Citation #1: C0200 - Resident Rights and Protection - General
Visit History:
t Visit: 11/6/2025 | Not Corrected
Regulation:
OAR 411-054-0027 (1) Resident Rights and Protection - General
(1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right:
(a) To be treated with dignity and respect.
(b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences.
(c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided.
(d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made.
(e) To receive information about the method for evaluating their service needs and assessing costs for the services provided.
(f) To exercise individual rights that do not infringe upon the rights or safety of others.
(g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse.
(h) To receive services in a manner that protects privacy and dignity.
(i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays).
(j) To have medical and other records kept confidential except as otherwise provided by law.
(k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone.
(l) To be free from physical restraints and inappropriate use of psychoactive medications.
(m) To manage personal financial affairs unless legally restricted.
(n) To have access to, and participate in, social activities.
(o) To be encouraged and assisted to exercise rights as a citizen.
(p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence.
(q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation.
(r) To be free of retaliation after they have exercised their rights provided by law or rule.
(s) To have a safe and homelike environment.
(t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion.
(u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.
Inspection Findings:
Based on observation, interview, and record review, it was determined the facility failed to ensure residents were treated with dignity and respect, received services in a manner that protected privacy and dignity, and ensure medical and other records were kept confidential for multiple sampled and unsampled residents. Findings include, but are not limited to:
During the re-licensure survey, conducted 11/03/25 through 11/06/25, the following concerns were identified:
* Multiple care staff were using walkie-talkies to communicate information regarding resident care needs, including ostomy care, incontinent care, a resident’s weight, and medication administration, to each other. The information relayed over the walkie talkies was considered private health information (PHI) and should have been kept confidential.
* On 11/04/25 at 9:15 am, Staff 1 (ED) was overheard talking to an outside provider about an unsampled resident’s dementia diagnosis and progression of the disease process, including medications the resident was taking and activities of daily living, in the front lobby where other people could overhear the conversation.
* On 11/05/25 and 11/06/25 the survey team observed written PHI for multiple sampled and unsampled residents in a file box hanging on a wall in a public space that was visible to individuals who should not have had access to the information.
The need to ensure residents were treated with dignity and respect, received services in a manner that protected privacy and dignity, and to ensure medical and other records were kept confidential was discussed with Staff 1, Staff 2 (RCC), Staff 3 (RCC), Staff 5 (LPN),and Witness 1 (RN Consultant) on 11/06/25 at 12:36 pm. They acknowledged the findings.
Plan of Correction:
C200 - Resident Rights, Dignity, Privacy & Confidentiality OAR 411-054-0027(1)(h), (j), (s)
1. What actions were taken to correct the violation for each example/resident?
• The facility immediately purchased and implemented headsets for all walkie-talkies, ensuring resident information is no longer broadcast publicly and is heard only by the intended staff member.
• Staff involved were re-educated on confidentiality requirements and instructed to use headsets at all times when discussing resident care or services.
• The PHI file box observed in a public hallway was removed immediately and relocated to a secured, staff-only area.
• The Executive Director received re-education on proper confidentiality practices and now conducts all resident-related conversations in private locations where discussions cannot be overheard by unauthorized individuals.
• All staff were re-educated on Resident Rights, specifically dignity, privacy, and handling of protected health information, per OAR 411-054-0027.
2. How will the system be corrected so this violation will not happen again?
• A revised communication protocol has been implemented requiring the use of headsets for walkie-talkie communication involving resident care, ensuring PHI is not overheard in public areas.
• The facility updated its Privacy & Confidentiality Policy to include safeguards for electronic and verbal communication, including mandatory headset use.
• Environmental rounds will now include checks to ensure confidential materials are never left in public spaces.
• Staff will receive ongoing privacy/confidentiality training annually and upon hire, with emphasis on secure communication and PHI protection.
• Compliance with headset use and privacy practices will be monitored through random audits incorporated into the Quality Assurance program.
3. How often will the area needing correction be evaluated?
• Weekly audits for the first 60 days to ensure proper headset use and secure storage of PHI.
• Monthly quality assurance checks thereafter to ensure continued compliance.
• Quarterly review of communication practices during staff competency evaluations.
4. Who will be responsible to see that the corrections are completed/monitored?
• Executive Director (ED) — oversight of privacy practices, policy implementation, and retraining.
• Resident Care Coordinator (RCC) — monitoring day-to-day staff compliance with headset use and PHI handling.
• Licensed Nurse/RN Consultant (as applicable) — supporting monitoring of PHI handling during clinical oversight.
• Quality Assurance Team — reviewing audit results and ensuring sustained compliance.
Citation #2: C0252 - Resident Move-in & Evaluation: Res Evaluation
Visit History:
t Visit: 11/6/2025 | Not Corrected
Regulation:
OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation
(1) INITIAL SCREENING AND MOVE-IN.
(a) The facility must determine whether a potential resident meets the facility's admission requirements.
(b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability.
(c) Each resident record must, before move-in and when updated, include the following information:
(A) Legal name for billing purposes.
(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding:
(i) Name.
(ii) Pronouns.
(iii) Gender identity.
(C) Prior living arrangements;
(D) Emergency contacts;
(E) Service plan involvement - resident, family, and social supports;
(F) Financial and other legal relationships, if applicable, including, but not limited to:
(i) Advance directives;
(ii) Guardianship; (iii) Conservatorship; and
(iv) Power of attorney.
(G) Primary language;
(H) Community connections; and
(I) Health and social service providers.
(2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.
(a) Resident evaluations must be:
(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and
(B) Performed at least quarterly, to correspond with the quarterly service plan updates.
(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.
(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.
(E) Documented, dated, and indicate who was involved in the evaluation process.
(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.
(3) EVALUATION REQUIREMENTS AT MOVE-IN.
(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.
(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.
(c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs.
(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.
(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.
(4) QUARTERLY EVALUATION REQUIREMENTS.
(a) Resident evaluations must be performed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.
(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.
(5) The resident evaluation must address the following elements:
(a) For service planning purposes, if indicated by the resident,
(A) Name.
(B) Pronouns.
(C) Gender identity.
(b) Resident routines and preferences including:
(A) Customary routines, such as those related to sleeping, eating, and bathing;
(B) Interests, hobbies, and social and leisure activities;
(C) Spiritual and cultural preferences and traditions; and
(D) Additional elements as listed in 411-054-0027(2).
(c) Physical health status including:
(A) List of current diagnoses;
(B) List of medications and PRN use;
(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and
(D) Vital signs if indicated by diagnoses, health problems, or medications.
(d) Mental health issues including:
(A) Presence of depression, thought disorders, or behavioral or mood problems;
(B) History of treatment; and (C) Effective non-drug interventions.
(e) Cognition, including:
(A) Memory;
(B) Orientation;
(C) Confusion; and
(D) Decision-making abilities.
(f) Personality, including how the person copes with change or challenging situations.
(g) Communication and sensory abilities including:
(A) Hearing;
(B) Vision;
(C) Speech;
(D) Use of assistive devices; and
(E) Ability to understand and be understood.
(h) Activities of daily living including:
(A) Toileting, bowel, and bladder management;
(B) Dressing, grooming, bathing, and personal hygiene;
(C) Mobility - ambulation, transfers, and assistive devices; and
(D) Eating, dental status, and assistive devices.
(i) Independent activities of daily living including:
(A) Ability to manage medications; (B) Ability to use call system;
(C) Housework and laundry; and
(D) Transportation.
(j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.
(k) Skin condition.
(l) Nutrition habits, fluid preferences, and weight if indicated.
(m) List of treatments - type, frequency, and level of assistance needed.
(n) Indicators of nursing needs, including potential for delegated nursing tasks.
(o) Review of risk indicators including:
(A) Fall risk or history;
(B) Emergency evacuation ability;
(C) Complex medication regimen;
(D) History of dehydration or unexplained weight loss or gain;
(E) Recent losses;
(F) Unsuccessful prior placements;
(G) Elopement risk or history;
(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and
(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.
(p) Environmental factors that impact the resident's behavior including, but not limited to:
(A) Noise.
(B) Lighting.
(C) Room temperature.
(6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.
Stat. Auth.: ORS 410.070, 441.122, 443.450
Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991
Inspection Findings:
Based on observation, interview, and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 2) and failed to ensure evaluations were performed at least quarterly and were relevant to the physical health status of the resident for 3 of 5 sampled residents (#s 1, 5, and 6) whose evaluations were reviewed. Findings include, but are not limited to:
1. Resident 2 moved into the facility in 10/2025 with diagnoses including type 2 diabetes.
The resident’s move-in evaluation was reviewed, and the following required elements had not been addressed:
* Customary routines, including bathing;
* List of current diagnoses;
* Visits to health practitioners, emergency room, hospital, or skilled nursing facilities in the past year;
* Personality, including how the person coped with change or challenging situations;
* Complex medication regimen; and
* Unsuccessful prior placements.
The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (RCC), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/06/25 at 11:51 am. No additional information was received.
2. Resident 1 moved into the facility in 04/2022 with diagnoses including acute respiratory failure and depression.
The resident’s clinical records were reviewed and revealed s/he had sustained four fractured ribs from a fall on 09/23/25 and had weight loss identified on 10/01/25. Resident 1 was observed on 11/05/25 doing the laundry for both him/herself and their spouse.
The resident’s quarterly evaluation, dated 10/12/25, was not reflective of his/her current needs and condition in the following areas:
* Skin;
* Feet;
* Fractures;
* Eye drops;
* Weight loss;
* Personal loss;
* Number of falls in the past three months; and
* Assistance needed with laundry.
The need to ensure evaluations were relevant to the current needs and condition of the resident was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (RCC), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/06/25 at 11:51 am. No additional information was received.
3. Resident 5 moved into the ALF in 01/2020 with diagnoses including heart failure, essential hypertension, and essential tremor.
During an interview with Resident 5 on 11/03/25 at 1:05 pm, the resident was observed using oxygen and received staff assistance with ostomy care. Resident 5 reported s/he needed assistance with showers, did not have CBGs checked daily, and reported s/he was never a smoker.
On 11/03/25 at 1:00 pm, Staff 10 (MT/CG) reported “I don’t believe [s/he] smokes, I mean [s/he] never comes out of [his/her] room, has oxygen, and hospice comes to see [him/her]” and “No, I don’t have any instructions to check [his/her] CBG’s.”
Review of Resident 5’s quarterly evaluation, dated 10/19/25, revealed it was not relevant to the needs and current condition of the resident in the following areas:
* Outside service providers;
* Respiratory services;
* Assistance level for ostomy care;
* Assistance with daily CBG monitoring;
* Assistance level for showering;
* Falls in the previous 90 days; and
* Smoking status.
The need to ensure evaluations were relevant to the current needs and condition of the resident was discussed with Staff 1 (ED), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/05/25 at 12:57 pm. They acknowledged the findings.
4. Resident 6 moved into the ALF in 10/2024 with diagnoses including systolic congestive heart failure and essential hypertension.
On 11/03/25 at 2:00 pm, Resident 6 reported s/he recently had a fall and was taken to the emergency room, needed staff assistance to empty their catheter bag, used a manual and electric wheelchair, and was unable to ambulate the stairwell during emergencies.
Review of Resident 6’s quarterly evaluation, dated 07/19/25, identified the evaluation was not updated quarterly and was not relevant to the needs and current condition of the resident in the following areas:
* Catheter Care;
* Use of electric and manual wheelchair;
* History of falls; and
* Assistance level for emergency evacuation.
The need to ensure evaluations were relevant to the current needs and condition of the resident was discussed with Staff 1 (ED), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/05/25 at 12:57 pm. They acknowledged the findings.
Plan of Correction:
C252 - Resident Move-In & Evaluation Requirements OAR 411-054-0034(1)–(4)
1. What actions were taken to correct the violation for each example/resident?
• Resident #2: The move-in evaluation was immediately reviewed and updated to include all missing required elements, including customary routines, diagnoses, past medical visits, personality, complex medication regimen, and prior placement history.
• Residents #1, #5, and #6: Evaluations were updated to reflect current clinical conditions, including fractures, weight changes, ADL needs, respiratory services, ostomy care, CBG monitoring, wheelchair use, fall history, catheter care, and evacuation assistance.
• All incomplete or outdated evaluations for the sampled residents were corrected and brought into compliance with OAR 411-054-0034.
• The ED, RCC, and LPN were re-educated on required evaluation elements and documentation standards.
2. How will the system be corrected so this violation will not happen again?
• A Move-In Evaluation Checklist was created and must now be completed before acceptance of any new resident. This checklist includes all required OAR elements and must be signed by the staff completing the evaluation and reviewed by the RCC.
• A Quarterly Evaluation Tracking System has been implemented to ensure all resident evaluations are completed every 90 days or sooner when a significant change occurs.
• A new Significant Change Notification Process now requires caregivers and nursing staff to immediately report changes in resident condition to the RCC or RN, triggering an evaluation update.
• All evaluations will undergo RN review to verify accuracy and completeness before being finalized.
• Move-in and quarterly evaluations are now part of the facility’s Quality Assurance audits to prevent lapses in future compliance.
3. How often will the area needing correction be evaluated?
• Weekly audits for 60 days to confirm evaluations are being completed on time and contain all required elements.
• Monthly QA audits thereafter, permanently, to ensure ongoing compliance.
• Evaluations will continue to occur before move-in, within the first 30 days, quarterly, and at every significant change, per OAR requirements.
4. Who will be responsible to see that corrections are completed/monitored?
• Resident Care Coordinator (RCC) — responsible for ensuring evaluations are complete, timely, and accurate.
• Executive Director (ED) — oversight of compliance and ensuring corrective systems remain in place.
• Licensed Nurse (LPN/RN) — responsible for reviewing evaluations for clinical accuracy and ensuring updates occur with significant changes.
• Quality Assurance Committee — responsible for reviewing monthly audit results and ensuring sustained compliance.
Citation #3: C0260 - Service Plan: General
Visit History:
t Visit: 11/6/2025 | Not Corrected
Regulation:
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.
Inspection Findings:
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were completed quarterly, were reflective of the residents’ needs and preferences, provided clear instructions for staff, were implemented, and/or were reviewed and updated following significant changes of condition for 3 of 6 Residents (#s 3, 5, and 6), whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 5 moved into the ALF in 01/2020 with diagnoses including essential hypertension, heart failure and essential tremor.
Review of the quarterly service plan, dated 07/17/25, identified the service plan was not reviewed and updated quarterly.
The need to ensure service plans were reviewed and updated quarterly was discussed with Staff 1 (ED), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/05/25 at 12:57 pm. They acknowledged the findings.
2. Resident 6 moved into the ALF in 10/2024 with diagnoses including systolic congestive heart failure and essential hypertension.
Review of the resident’s clinical record identified the following:
a. The current service plan was dated 07/22/25 and was not updated quarterly.
b. The resident had a significant change of condition on 08/20/25 and a second significant change of condition on 10/16/25. The facility failed to update the resident’s service plan following each significant change of condition.
The need to ensure service plans were reviewed and updated quarterly and following significant changes of condition was discussed with Staff 1 (ED), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/05/25 at 12:57 pm. They acknowledged the findings.
3. Resident 3 moved into the facility in 01/2021 with diagnoses including failure to thrive.
Observations of the resident, interviews with staff, and review of the 07/15/25 service plan and temporary service plans were completed between 11/03/25 and 11/06/25.
a. The service plan was not reflective of the resident’s current care needs, did not provide clear direction to staff, and/or was not implemented in the following areas:
* Floating heels when in bed;
* Side rails and precautions related to the side rails;
* Use of a coccyx bandage at all times;
* Use of a clothing protector during meals; and
* Ability to use the call light.
On 11/06/25 at 9:35 am, Resident 3 was observed, during ADL care in bed, with his/her feet directly on the mattress. Staff 8 (CG) and Staff 15 (CG) confirmed the resident was not currently wearing a coccyx bandage, and staff were not floating the resident’s heels while in bed.
b. Resident 3’s service plan, dated 07/15/25, was not reviewed and updated quarterly. On 11/05/25 at 1:08 pm, Staff 2 (RCC) confirmed the resident’s quarterly service plan update had not been completed.
The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, were implemented, and were updated quarterly was discussed with Staff 1 (ED), Staff 2, Staff 3 (RCC), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/06/25 at 12:36 pm. They acknowledged the findings.
Plan of Correction:
C260 - Service Plan Requirements OAR 411-054-0036(1)–(5)
1. What actions were taken to correct the violation for each example/resident?
• Resident #5: The overdue quarterly service plan was immediately reviewed and updated to reflect current needs, including ostomy care, respiratory services, assistance level for showers, smoking status, and CBG monitoring.
• Resident #6: The service plan dated 07/22/25 was immediately updated to reflect both significant changes (8/20/25 and 10/16/25). Updates included catheter care, mobility status, wheelchair use, fall history, and evacuation support needs.
• Resident #3: The service plan was updated to reflect current needs and ensure clear direction to staff, including floating heels, side-rail precautions, coccyx bandage use, clothing protector needs at meals, and the resident’s ability to use the call system.
• All service plans for sampled residents were brought into compliance immediately, with documentation dated and initialed per OAR requirements.
• All staff involved in service plan development (ED, RCC, LPN) were re-educated on required service plan content and timeline requirements.
2. How will the system be corrected so this violation will not happen again?
• A Quarterly Service Plan Compliance Calendar has been implemented to track due dates for all resident service plans. The RCC receives automatic alerts two weeks before each due date.
• A Significant Change Reporting Protocol was implemented to ensure caregivers notify the RCC or nurse immediately when a resident experiences a change in condition, triggering prompt service plan review and update.
• The facility implemented a Service Plan Quality Review Tool to ensure all required elements are completed, individualized, and provide clear instructions for staff.
• All updated service plans will now receive mandatory RN review within 48 hours, in alignment with OAR guidance.
• Service plans are now incorporated into the monthly QA audit, which will monitor timeliness, clarity, and implementation.
• Staff have been retrained on locating and using service plan instructions, ensuring services provided match what is written.
3. How often will the area needing correction be evaluated?
• Weekly audits for 60 days to confirm timely quarterly reviews, significant change updates, and accurate implementation.
• Monthly Quality Assurance reviews thereafter, including random service plan audits.
• Ongoing RN review of service plan changes following any significant change of condition.
4. Who will be responsible to see that corrections are completed/monitored?
• Resident Care Coordinator (RCC) — responsible for completion and accuracy of all service plans.
• Executive Director (ED) — oversight of compliance systems and ensuring staff follow timelines and documentation standards.
• Licensed Nurse/RN — responsible for reviewing service plan updates within 48 hours and ensuring clinical accuracy.
• Quality Assurance Committee — responsible for monitoring audit results and verifying long-term compliance.
Citation #4: C0280 - Resident Health Services
Visit History:
t Visit: 11/6/2025 | Not Corrected
Regulation:
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.
Inspection Findings:
Based on observation, interview, and record review, it was determined the facility failed to ensure a timely RN assessment was completed for 2 of 2 sampled residents (#s 1 and 3) who experienced significant changes of condition related to weight loss. Findings include, but are not limited to:
1. Resident 3 moved into the facility in 01/2021 with diagnoses including failure to thrive.
The resident’s 07/15/25 service plan, 04/23/25 through 07/18/25 progress notes, 07/17/25 through 10/31/25 temporary service plans (TSPs), and 04/01/25 through 10/17/25 weight records were reviewed. Observations were made, and staff were interviewed.
The following weights were recorded by the facility:
* 04/01/25: 190.6 pounds;
* 05/02/25: 189 pounds;
* 06/01/25: 189 pounds;
* 07/04/25: 186.8 pounds;
* 08/04/25: 189.4 pounds;
* 09/01/25: 186.6 pounds;
* 10/01/25: 164.2 pounds;
* 10/17/25: 150.6 pounds; and
* 11/05/25: 160.2 pounds (obtained during survey).
Resident 3 experienced a 26.4 pound weight loss, or 13.85% of his/her total body weight, in six months (from 04/01/25 through 10/01/25) and a 22.6 pound weight loss, or 12.09% of his/her total body weight, in three months (from 07/04/25 through 10/01/25). The losses represented significant changes of condition and required a timely RN assessment.
Observations were taken of the resident during breakfast on 11/04/25 and 11/05/25. The resident was observed to be independent with eating, following set-up assistance to position upright in bed and provide food cut-up. S/he consumed approximately 25% of both meals. Additionally, the facility was encouraging Resident 3 to come to the dining room for lunch and dinner meals to increase overall intake. Resident 3 was brought to the dining room for lunch on 11/05/25 and on 11/06/25.
An RN assessment for the resident’s hospice admission, which included the resident’s weight loss, was completed on 10/17/25, 16 days following the identification of the resident’s weight loss.
On 11/04/25 at 1:38 pm, Witness 1 (RN Consultant) reported her system for monitoring weight changes included reviewing the electronic 72-hour log weekly and the 24-hour report weekly. Witness 1 acknowledged she was not aware of the severe weight loss until she completed the resident’s significant change of condition assessment related to his/her hospice admission.
The need for significant changes of condition to be assessed timely by an RN was discussed with Staff 1 (ED), Staff 2, Staff 3 (RCC), Staff 5 (LPN), and Witness 1 on 11/06/25 at 12:36 pm. They acknowledged the findings.
2. Resident 1 moved into the facility in 04/2022 with diagnoses including edema.
The resident’s clinical records, including progress notes, dated 08/01/25 through 11/03/25, weight records, dated 03/02/25 through 11/01/25, and physician’s orders, dated 09/08/25, were reviewed. Observations were made, and staff were interviewed.
Resident 1 had an order to be weighed weekly and was prescribed indapamide (to treat lower leg fluid retention) and spironolactone (to treat edema).
The following weights were recorded by the facility:
* 09/01/25 - 253 pounds;
* 09/08/25 - 253.4 pounds;
* 09/15/25 - no weight documented;
* 09/22/25 - no weight documented; and
* 10/01/25 - 231.8 pounds.
Resident 1 experienced a 21.2 pound weight loss, or 8.37% of his/her total body weight, in one month. This weight loss represented a significant change of condition and required a timely RN assessment.
The next documented weight was on 10/31/25 as 230.3 pounds. The RN assessment for the significant change of condition was dated on 10/31/25.
On 11/04/25 at 2:29 pm, Witness 1 (RN Consultant) verified she reviewed the 24-hour and 72-hour alerts to find out what changes of condition were identified in the electronic system.
The need for significant changes of condition to be assessed timely by an RN was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (RCC), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/06/25 at 11:51 am. They acknowledged the findings.
Plan of Correction:
C280 - Resident Health Services – RN Assessment Requirements OAR 411-054-0045(1)(f)
1. What actions were taken to correct the violation for each example/resident?
• Resident #3: An RN assessment was immediately completed to address the documented weight loss, review nutritional status, evaluate contributing factors, and determine interventions. The service plan was updated accordingly.
• Resident #1: A timely RN assessment was completed to evaluate the resident’s weight loss and overall clinical status, ensure appropriate interventions, and update the resident’s service plan as needed.
• RN reviewed all residents who had experienced weight changes within the past 90 days to ensure no other significant changes had gone unassessed.
• All nurses were re-educated on OAR 411-054-0045, emphasizing that an RN assessment must occur with every significant change of condition, including notable weight fluctuations.
2. How will the system be corrected so this violation will not happen again?
• A Significant Change Notification Process was implemented, requiring caregivers and medication staff to immediately notify the RN and RCC when a resident shows weight loss, weight gain, decline in function, new symptoms, falls, or other notable clinical changes.
• The facility adopted a Weight Monitoring Protocol, requiring the nurse to review all monthly weights and identify any resident meeting significant change criteria (e.g., =5% in 30 days, =10% in 180 days).
• A Clinical Change Tracking Log was created; the RN now audits this log weekly to confirm assessments are completed timely.
• RN will complete assessments within 24–48 hours of notification of a significant change.
• Service plans will not be marked “complete” until RN review and documentation of assessment are completed.
• RN responsibilities were clarified in writing and added to the nursing policy manual, consistent with OAR 411-054-0045 expectations.
3. How often will the area needing correction be evaluated?
• Weekly audits for 60 days to ensure all significant changes have corresponding RN assessments.
• Monthly QA reviews thereafter to confirm assessments continue to be completed timely.
• Monthly RN review of weights to identify potential ongoing risk and intervene early.
4. Who will be responsible to see that corrections are completed/monitored?
• Registered Nurse (RN) — completion of all significant change assessments and documentation.
• Resident Care Coordinator (RCC) — ensuring timely communication of changes and confirming assessments are entered and linked to service plan updates.
• Executive Director (ED) — oversight of compliance with nursing assessment requirements and ensuring system-wide adherence.
• Quality Assurance Committee — monthly monitoring of clinical audit outcomes.
Citation #5: C0295 - Infection Prevention & Control
Visit History:
t Visit: 11/6/2025 | Not Corrected
Regulation:
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
Inspection Findings:
Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 2 of 6 sampled residents (#s 3 and 5) whose ADL care was observed, and for multiple residents who relied on caregivers to remove incontinence trash. Findings include, but are not limited to:
1. Resident 3 moved into the facility in 01/2021 with diagnoses including asthenia (abnormal physical weakness). The resident was dependent on staff for incontinence care.
At 10:02 am on 11/04/25, Staff 15 (CG) and Staff 20 (CG) were observed providing incontinence care for Resident 3 in his/her bed. Staff 15 and Staff 20 were observed donning gloves and then assisting the resident in rolling to his/her left side. Staff 20 removed a soiled brief and incontinence pad, provided perineal care, placed a fresh incontinence pad, administered barrier cream, and placed a fresh brief without completing hand hygiene between dirty and clean tasks. Resident 3 was then rolled to his/her right where the incontinence pad and brief were adjusted by Staff 15. Staff 15 reached over the bed while holding the soiled incontinence products. Staff 15 then released the soiled products which landed on the carpeted floor. Staff 15 adjusted the resident’s bed, moved his/her bedside table, and touched her walkie talkie. No hand hygiene had been completed between dirty and clean tasks. The surveyor requested hand hygiene be completed at that time.
The need to maintain effective infection prevention and control protocols was reviewed with Staff 1 (ED), Staff 2, Staff 3 (RCC), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/06/25 at 12:36 pm. They acknowledged the findings.
2. On 11/03/25 at 1:05 pm, Resident 5 gave the surveyor permission to observe staff assisting him/her with ostomy care.
Staff 3 (RCC) was training Staff 10 (MT/CG) to perform ostomy care in the resident’s apartment. Staff 3 took disposable gloves out of her pocket and donned the gloves before entering the resident's room. Staff 3 went back and forth from the main room to the bathroom gathering the ostomy supplies. Staff 3 removed the wafer and ostomy bag containing feces and placed it in a small trash bag. Staff 3 tied the trash bag and set it down on the resident's wheelchair seat. Without doffing the potentially contaminated gloves, performing hand hygiene, and donning clean gloves Staff 3 took out two wipes and cleaned the skin around the stoma. The wipes were thrown away in the resident's personal trash can next to his/her bed. Staff 3 picked up barrier prep and stoma powder that was then applied directly to the skin around the stoma. Staff 3 dusted off the excess stoma powder with her soiled gloved index finger and proceeded to place the new wafer and ostomy bag around the stoma.
The findings were shared with Staff 1 (ED), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/05/25 at 12:57 pm. They acknowledged the findings.
3. During the tour of the facility on 11/03/25, from 11:15 am through 12:20 pm, a trash bag was observed under the exercise balls in the exercise room. Upon inspection, the trash bag appeared to contain used incontinence products wrapped in dirty gloves, with three such items found in the bag. There was also a disposable incontinence pad in the bag. The survey team directed facility staff to remove the trash bag from the exercise room. During a recheck of the area, the bag had been removed.
The findings were shared with Staff 1 (ED) and Staff 6 (Plant Operations Tech) on 11/05/25 at 9:10 am. They acknowledged the findings.
Plan of Correction:
C0500 - Infection Prevention & Control
OAR 411-054-0050(1)
1. What actions were taken to correct the violation for each resident/example?
• For Residents #3 and #5, immediately upon survey findings, staff were retrained on proper ADL techniques, including glove use, hand hygiene, and correct handling/disposal of incontinence materials.
• Incontinence trash receptacles were replaced or repositioned to prevent overflow.
• All caregivers involved in the documented observations were counseled and re-instructed on infection-control procedures, including safe removal of soiled items, transport of waste, and maintaining sanitary resident environments.
• Resident rooms with identified issues were cleaned and disinfected immediately.
2. How will the system be corrected so this violation will not happen again?
• The facility implemented a standardized Infection-Control Protocol for ADLs, transfers, toileting, catheter care, and incontinence management—with step-by-step expectations accessible to staff.
• A new Infection Control Checklist was added to daily quality rounds to ensure trash removal, PPE compliance, supply availability, and cleanliness of care areas.
• A designated Infection Control Lead (RN or LPN) now conducts weekly audits of ADL care practices using direct observation.
• All caregivers completed (or will complete) Oregon Care Partners: “About Infection Control and Prevention”, per the imposed license condition requirements. Certificates will be maintained in personnel files.
• PPE stations (gloves, sanitizer, bags, wipes) were replenished and reorganized to ensure immediate access during ADLs.
• A new policy requires double-bagging and prompt removal of incontinence trash during each shift, and replacing receptacle liners after each use when contaminated.
3. How often will the area needing correction be evaluated?
• Daily checks of incontinence trash handling and ADL sanitation for 30 days.
• Weekly infection-control audits by the nurse or Infection Control Lead for 90 days.
• Monthly Quality Assurance meetings will include audit results and any needed corrective actions.
• Ongoing quarterly review after the correction period.
4. Who will be responsible to ensure corrections are implemented and monitored?
• Infection Control Lead (RN or LPN) — responsible for weekly audits and staff coaching.
• Resident Care Coordinator (RCC) — ensures ADL care practices follow written infection-control standards.
• Executive Director (ED) — oversight of compliance, training completion, and enforcement of policy adherence.
• All Care Staff — responsible for following infection-control procedures during resident care.
Citation #6: C0303 - Systems: Treatment Orders
Visit History:
t Visit: 11/6/2025 | Not Corrected
Regulation:
OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders
(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.
Inspection Findings:
Based on observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer for 3 of 6 sampled residents (#s 1, 2, and 4) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 1 moved into the facility in 04/2022 with diagnoses including edema.
The resident’s physician’s orders, dated 09/08/25, MARs, dated 10/01/25 through 11/03/25, and weight records, dated 03/02/25 through 11/01/25, were reviewed, and the following was identified:
a. The physician's orders directed staff to obtain Resident 1's weight "every Friday." There was no documented evidence the facility obtained the resident's weight on six occasions between 04/25/25 and 10/31/25.
b. There was no documented evidence of signed physician or other legally recognized practitioner orders in the resident’s facility record for the following medications that were transcribed on Resident 1's MARs:
* Naloxone (for suspected opioid overdose); and
* Scheduled oxycodone (for pain).
The need to ensure medication and treatment orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (RCC), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/06/25 at 11:51 am. They acknowledged the findings.
2. Resident 2 moved into the facility in 10/2025 with diagnoses including type 2 diabetes and high blood pressure.
The resident’s physician’s orders, dated 10/03/25, and MARs, dated 10/03/25 through 11/03/25, were reviewed and the following was identified:
a. Resident 2 was prescribed metoprolol (to lower blood pressure), 100 mgs, twice daily. On the signed orders, the doctor's parameters directed staff to "hold for [systolic blood pressure] less than 110 or [heart rate] less than 50." The facility administered the medication outside of the physician ordered parameters 13 out of 32 times over a span of 16 days. In addition, there was no documented evidence staff obtained the resident's blood pressure prior to administering the medication from 10/11/25 through 10/21/25.
b. There was no documented evidence of signed physician or other legally recognized practitioner orders in the resident’s facility record for the following medications that were transcribed on Resident 2's MARs:
* Tylenol, both scheduled and PRN (for pain);
* Alvesco inhaler (to improve breathing);
* Miralax (for bowel care);
* Jardiance (for diabetic management);
* Milk of Magnesia (for bowel care); and
* Vitamin D (for supplement).
The need to ensure medication and treatment orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (RCC), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/06/25 at 11:51 am. No additional information was received.
3. Resident 4 moved into the facility in 10/2017 with diagnoses including pressure ulcer and paraplegia (paralysis of the lower body). The resident was identified as incontinent, had a recent history of diarrhea, and had a chronic buttock wound that would heal and re-open.
Resident 4’s current physician's orders, the 08/01/25 through 10/31/25 MARs, and 08/01/25 through 11/03/25 progress notes were reviewed.
The resident had a signed prescriber order to apply a 50:50 mixture of antifungal powder and TRIAD cream to his/her bottom after every incontinent stool as needed for skin breakdown. This treatment was initiated on 08/19/25.
There was no documentation of the administration of this treatment in the resident’s MAR.
On 11/06/25 at 9:55 am, Resident 4’s wound supplies were observed, and an interview was completed. The resident reported the staff were not using the antifungal powder very often, only as a preventative and cure for yeast.
The need to ensure all treatments were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (RCC), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/06/25 at 12:59 pm. They acknowledged the findings.
Plan of Correction:
C0555 - Systems: Treatment Orders
OAR 411-054-0055(1)(a) & (f)
1. What actions were taken to correct the violation for each example/resident?
• For Residents #1, #2, and #4, all medication and treatment orders were immediately reviewed, clarified with the prescribing provider as needed, and updated in the resident record.
• Missing or unsigned orders were obtained from the practitioner and placed in the chart.
• All active orders were compared to the MAR and treatment sheets to ensure accuracy and consistency.
• Caregivers and medication staff involved were counseled on the importance of following written orders exactly as prescribed.
• Any missed treatments or deviations identified during the review were corrected immediately, and the RN assessed residents to ensure no adverse effects.
2. How will the system be corrected so this violation will not happen again?
• A Medication & Treatment Order Verification Process has been established, requiring that all new orders:
o be signed by a legally recognized prescriber,
o be entered into the resident’s record the same day received, and
o be reconciled against the MAR within 24 hours by licensed nursing staff.
• The facility implemented a 48-hour RN review requirement for all new orders, changes, and discontinuations.
• A Monthly Medication & Treatment Order Audit tool has been added to QA to ensure all orders are current, signed, and implemented correctly.
• Pharmacy will now send monthly cycle review reports, which the RN will compare to the MAR and to written orders.
• Staff retraining occurred on:
o reading and following written orders,
o documenting treatments accurately,
o ensuring no medication or treatment is administered without a valid written order.
• Policies were updated to state that verbal orders must be signed by the provider within 48 hours and no undocumented treatments may be performed.
3. How often will the area needing correction be evaluated?
• Weekly audits for 60 days of all active orders, MARs, and treatment sheets.
• Monthly QA audits thereafter, permanently.
• Daily med-pass oversight by the RN or RCC for 14 days to ensure treatments and medications match the written orders.
• Quarterly pharmacy review will also be used to confirm ongoing compliance.
4. Who will be responsible to ensure corrections are completed and monitored?
• Registered Nurse (RN) — responsible for verifying orders, conducting audits, and ensuring clinical accuracy.
• Resident Care Coordinator (RCC) — oversight of caregiver implementation of treatments and ensuring orders are followed as written.
• Executive Director (ED) — ensures system changes remain in place and policies are followed.
• Medication/Pharmacy Consultant — supports reconciliation of orders and medication system accuracy.
• QA Committee — reviews audits and oversees long-term compliance.
Citation #7: C0310 - Systems: Medication Administration
Visit History:
t Visit: 11/6/2025 | Not Corrected
Regulation:
OAR 411-054-0055 (2) Systems: Medication Administration
(2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications, including OTC medications that were ordered by a legally recognized prescriber and administered by the facility, for 3 of 6 Residents (#s 2, 4, and 5) whose orders and MARs were reviewed. Findings include, but are not limited to:
1. Resident 5 moved into the ALF in 01/2020 with diagnoses including essential hypertension, heart failure, and essential tremor.
Observations and interview with Resident 5 and multiple care staff identified the resident was being administered oxygen at four liters per minute, MTs were using MicroGuard (stoma powder) and the resident’s wounds were healed at the time of the survey, which indicted s/he was administered the wound care treatments.
MARs dated 10/01/25 through 11/03/25 and current physician orders were reviewed and identified the following treatments were not transcribed onto the MAR:
* Oxygen, four liters per minute;
* MicroGuard;
* Left gluteal wound care instructions; and
* Silver sulfide (for wound care).
During an interview on 11/04/25 at 2:10 pm, Staff 2 (RCC) confirmed the facility used a MAR for all medications and treatments, and there was not a TAR to review.
The need to ensure MARs were kept accurate was discussed with Staff 1 (ED), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/05/25 at 12:57 pm. They acknowledged the findings.
2. Resident 2 moved into the facility in 10/2025 with diagnoses including type 2 diabetes and diabetic neuropathy.
The resident’s 10/03/25 physician’s orders and MARs, dated 10/03/25 through 11/03/25, were reviewed, and the following was identified:
a. Resident 2 had a physician's order for scheduled insulin, 80 units daily at 6:00 pm. The parameters directed staff to check the resident's blood sugar once daily and to hold the insulin for capillary blood glucose (CBG) readings less than 100 and to contact his/her physician for CBGs less than 100. This was not transcribed onto Resident 2's MAR.
b. The physician wrote an order that directed staff to "apply new Libre [a system to monitor the resident's CBGs] to patient's arm once every 15 days." This was not transcribed to the MAR.
c. Resident 2 had a physician's order for naloxone nasal spray (to treat suspected opioid overdose) which directed unlicensed staff to spray the contents in one nostril as needed. If the resident was not breathing or responding, staff were to "use a new nasal spray in [two to three] minutes in the other nostril." Two to three minutes is not a clear parameter for unlicensed staff.
The need to ensure MARs were kept accurate was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (RCC), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/06/25 at 11:51 am. They acknowledged the findings.
3. Resident 4 moved into the facility in 10/2017 with diagnoses including pressure ulcer and paraplegia (paralysis of the lower body) and had a recent history of diarrhea.
The resident’s 09/16/25 physician orders, 08/2025 through 10/2025 MARs, and 07/30/25 through 10/30/25 “Home Health and Hospice Visit Forms” were reviewed. The following was revealed:
The resident was receiving HH RN services for the management of a chronic buttock wound. The provider wrote the following treatment orders/recommendations:
* 07/30/25: apply zinc BID to coccyx and foam to the left ischium (pelvis) PRN;
* 08/13/25: When [loose] stool stops apply thin layer of antifungal ointment, Sure Prep, and cover with sacral foam dressing;
* 08/27/25: Dry foam PRN when soiled or dislodged; and
* 09/17/25: Change left buttocks foam dressing PRN with disruption or if it gets wet/soiled.
The facility used only the MAR to document medication and treatment administrations. The resident’s treatment orders, including which bandage should be administered and when, were not included in the resident’s MAR. Therefore, the facility failed to keep an accurate MAR.
On 11/05/25 at 2:00 pm, Witness 1 (RN Consultant) and the surveyor reviewed the resident’s MAR and confirmed the zinc treatment was never transcribed.
On 11/06/25 at 9:55 am, observations were made of the resident’s room. S/he had different bandages stored in the room. At this time, Resident 4 stated staff had recently used two different bandages at the same time, and s/he didn’t realize that until the bandages were removed.
On 11/06/25 at 10:08 am, Staff 2 (RCC) and the surveyor reviewed the resident’s MAR and confirmed there was no documentation to staff regarding which bandages to administer.
As of 10/21/25, the resident’s buttock wound was documented as healed by the HH RN.
The need to ensure MARs were kept accurate was discussed with Staff 1 (ED), Staff 2, Staff 3 (RCC), Staff 5 (LPN), and Witness 1 (RN Consultant) on 11/06/25 at 12:59 pm. They acknowledged the findings.
Plan of Correction:
C0557 - Systems: Medication Administration – Accurate MAR
OAR 411-054-0055(2)
1. What actions were taken to correct the violation for each example/resident?
• For Residents #2, #4, and #5, the MAR was immediately updated to include all prescribed OTC medications and to reconcile discrepancies between written orders, pharmacy records, and the MAR.
• Medication orders were reviewed for completeness, including dose, route, frequency, and indication.
• The RN verified that each resident’s full medication list matched provider orders and pharmacy dispensing records.
• Medication staff involved were re-educated on MAR accuracy requirements and the need to enter all prescriber-ordered OTC medications.
• RN completed a resident status check to ensure no adverse outcomes occurred from missing MAR documentation.
2. How will the system be corrected so this violation will not happen again?
• The facility implemented a Medication Reconciliation Protocol requiring:
o RN review of all new orders within 24–48 hours,
o Verification that all OTC medications ordered by a prescriber are added to the MAR,
o Confirmation that pharmacy labels, written orders, and MAR entries match.
• A new MAR Accuracy Checklist must now be completed weekly by the RN or RCC to capture missing medications, duplicate entries, or outdated orders.
• Quarterly pharmacy consultant reviews will be used to cross-check MAR accuracy.
• The ED and RN revised the Medication Administration Policy to explicitly state that all medications ordered by a prescriber—including OTC items—must be included on the MAR before administration.
• Training was provided to all medication staff on:
o accurately transcribing orders,
o verifying OTC orders are included,
o preventing omissions during MAR setup or monthly roll-over.
3. How often will the area needing correction be evaluated?
• Daily med-pass reviews for 14 days to ensure MAR accuracy and correct transcription.
• Weekly audits for 60 days using the MAR Accuracy Checklist.
• Monthly ongoing pharmacy audit and RN MAR review as part of standard QA.
4. Who will be responsible to ensure corrections are completed and monitored?
• Registered Nurse (RN) — responsible for order verification, MAR accuracy, and audit oversight.
• Resident Care Coordinator (RCC) — supports daily med-pass monitoring and ensures staff follow updated procedures.
• Executive Director (ED) — ensures system changes remain in effect and compliance is sustained.
• Pharmacy Consultant — provides monthly review and assists with identifying discrepancies.
• QA Committee — monitors audit results and ensures long-term compliance.
Citation #8: C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan
Visit History:
t Visit: 11/6/2025 | Not Corrected
Regulation:
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.
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure multiple unsampled residents and 1 of 1 sampled resident (#2) had an Acuity-Based Staffing Tool (ABST) evaluation completed prior to admission, failed to update the ABST when residents had a significant change in condition for 3 of 3 sampled residents (#s 1, 3, and 6), and failed to complete quarterly updates as required for 5 of 5 sampled residents (#s 1, 3, 4, 5, and 6) whose ABSTs were reviewed. Findings include, but are not limited to:
1. The facility’s ABST data was compared with the current resident roster during the survey, and one sampled resident (#2) and five unsampled residents were not entered into the ABST system prior to move-in at the time of the survey on 11/03/25.
2. The facility’s ABST data and residents’ evaluations and service plans were reviewed, and it was noted that 3 of 3 sampled residents (#s 1, 3, and 6) experienced significant changes in condition. However, their ABSTs were not updated following the change in condition, as required.
3. The facility’s ABST data and residents’ evaluations and service plans were reviewed during the survey and revealed 5 of 5 sampled residents (#s 1, 3, 4, 5, and 6) had ABST evaluations that were not updated quarterly, as required.
The need to ensure residents’ ABST evaluations were completed prior to move-in, updated following a significant change of condition, and updated at least quarterly was discussed with Staff 1 (ED) and Staff 2 (RCC) on 11/05/25 at 2:15 pm. They acknowledged the findings.
Plan of Correction:
C0037 - Acuity-Based Staffing Tool – Updates & Staffing Plan
OAR 411-054-0037(4)
1. What actions were taken to correct the violation for each example/resident?
• Resident #2: ABST was completed immediately, as it had not been done prior to admission.
• Residents #1, #3, and #6: ABSTs were updated to reflect significant changes in condition, including mobility status, weight changes, ADL support needs, and clinical complexity.
• Residents #1, #3, #4, #5, and #6: Quarterly ABST updates were completed and signed.
• A full-house audit was conducted; any missing, outdated, or inaccurate ABSTs were corrected to ensure all residents’ needs were fully represented.
• Staffing levels for current shifts were adjusted immediately to ensure required staff were present based on the ABST acuity totals.
2. How will the system be corrected so this violation will not happen again?
• A pre-admission ABST requirement was implemented: no resident will be accepted unless an ABST has been completed, reviewed by the RCC, and approved by the ED.
• A Quarterly ABST Tracking System (calendar + electronic reminders) was implemented, alerting RCC and ED when quarterly updates are due.
• A Significant Change ABST Protocol now requires an updated ABST to be completed within 24–48 hours of:
o falls,
o weight loss or gain beyond threshold,
o new ADL needs,
o new diagnoses,
o hospital return,
o functional decline.
• The ED and RCC now hold a weekly staffing review meeting to ensure staffing numbers match the acuity totals indicated in the ABST.
• The staffing schedule template was updated to include required staffing minimums based on ABST calculations, ensuring the facility is always staffed according to OAR requirements.
• The RN reviews ABST changes for clinical accuracy and ensures ADL/care tasks listed in the tool align with the resident’s service plan.
3. How often will the area needing correction be evaluated?
• Weekly audits for 60 days of ABST accuracy, completion dates, and staffing alignment.
• Monthly QA audits thereafter to ensure compliance long-term.
• Quarterly full-house ABST review as required by rule.
• Daily shift review of staffing to ensure staff present match ABST requirements.
4. Who will be responsible to ensure corrections are completed and monitored?
• Resident Care Coordinator (RCC) — responsible for ABST completion, updates, and accuracy.
• Executive Director (ED) — responsible for ensuring staffing patterns meet ABST requirements and rule compliance.
• Registered Nurse (RN) — reviews ABST clinical content and ensures resident conditions are accurately reflected.
• QA Committee — responsible for ongoing monitoring and reviewing audit trends.
Citation #9: C0420 - Fire and Life Safety: Safety
Visit History:
t Visit: 11/6/2025 | Not Corrected
Regulation:
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.
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure written fire drill records included all required elements. Findings include, but are not limited to:
Six months of facility fire drill and fire and life safety records, from 05/2025 to 10/2025, were reviewed on 11/04/2025 and 11/05/25, and the following was revealed:
* All the fire drills reviewed lacked documented evidence of the location of the simulated fire origin;
* The 05/2025 and 07/2025 fire drills lacked clearly documented evidence of the number of occupants evacuated; and
* There was no documented evidence the facility made immediate changes to ensure the evacuation standards were being met when residents resisted or failed to participate in the fire drills.
The need to ensure staff included all required elements on written fire drill records was reviewed with Staff 6 (Plant Operations Tech) on 11/05/25 at 12:15 pm and Staff 1 (ED) on 11/05/25 at 2:15 pm. They acknowledged the findings.
Plan of Correction:
C0090
Fire & Life Safety – Fire Drill Requirements
OAR 411-054-0090(1)
1. What actions were taken to correct the violation for each example/resident?
• All existing fire drill logs were reviewed, and missing required elements (date, time, shift, scenario, evacuation time, staff present, resident participation, any issues encountered, corrective measures) were added when available.
• Staff responsible for conducting fire drills were re-educated immediately on correct documentation practices and OAR requirements.
• A fire drill was performed and documented correctly to ensure immediate compliance while survey was ongoing.
• The ED verified the facility’s fire alarm and response procedures with the contracted fire safety provider to ensure protocols were current and functioning.
2. How will the system be corrected so this violation will not happen again?
• A Revised Fire Drill Documentation Form was implemented that includes every required OAR element:
o date
o time
o shift
o scenario used
o evacuation route
o residents who participated
o staff who participated and roles
o total evacuation time
o issues encountered and required corrective action
• Fire drills will now be scheduled monthly on rotating shifts to ensure all staff receive drill participation.
• A Fire Drill Procedure Binder was created and placed in the staff office with:
o step-by-step instructions for conducting drills
o documentation expectations
o immediate corrective action requirements
• The ED or designee will provide quarterly in-services on fire safety and drill expectations.
• The facility’s Fire & Emergency Policy was updated to clarify:
o frequency of drills
o documentation requirements
o staff responsibilities during drills
3. How often will the area needing correction be evaluated?
• Monthly review of fire drill logs for accuracy and completeness.
• Quarterly audits by the ED to ensure drills occur on each shift as required.
• Annual review of fire safety policies during mandatory staff training.
4. Who will be responsible to ensure corrections are completed and monitored?
• Executive Director (ED) — oversight of fire drill scheduling, documentation, and compliance.
• Resident Care Coordinator (RCC) — ensures caregivers participate and understand emergency procedures.
• Maintenance Director — ensures alarm systems function properly and supports drill execution.
• QA Committee — reviews monthly logs and ensures sustained compliance.
Citation #10: C0613 - General Building: Doors-Walls, Cleanable
Visit History:
t Visit: 11/6/2025 | Not Corrected
Regulation:
OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable
(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.
Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure interior surfaces were clean and in good repair. Findings include, but are not limited to:
The facility was toured with Staff 1 (ED) and Staff 6 (Plant Operations Tech) on 11/05/2025 at 9:15 am. The following was noted:
First Floor:
* Scuffs, chipped paint, gouges in the wood, and drips on the paint were noted on walls, doors, handrails, and pillars throughout the facility, making some surfaces uncleanable.
* Splintered wood was noted on the handrail near rooms 125-126, making the surface uncleanable.
* Baseboards were missing from the hallway near the front desk, making the surfaces uncleanable.
* The following was noted in the activity room: some cupboards had grey/brown debris and/or sticky food residue inside. Inside the refrigerator there were dirt particles, and two hairs were noted in the shelves of the door. There was food splattered on the door, sides, and top of the inside of the microwave. Window tracks had grey/brown debris on their surfaces.
* There was grey/brown debris noted at the base of the pillars in the dining room and on the window blinds in the activity room.
* Visible dust build-up was noted in the following ventilation screens: the wall next to the elevator, the wall near the men’s and women’s restrooms, and the ceiling in the women’s restroom.
* Exterior windows near apartments 135 and 136 had a visible build-up of spider webs.
* Ceiling tiles had either holes, cracks, or the appearance of water damage in the following areas: near apartment 123, near the fire door by the staff laundry room, and by the exit sign near the staff laundry room.
Second Floor:
* Scuffs, chipped paint, gouges in the wood and drips on the paint were noted on walls, doors, and handrails throughout the facility, making some surfaces uncleanable.
* Visible dust build-up and drips were noted on the railings in the following locations: across from the elevator, in the puzzle area, and next to the salon.
* Visible dust build-up was noted in the ventilation screen in the ceiling near apartment 235 and on the window blinds at the end of the hall near apartment 229.
The need to ensure the facility’s interior surfaces were clean and in good repair was reviewed with Staff 1 (ED) on 11/05/25 at 2:15pm. She acknowledged the findings.
Plan of Correction:
C0300
General Building: Doors–Walls, Cleanable Surfaces
OAR 411-054-0300(4)(i)
1. What actions were taken to correct the violation?
• All interior areas identified during the survey as unclean or needing repair were immediately cleaned, sanitized, or repaired.
• Walls, doors, baseboards, and high-touch surfaces showing damage, staining, or deterioration were repainted, patched, or deep cleaned.
• Maintenance completed immediate corrective work orders to address peeling paint, scuff marks, residue buildup, or worn flooring.
• Environmental services and caregiver staff involved were re-instructed on standards for cleanliness and reporting structural or surface concerns promptly.
2. How will the system be corrected so this violation will not happen again?
• A Facility-Wide Environmental Cleaning Checklist has been implemented to ensure all interior surfaces are maintained in good repair and cleaned on a routine schedule.
• The Maintenance Director implemented a Preventive Maintenance Program that includes:
o weekly walkthroughs of all hallways and common areas,
o monthly inspection of all resident rooms,
o quarterly deep-clean and repair cycles.
• A Work Order Request System was updated to ensure staff can easily report damaged surfaces, peeling paint, or cleanliness issues, with required follow-up within 48–72 hours.
• Environmental Services staff received training on:
o cleaning standards for assisted living,
o sanitation practices,
o required frequencies for routine and deep cleaning.
• The ED and Maintenance Director jointly review environmental concerns during daily rounds to ensure compliance with OAR requirements.
3. How often will the area needing correction be evaluated?
• Daily environmental rounds by the ED or designee for 30 days.
• Weekly inspection rounds by the Maintenance Director for 90 days to ensure repairs are completed.
• Monthly QA audits thereafter to ensure long-term compliance.
• Quarterly deep-clean schedule will remain permanent.
4. Who will be responsible to ensure corrections are completed and monitored?
• Maintenance Director — responsible for all repairs, preventive maintenance, and structural upkeep.
• Environmental Services Supervisor — responsible for ensuring cleanable surfaces are maintained per sanitation standards.
• Executive Director (ED) — oversight to ensure building standards meet OAR requirements.
• QA Committee — responsible for monitoring trends and ensuring ongoing compliance.