bins in the main kitchen area.i. Dish machine in Blackberry was found not sanitizing at correct sanitation level. Facility did not have a current practice to ensure ware washers were sanitizing at correct level before use. Multiple machines in varying cottages had to be primed before correct sanitation levels were reached. Not all cottage staff were aware of needing to prime the machine. Staff 2 was not able to identify when the machine in Blackberry was last correctly sanitizing dishes. Machine was put out of order until maintenance could attend to the issue. When the machine was pulled out for inspection, a large amount of dirt/dust and food debris was located under the machine. Staff 2 acknowledged the area needing cleaning. Surveyor reviewed above areas with Staff 2 (Dietary Director) and s/he acknowledged the identified areas. At approximately 2:45 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Business Office Manager). S/he acknowledged the areas.
Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observation of the five cottage kitchens as well as the main kitchen meal preparation and food storage area on 10/12/23 at 2:30 pm through 3:30 pm revealed the following deficiencies:a. The following areas were found in need of repair:* Cabinets below sinks in Clover Cottage with severe water damage and active mold growth and wood rot;* Holes in walls of lower cabinets under sinks in Clover and Acorn Cottages; and* Cabinets and drawers in many cottages with damage, heavily scored, chipped paint or exposed porous wood on the interiors.b. Evidence noted with dishes being put away wet with stagnate water found. The surveyor reviewed above areas with Staff 2 (Dietary Director) on 10/12/23 and s/he acknowledged the identified areas. At 3:00 pm Staff 3 (Maintenance Director) was made aware of the continued poor repair of cabinets in cottages and the mold growth in Clover. S/he acknowledged they were aware of the issue and that materials had been purchased but had not been able to complete the needed repairs. Surveyor emphasized the health and safety risk of the large area of mold growth and that food preparation should not occur in that cottage kitchen until replaced. Both Staff 2 and 3 voiced understanding. At approximately 3:15 pm the surveyor reviewed the areas in need repair and practices with Staff 1 (Business Office Manager). S/he acknowledged the areas.

Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240.

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

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the unannounced complaint investigation conducted 02/07/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 02/07/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 02/07/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the kitchen inspection, conducted 08/15/22, 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 kitchen inspection, conducted 11/02/22, 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, record review and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchens, food storage areas, food preparation, and food service on 08/15/22 revealed:* Splatters, spills, drips, and debris noted on: - Can opener blade and casing; - Interior of drawers, cupboards and cabinets; - Interior of reach in refrigerators; and - Floor of pantries.* Damage to the door jambs creating an un-cleanable surface.* Missing laminate on multiple drawers and cabinets creating an un-cleanable surface.* Egg shells were left in the cardboard egg holder. * There was not a small diameter probe thermometer available to measure thin foods.* Staff were observed to not change gloves between tasks while preparing lunch or sanitize hands upon entering the kitchen; and* Caregiving staff assisting with meal service and delivery were not using aprons.* There was not evidence the sanitizer was monitored and sanitizer strips were available for the triple compartment sink used to wash cooking items to ensure the correct sanitizing solution. The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) and Staff 2 (Dietary Manager). They 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 not limited to:Refer to C 240.

The findings of the Change of Owner re-licensure survey, conducted 8/2/21 through 8/4/21 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, Home and Community Based Services Regulations OARs 411 Division 004 and 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 first re-visit survey to the re-licensure survey of 08/04/21, conducted 11/08/21 through 11/09/21, 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 for Home and Community Based Services Regulations.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 re-visit to the re-licensure survey of 08/04/21, conducted on 02/17/22, 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 OARs 411 Division 004 Home and Community Based Services.

Based on observation and interview, it was determined the facility failed to ensure appropriate infection control practices were in place related to resident incontinent care. Findings include, but are not limited to:Observations of incontinent care were made on 8/2/21 and 8/4/21, related to two dependent residents who resided in Acorn Cottage and Clover Cottage.Resident 2 and Resident 4 were each observed for ADL care and incontinent care in their respective cottages. Staff were observed to place visibly soiled briefs, that had been removed from underneath the residents, directly on the floor. The staff placed used gloves and wipes on the floor with the briefs. Staff in Clover Cottage then removed soiled bedding from underneath the resident and threw it onto the bare floor. The staff in both cottages were additionally observed as they began to carry the soiled items not bagged, out of the residents' bedrooms to the disposal area. Surveyors intervened and directed staff to bag the items before removing them and walking through the facility. Staff were also advised by the surveyors that soiled items were not to be placed directly on the floor and needed to be bagged as well.Due to the level of soilage observed on the items placed on the floor in Clover Cottage, the surveyor directed staff to disinfect the floor of the resident's room. Staff interviews conducted on 8/2/21 and 8/4/21 revealed the staff involved in the incontinent care observations were unaware they should not carry not bagged items through the facility and were only somewhat aware that soiled items should not go onto the bare floor. The need to ensure that all staff implemented appropriate infection control practices and that soiled items were not put on the floor or carried not bagged through the facility was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/2/21 and 8/4/21. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in November 2014 with diagnoses including dementia and osteoporosis. The resident's service plan dated 6/24/21 and interviews with care staff between 8/2/21 and 8/4/21 indicated the resident was dependent for all ADL care. The resident was unable to direct her/his own care or communicate verbally. Review of incident investigations and progress notes from 5/1/21 through 8/2/21 showed the following: * A progress note dated 5/1/21 indicated the resident had an assisted fall to the floor after being assisted with incontinent care. No injury was noted. There was no investigation completed related to this incident to rule out abuse and neglect. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Executive Director) Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/4/21. The staff acknowledged the findings. 4. Resident 4 was admitted to the facility May 2021 with diagnoses including dementia and agitation.The resident's service plan dated 7/15/21 and interviews with care staff between 8/2/21 and 8/4/21 indicated the resident was dependent for all ADL care. The resident was unable to direct her/his own care and had a great deal of pain related to a recent hip fracture. Review of incident investigations and progress notes from 8/2/21 through 8/4/21 showed the following: * A progress note dated 5/20/21 indicated Resident 4 was touching and fixated on another resident in the unit who was becoming agitated by the unwanted touch. When staff attempted to separate the residents, Resident 4 became more agitated, swinging her/his arms and grabbing at the other resident. Resident 4 hit the other resident in the head and grabbed her/his arms.The incident was not investigated nor reported to the local SPD office.* A progress note dated 6/5/21 indicated the resident claimed s/he was being beaten and scratched. No additional information was noted. The incident was not investigated nor reported to the local SPD office.* A progress note dated 7/4/21 indicated the resident was found on the floor, resident stated s/he put themselves on the floor. There were no witnesses to confirm the residents statement, no injuries were noted. The incident was not investigated to rule out potential abuse and neglect.* A progress note dated 7/9/21 indicated staff witnessed the resident lay herself/himself down on the floor. Staff assisted the resident to her/his feet. The resident took "four steps" and "dropped" her/his weight, staff assisted the resident to the floor. The resident screamed when staff attempted to touch/assist off the floor the second time. EMTs were called and the resident was transported to the ER. The resident was found to have a left hip fracture and admitted to the hospital.The incident was not investigated nor reported to the local SPD office. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Executive Director) Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/4/21. The staff acknowledged the findings. The facility was asked to report the incidents from 5/20/21, 6/5/21 and 7/9/21 to their local SPD office and a confirmation was provided prior to exit.
2. Resident 1 was admitted to the facility in June 2020 with diagnoses including dementia.Review of the resident's progress notes for 5/4/21 through 8/2/21 showed the following:* Resident 1 was found undressed and in bed with another resident on 5/17/21. The incident was not investigated and there was no documentation the incident was reported to the local SPD office; and* Resident 1 was found sitting on a bench in the garden with another resident who was observed to have her/his hands in Resident 1's " lower private area" on 6/08/21. The incident was not investigated and there was no documentation the incident was reported to the local SPD office. The need to investigate and report incidents to the local SPD office when needed, to rule out abuse and neglect was discussed with Staff 1 (Executive Director) on 8/3/21. He acknowledged the findings. Staff 1 was asked to report the incidents to the local SPD office and provided confirmation of the reports prior to survey exit.
Based on interview and record review, it was determined the facility failed to ensure accidents, incidents including resident to resident altercations and sexual behaviors were thoroughly investigated to rule out abuse or neglect and reported to the local SPD office as appropriate for 4 of 5 sampled residents (#s 1, 3, 4 and 5). Findings include, but are not limited to:1. Resident 5 was admitted to the facility in May of 2020 with diagnoses including dementia.Review of an incident report dated 6/29/21 showed the following:Resident 5 was involved in a resident-to-resident altercation on 6/29/21. Another resident was physically aggressive towards Resident 5 and hit her/him. Staff asked Resident 5 where they were hit and s/he took off her/his shirt and showed staff reddened areas on her/his chest and lower back.Review of the incident report dated 6/29/21 identified the incident was not reported to the local SPD office. The need to ensure resident to resident altercations were thoroughly investigated to rule out abuse and neglect and reported to the local SPD office as appropriate was discussed with Staff 1 (Executive Director) on 8/3/21. He acknowledged the findings.Staff 1 (Executive Director) was asked to report the incident to their local SPD on 8/3/21 and a confirmation was provided prior to survey.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean. Findings include, but are not limited to:Observations of the main kitchen on 8/2/21 revealed the following:* There was dirt and debris built up above the dish washing sink;* The floor and wall under the dish washing sink had dirt, debris and a black substance; * Floor throughout the kitchen had dirt and debris; and* Paint was found in the hand washing sink and the dish washing sink. Interview with Staff 25 (Executive Chef) on 8/2/21 revealed the maintenance staff washed their painting equipment in the hand and dishwashing sinks. Interview with Staff 1 (Executive Director) on 8/2/21 stated he was unaware the maintenance staff were cleaning their painting equipment in the kitchen. The need to ensure the kitchen was kept clean was discussed with Staff 1 on 8/2/21. He acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair. This is a repeat citation. Findings include, but are not limited to:Observations of the main kitchen on 11/08/21 revealed the following:* Paint was found in the hand washing sink and the dish washing sink; and* Shelves above dish washing sink had exposed bare wood and/or splintered wood.The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Executive Director) on 11/08/21. He acknowledged the findings.

2. Resident 3 was admitted to the facility in November 2014 with diagnoses including dementia and breast cancer. Weight records dated 3/1/21 through 8/2/21 and progress notes dated 5/4/21 through 8/2/21, indicated the resident experienced a six pound weight loss from 4/23/21 to 5/26/21. This constituted a 5.40% severe weight loss in one month. The resident was placed on hospice on 4/22/21 related to a terminal diagnosis of breast cancer, increased ADL assistance and decline in food intake. Staff were to provide meal assistance and health shakes multiple times per day. The resident's intake continued to decline but her/his weight loss slowed with an additional one pound loss in the last month.The facility failed to ensure an RN assessment was completed for the severe weight loss and the hospice admission which documented findings, resident status and interventions made as a result of the assessment.Observations of the resident on 8/2/21 and 8/3/21 showed the resident had declined significantly. The resident was unable to intake any food. The staff were maintaining her/his comfort at the end of life as directed by the hospice provider. The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/3/21 and 8/4/21. The staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 3 of 4 sampled residents (#s 2, 3 and 5) who experienced a significant change of condition. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in January 2021 with diagnoses including dementia. Weight records and progress notes dated 5/4/21 through 8/2/21 were reviewed and indicated the resident experienced a nine pound unplanned weight loss between 6/1/21 and 7/2/21. The loss of over 8% of body weight constituted a significant change of condition for weight loss.The facility failed to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment.Multiple observations of the resident between 8/2/21 and 8/4/21 showed the resident eating in the dining room with staff providing cues and meal assistance at times. The need to ensure an RN assessment was completed for significant changes of condition was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/RN), and Staff 3 (LPN). They acknowledged the findings.
3. Resident 5 was admitted to the facility in May of 2020 with a diagnosis of dementia. Review of the resident's weight records on 8/3/21 revealed the following:Weight records from 2/2/21 through 7/27/21 and a progress note dated 6/11/21 indicated the resident sustained a 12.2 pound weight loss between 6/8/21 and 7/6/21. This constituted a severe weight loss of 5.3% in a 30 day period. In interview on 8/3/21 Staff 2 (Wellness Director/RN) indicated she did not know she needed to complete an RN assessment for a significant change of condition for weight loss.The need to ensure RN assessments were completed for severe weight loss was discussed with Staff 1 (Executive Director) and Staff 2 on 8/3/21. They acknowledged the findings.


Based on observation, interview, and record review, it was determined the facility failed to ensure an RN significant change of condition assessment was completed in a timely manner for 2 of 2 sampled residents (#s 9 and 10) who experienced significant changes. This is a repeat citation. Findings include, but are not limited to:1. Resident 9 was admitted to the facility in 06/2016 with diagnoses including dementia.Resident 9 was observed by the surveyor on 11/09/21 to independently feed him/herself with 1:1 supervision. Review of 10/15/21 through 11/08/2021 progress notes, RN assessments, and 07/2021 through 11/2021 weight records revealed the following:Resident 9 weighed 198.2 lbs. on 09/21/21. On 10/04/21, his/her weight dropped to 188.2 lbs. On 11/01/2021, 27 days after the weight was obtained, the RN completed an assessment and documented the weight represented a one month 10 lb. loss, or 5.05% of total body weight, which she indicated was significant. The RN was not available during the survey for an interview.The need to ensure the RN completed an assessment in a timely manner was discussed with Staff 1 (Executive Director) on 11/09/2021. He acknowledged the findings.

2. Resident 10 was admitted to the facility in 05/2021 with diagnoses including Alzheimer's disease.The resident's progress notes, dated 10/15/21 through 11/08/21, current service plan, temporary service plans, and 06/2021 through 11/01/21 weight records were reviewed and staff were interviewed. The following weights were identified:* 08/02/21: 120 lbs.;* 09/01/21: 122 lbs.; and* 10/05/21: 105 lbs.Between 09/01/21 and 10/05/21 the resident lost 17 lbs., or 13.93% of his/her total body weight, which constituted a severe weight loss.The RN completed a significant change of condition assessment on 10/26/21, 21 days after the 30 day severe weight loss was identified on 10/05/21. The RN's assessment indicated the resident started furosemide (a diuretic) on 09/29/21 for "ongoing 3+ edema to lower legs," and the swelling to the resident's "bilateral lower legs was significantly reduced." The RN indicated the weight loss noted on 10/05/21 "likely reflects this fluid loss."The RN was not available during the survey for an interview.The need to ensure RN assessments were completed in a timely manner for all significant changes of condition was discussed with Staff 1 (Executive Director) on 11/09/21. He acknowledged the findings.1. The weight loss assessments and changes of conditions completed for those identified during survey. Timing of weights evaluated and changed. Each cottage will have a designated week that all weights will be taken and reported each month. Any change of conditions will be assessed and completed with 3 days. 2. Additional steps added to the monthly Weight Clinic meetings to include RN assessment for those residents that report weight loss outside the set parameters.3. Weight Clinic meeting will now take place weekly one cottage at a time. Follow-up expectatins to be completed within 3 days.4. The RN and executive director are responsible for ensure proper assessment and follow up are compelted within the alotted time.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#1) who received insulin injections by unlicensed staff. Findings include, but are not limited to:Delegation records for Resident 1, reviewed on 8/3/21, indicated Staff 2 (Wellness Director/RN) failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 4 (RCC), Staff 7 (RCC), Staff 15 (MT) and Staff 21 (MT) to include:* Nursing assessment and condition of the client to determine if the client's condition was stable and predictable;* The rationale for deciding the task of nursing care could be safely delegated to unlicensed persons;* The skill and ability of the unlicensed persons;* Documentation that the task was taught to the unlicensed persons and they were competent to safely perform the task; and* Frequency the client should be reassessed, including rationale.Staff 4 (RCC) and Staff 7 (RCC) lacked documentation of completion for all required components for the periodic inspection, supervision and re-evaluation of the delegated task to include: * Individual observation/return demonstration of task to determine if the unlicensed staff remained capable and willing to safely perform the task; and * Frequency for subsequent re-evaluations, including rationale.There was no documented evidence that Staff 15 (MT) was re-evaluated after the initial delegation on 3/10/21.The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (Executive Director), Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/3/21. Staff 2 acknowledged the identified areas needing additional documentation. On 8/4/21 Staff 2 reported licensed nurses were administering all insulin injections until the delegations were completed according to the OSBN Administrative Rules.

Based on interview and record review, it was determined the facility failed to ensure there was adequate professional oversight of the medication and treatment administration system for 2 of 2 sampled residents (#s 9 and 10) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 06/2016 with diagnoses including dementia. Review of the 10/15/21 through 11/08/21 MARs revealed the resident had both PRN APAP (acetaminophen) and hydrocodone for pain. The MAR listed parameters which instructed staff to administer APAP first. On the following dates, staff administered hydrocodone without first administering APAP: * 10/20/2021; * 10/25/2021;* 11/02/2021; and * 11/08/2021.During interviews with Staff 1 (Executive Director), Staff 26 (LPN), and Staff 27 (LPN) on 11/09/21, they reported there was not a system in place to ensure parameters for PRN medications were followed by staff. The need to ensure there was adequate professional oversight of the medication and treatment system was discussed with Staff 1 on 11/09/21. He acknowledged the findings.
2. Resident 10 was admitted to the facility in 05/2021 with diagnoses including Alzheimer's disease. Review of the 10/15/21 through 11/08/21 MARs revealed the resident was prescribed both PRN Haloperidol and lorazepam, psychotropic medications used for anxiety and agitation. The MAR listed parameters which instructed staff to administer Haloperidol first. On 11/03/21 staff administered the lorazepam without administering the Haloperidol first. In an interview on 11/09/21, Staff 26 (LPN) reported there was not a system in place to ensure parameters for PRN medications were followed by staff. The need to ensure there was adequate professional oversight of the medication and treatment system was discussed with Staff 1 (Executive Director) on 11/09/21. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents' MARs were complete, accurate and provided clear instruction and parameters for administration of PRN medications for 3 of 6 sampled residents (#s 2, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in May 2021 with diagnoses including dementia. Review of the resident's 5/13/21 through 8/2/21 progress notes and physician orders and the 7/1/21 through 8/2/21 MARs/TARs showed the resident sustained a hip fracture on 7/9/21 and had the following medications:* Aceteminophen 325 mg tablet, as needed every six hours for pain;* Morphine 20 mg/ml give every hour as needed for pain or shortness of breath;* Oxycodone HCL 5 mg tablet, give every six hours as needed for pain; and* Tramadol HCL 50mg table give every 12 hours as needed for pain. There was no indication which medication should be used first or in what order the remaining medications should be utilized for the resident's pain. The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/4/21. The staff acknowledged the findings.
3. Resident 2's July 1 through August 2, 2021 MARs were reviewed and identified the following PRN pain medications: * Acetaminophen oral PRN every 8 hours for pain;* Acetaminophen suppository every 4 hours PRN for mild pain;* Hydrocodone-Acetaminophen 5-325 mg every 12 hours PRN for pain; and* Morphine Sulphate solution 5 mg every 1 hour as needed for pain or shortness of breath. There were no instructions for which medication should be used first or in what order the remaining medications should be utilized for the resident's pain. The need to ensure MARs included clear parameters and direction to staff for medication administration was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/4/21. They acknowledged the findings.
2. Resident 5 was admitted to the facility in May of 2020 with a diagnosis of dementia.Review of the resident's 7/1/21 through 8/2/21 MAR showed the following orders:*APAP 325 mg every four hours as needed for pain; and*Acetaminophen 650 mg suppository every four hours as needed for pain. There were no resident specific parameters to which PRN medication to administer first for pain.The need to ensure the MAR had resident specific parameters for PRN pain medication was discussed with Staff 1 (Executive Director) and Staff 3 (LPN). They acknowledged the findings.

2. Resident 8 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's disease with behavioral disturbance.The resident's 10/29/21 through 11/08/21 MARs were reviewed and identified the following PRN treatments:* Clotrimazole 1% cream on abdomen for yeast rash; and * Nystatin powder for yeast rash.There were no instructions regarding which medication should be used first to treat the resident's yeast rash.The need to ensure MARs included clear parameters and direction to staff for treatment application was discussed with Staff 26 (LPN). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters and instructions for PRN medications for 2 of 4 sampled residents (#s 8 and 9) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 10/2016 with diagnoses including dementia. Review of the resident's 10/15/21 through 11/08/2021 MARs revealed the following:* Three PRN bowel medications for constipation were listed on the MAR. Peg 3350 510 g and Glycerine Suppository 2 g both included instructions to administer on day four of no bowel movement. There were no instructions to staff regarding which medication to administer first. * Iodosorb 0.9% gel was indicated on the MAR to be administered PRN. There were no instructions to staff which indicated the circumstances under which the medication was to be administered. * Zinc Ointment Barrier Cream and Zinc Oxide 20% ointment were both entered onto the MAR as scheduled treatments for wound care to the resident's buttocks. The medications were initialed as administered three times daily from 10/15/2021 through 11/07/21. During an interview with Staff 22 (MT), she reported that one barrier cream was administered to the resident. Staff 26 (LPN) reported during a subsequent interview they were the same medication and one was a duplicate entry. The need to ensure MARs were accurate and included resident-specific parameters for PRN medications was discussed with Staff 1 (Executive Director), Staff 26, and Staff 27 (LPN) on 11/09/21. They acknowledged the findings.
1. The evalution of the resident's medication administrative records (MAR's) reviewed and assessed for all needed and proper information, including current month/day/year, name of medication, reason for the RX, dosage, date and time give, side effects, any time sensitive dosages identified, when to call the nurse, allergies, specific parameters for PRN medications, and when more than one of the same types of medication are prescribed, instructions are included to which should be used first or in what order the medication should be administered to address the resident pain. 2. Each new prescription profiled will be assessed by nursing, for all required information including all listed as above so to be administred as prescribed with clear directions. Needed clarifications to orders received will be addressed promptly with the prescribing physican. 3. The MAR is evaluated for proper completion on each new order. The contracted pharmacy reviews all orders before profiling. Quarterly orders are sent to the prescribing physician for review and signature. 4. The facility RN is responsible for proper completion of all medications orders.

2. Resident 3 was admitted to the facility in November 2014 with diagnoses including dementia.Review of the resident's 7/1/21 through 8/3/21 MAR and 5/3/21 physician orders showed the following psychotropic medications:The resident was prescribed Lorazepam (anti-anxiety medication) 0.5mg every four hours as needed for anxiety, agitation or nausea. The medication was not administered from 7/1/21 through 8/1/21. The MAR contained no information on what staff should watch for or what the resident's anxiety and agitation looked like. The need to ensure the MAR reflected what staff should observe for prior to treatment with PRN psychotropic was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/4/21. They acknowledged the findings.3. Resident 4 was admitted to the facility in May 2021 with diagnoses including dementia and agitation.Review of the resident's 7/1/21 through 8/3/21 MAR and 7/14/21 physician orders showed the following psychotropic medications:* The resident was prescribed Quetiapine (antipsychotic medication) 25 mg every three hours as needed for agitation. The medication was administered on six occasions between 7/1/21 and 8/3/21. There were no non-drug interventions listed for staff to attempt prior to administration of the medication, nor were there any instructions for staff on what the resident's agitation looked like. * The resident was prescribed Haloperidol (antipsychotic medication) 2.0 mg/ml every four hours as needed for restlessness or agitation. The medication was not administered between 7/1/21 ad 8/3/21. There was no information for staff on what the resident's agitation and restlessness looked like. * The resident was prescribed Lorazepam (anti-anxiety medication) 0.5 mg every hour as needed for anxiety or shortness of breath. The medication was not administered between 7/1/21 and 8/3/21.There were no non-drug interventions listed for staff to attempt prior to administration of the medication nor were there any instructions for staff on what the resident's agitation looked like.The need to ensure the MAR reflected non-drug interventions to attempt prior to medication administration and what staff should observe for prior to treatment with PRN psychotropics was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/4/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 4 of 6 sampled residents (#s 2, 3, 4 and 5) who were prescribed PRN medication to address behaviors. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in November 2014 with diagnoses including dementia.Review of the resident's 7/1/21 through 8/3/21 MAR and physician orders showed the following psychotropic medications:* Lorazepam 1 mg (a psychotropic medication) every four hours as needed every day for anxiety or restlessness;* Haloperidol 2 mg (a psychotropic medication) every four hours as needed for anxiety, restlessness or nausea; and* Quetiapine 25 mg (a psychotropic medication) every day as needed for agitation.The facility administered the Lorazepam to the resident on six occasions in July 2021. The facility failed to ensure there were specific parameters for staff describing how the resident expressed anxiety, restlessness and agitation.The need to ensure there were resident-specific descriptions of how the resident expressed anxiety, restlessness and agitation was reviewed with Staff 1 (Executive Director), Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/4/2021. They acknowledged the findings.
4. Resident 5 was admitted to the facility in May of 2020 with diagnoses including dementia.The resident had a physician's order for PRN Haloperidol for agitation that was administered on 7/30/21.Review of the resident's 7/1/21 through 8/2/21 MAR and progress notes revealed there were no resident specific non-drug interventions attempted before administering PRN Haloperidol on 7/30/21. Interview with Staff 10 (MT) on 8/4/21 revealed the MAR lacked non-drug interventions for the PRN Haloperidol. The need to ensure staff were instructed on the resident specific non-drug interventions and attempted the interventions before administering PRN psychoactive medications was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/3/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had written, resident-specific parameters and non-pharmaceutical interventions for staff to attempt prior to administering the medication for 1 of 2 sampled residents (#8) who were prescribed a PRN psychotropic. This is a repeat citation. Findings include, but are not limited to:Resident 8 was admitted to the facility in 10/2021 with diagnoses including Alzheimer's disease with behavioral disturbance.Review of the resident's 10/29/21 through 11/08/21 MARs and physician orders showed the following:* The resident was prescribed Quetiapine 25 mg (a psychotropic medication), a half tablet, twice daily as needed for depression/anxiety.* The PRN medication was administered to the resident on seven occasions.* There were no specific parameters for staff describing how the resident expressed anxiety and depression.* There were no non-drug interventions listed for staff to attempt prior to administration of the medication.An interview with Staff 37 (MT) on 11/08/21 revealed the MAR lacked specific signs and symptoms of how the resident exhibited depression and anxiety, and lacked non-drug interventions for the PRN Quetiapine.The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and depression and the MAR reflected non-drug interventions to attempt prior to the administration of PRN psychotropic medication was discussed with Staff 26 (LPN) on 11/08/21. She acknowledged the findings.

1. MARs evaulated for proper completion including service plan to address non-pharmacological interventions that need to be attempted to adminsitration of a psychotropic medication. MARs updated to reflect specific signs and symptoms of how each resident exhibites depression and anxiety. Also reviewed and corrected if needed; listing of side effects when to call RN and prescribing physician to report side effects. 2. Each new prescription profiled checked against the prescribing physician's original order. Psychotropic medications orders are monitored for all required information as listed under #1. Personal information regarding each residents personal way of showing anxiety and depression. 3. The MAR is evaluated for proper completion on each new order. The contracted pharmacy reviews all orders before profiling. 4. The facility RN is responsible for proper completion of all medications orders.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 2 of 2 sampled residents (#s 2 and 5) who were reviewed for devices with restraining qualities. Findings include, but are not limited to:1. Resident 5 was identified during the acuity interview on 8/2/21 to have a lap buddy while in her/his wheelchair. Observations of the resident from 8/2/21 through 8/4/21 showed a lap buddy was in place while the resident was up in their wheelchair. Observations additionally showed the resident was able to remove and reinstall the lap buddy unaided by staff.There was no documented evidence a thorough assessment was completed by an RN, PT or OT prior to use of the device with potential restraining qualities.The need to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use was discussed with Staff 1(Executive Director) and Staff 2 (Wellness Director/RN) on 8/4/21. They acknowledged the findings.
2. Resident 2 was admitted to the facility in January 2021 with a diagnosis of dementia and history of multiple falls. On 8/2/21 the resident's bed was observed to have a perimeter mattress in place. There was no documented evidence the device with potentially restraining qualities had been thoroughly assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use.The lack of assessment for use of a supportive device with potentially restraining qualities was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/RN) and Staff 3 (LPN) on 8/4/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 8, 11 and 13) received training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 8/3/21.Review of staff training records revealed Staff 8 (CG), Staff 11(CG) and Staff 13 (CG) did not receive abdominal thrust training within 30 days of hire. The need to ensure all newly hired staff were trained in abdominal thrust within 30 days of hire was discussed with Staff 1 (Executive Director) on 8/3/21. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240, C 280, C 310, C 330, C 513, Z 142, Z 162, and Z 164.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to:Observations of the facility on 8/2/21 and 8/3/21 showed the following areas were in need of cleaning and/or repair in Sunflower, Blackberry, Dandelion and Clover Cottages:* Multiple walls, doors and door frames throughout the facility were dinged, chipped, gouged, scraped and/or had black streaks;* Red splatters were located on the dining room blinds in Blackberry Cottage;* Baseboards in multiple areas were scrapped, dinged or had long black scuffs;* Common area carpets had multiple large dark stains;* Showers had missing tile, chipped or gouged walls next to the shower and/or black accumulation along the bottom of the shower stall; and* Missing caulking and/or black stains were noted along the base of toilets in multiple bathrooms.The need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (Executive Director) on 8/2/21. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. This is a repeat citation. Findings include, but are not limited to:Observations of the facility on 11/08/21 showed the following areas were in need of cleaning and/or repair in Sunflower, Blackberry, Dandelion, and Clover Cottages:* A shower room had missing tile in Clover Cottage;* Missing caulking and/or black stains were noted along the base of toilet in Clover Cottage;* A layer of accumulated dust was visible on ceiling vents in multiple shower rooms and bathrooms; and* Multiple shower rooms and bathroom doors and door frames throughout the facility were dinged, chipped, and scraped.The need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (Executive Director) on 11/08/21. He 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 not limited to:Refer to C160, C 231, C 240, C 372 and C 513.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 240, C 455, and C 513.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 8, 11, 13 and 20) and 2 of 3 long term staff (#s 10 and 17) completed the required six hours of dementia related annual in-service training. Findings include, but are not limited to:a. Staff training records were reviewed on 8/3/21 and revealed the following:There was no documented evidence Staff 8 (CG), Staff 11 (CG), Staff 13 (CG) and Staff 20 (MT) demonstrated competencies in the following areas within 30 days of hire:* Identification, documentation and reporting changes of condition; and* Conditions that require assessment, treatment, observation and reporting.b. There was no documented evidence Staff 10 (MT) and 17 (MT) completed 6 hours of annual dementia care training.The need to ensure all newly hired staff completed all required 30-day competencies and all long term staff completed six hours of annual dementia related in-service training was discussed with Staff 1 (Executive Director) on 8/3/21. He 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 not limited to:Refer to C 280, C 282, C 310, C 330 and C 340.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 280, C 300, C 310, and C 330.

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 4 of 6 sampled residents (#s 2, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:Resident 2, 4, 5, and 6's service plans offered some information about the resident's interests, but the facility had not fully evaluated the resident's:* Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary.There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.Observation in all five cottages on 8/2/21 through 8/4/21 identified there was a lack of unscheduled and scheduled activities occurring for residents who were unable to self-initiate activities on their own. Multiple residents in four of the five cottages were observed napping in wheelchairs or at dining tables throughout the day with minimal to no interaction by activity or care staff. A posted activity calendar was in each cottage but many of the activities did not occur at the indicated time and no replacement activity was initiated. Interview with Staff 16 (Activities Director) on 8/3/21 reported the average amount of time for activities provided in each of the five cottages was up to 60 minutes per day. Staff 16 indicated the activity staff was also responsible for covering the floor when there were staffing shortages and transportation of residents to appointments. The need to ensure the facility provided meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the residents and ensure individualized activity plans were developed for each resident was discussed with Staff 1 (Executive Director) and Staff 3 (LPN) on 8/4/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in resident activity evaluations and individualized activity plans were developed for each resident based on their activity evaluation for 2 of 2 sampled residents (#s 9 and 10) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:Though Resident 9 and 10's service plans offered some information about the residents' interests, the facility had not fully evaluated: * Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.The need to ensure the facility addressed all required elements in resident activity evaluations and developed individualized activity plans for each resident was discussed with Staff 1 (Executive Director) on 11/09/21. He acknowledged the findings.