Brookdale Newberg

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

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 01/06/26 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas: * Vents on the outside of the ice maker – dusty; * Ceiling vents and surrounding area near ice maker and dishwashing area – dusty; * Floor under the dishwasher – significant build up of black matter; * Wall behind cooking equipment – greasy drips/spills; * Shelf below steam table containing various gallon jugs – drips/spills; * Spice shelves in prep area – dusty/food debris; * Wall beneath spice shelves – drips/splatter; * Wall above spice shelf - dusty; * Commercial can opener blade – food debris; * Ceiling light cover in prep area – dusty; * Knife holder – dusty: and * Bulk food bin lids – food debris. Improper food storage of items in the walk in refrigerator and freezer included: * Undated leftovers included slice cucumbers, coleslaw, sliced lunch meat, cranberry sauce; * Leftover items with loose fitting lids included coleslaw, plastic wrap on pan of cooked chicken, open box of sausage links; * Speed rack with uncovered pizza and bread pudding; * Expired food included box of moldy cucumber; * Individual servings of ice cream uncovered in freezer; and *Open bulk food bags in bins - undated. Other areas of concern included: * Colored cutting boards very heavily scored and worn. * White cutting board on service line – stained and heavily scored. The areas of concern were discussed with Staff 1 (Dining Manager) and discussed with Staff 2 (Executive Director) on 01/06/26. The findings were acknowledged by both at 2:00 pm.

1. Vents on the ice maker will be cleaned as well as ceiling vents in the kitchen. Floor under dishwasher will be cleaned, wall behind cooking equipment will be cleaned of grease as well as shelves below steam table. Spice shelves will be cleaned of dust as well as wall above the spice shelves. Commercial can opener will be cleaned of debris, and ceiling light covers will be cleaned as well as knife holder and bulk food bin lids. Food in walk in fridge and freezer will labeled and dated and ensured that they are covered properly. Food expiration dates will be checked and any expired food will be discarded. Bulk food in bins will be dated. Cutting boards with discoloration that are heavily scored will be replaced. 2. Cleaning schedule has been developed with daily, weekly, monthly check offs for accountability. Fridge and Freezer inspections will be done daily after meal service to ensure items are covered and dated. Dry storage room will be checked daily as well to ensure food is covered and labeled. Cutting boards will be ordered. Staff inservice on cleaning protocols and procedures as well as proper food storage and removal of expired foods. 3. Audit of cleaning schedule, fridge, freezer and dry storage area inspections will be reviewed weekly to ensure compliance. 4. Dining service manager and Executive director will be responsible to ensure POC is followed.

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

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

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 01/09/25 at 10:40 am, the facility kitchen was observed to need cleaning in the following areas: * Microwave – interior had food splatters/debris; * Wall behind stove, grill and deep fat fryer – food and grease drips/spills; * Sides of deep fat fryer – food and grease drips/spills; * Hood vents and ceiling within the hood – grease/dust buildup; * Lower shelf below steam table – buildup of drips/spills; * Dishwashing area – top of dishwasher buildup of debris, equipment below dishwasher had buildup of spills/drips/debris, wall behind and below sink and spray hose significant buildup of black matter; * Ceiling, ceiling vent and light cover between prep counters (near walk in refrigeration units) – significant buildup of dust; and * Wall above prep counter across from refrigeration units – buildup of dust. Improper storage: * Speed cart stored in high traffic area near prep counters and walk in refrigerator – contained uncovered pies which had potential for cross contamination. The areas of concern were observed and discussed with Staff 1 (Dining Manager) and discussed with Staff 2 (DDO/Corporate Staff) and Staff 3 (Executive Director from anther facility assisting interim director) on 01/09/25. The findings were acknowledged.

1. Areas in need of cleaning as referenced in the statement of deficiencies have been cleaned. Speed cart cover has been ordered. 2. Education has been provided to dining staff on kitchen cleanliness, cross contamination and kitchen cleaning schedules. 3. Dining Services Manager or designee will monitor cleaning schedules daily for 30 days then twice weekly thereafter. Executive Director will conduct kitchen walk through 3 times a week for the next 60 days to monitor compliance and then weekly thereafter. 4. Executive Director & Dining Service Manager are responsible for this plan of correction.

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

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the re-licensure survey, conducted 01/06/25 through 01/09/25, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations. Refer to deficiencies in the report.

Refer to plans of correction for the following citations: C154, C200, C231, C260, C262, C270, C280, C303, C310, C261, C370, C613, C645

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.

Based on observation, interview and record review, it was determined the facility failed to have effective methods of responding to and resolving resident complaints. Findings include but are not limited to: Observations and individual resident interviews made during the survey, feedback from a 01/07/25 group interview and review of resident council notes dated 10/10/24, 11/14/24 and 12/12/24 noted the following: a. Housekeeping * 10/10/24 and 11/14/24 - Resident council notes related to concerns of resident apartment garbage cans not being emptied daily; * 1/06/25 - Interview with an unsampled resident in which s/he reported concerns related to the garbage cans inside his/her apartment not being emptied for several days in a row, causing an unpleasant odor to be present in his/her apartment; and * 01/07/25 - Group interview, several residents brought concern of staff not emptying garbage cans in resident apartments daily. b. Dining Services * 10/10/24, 11/14/24 and 12/12/24 - Resident council notes related to concerns of diabetic residents who received insulin prior to meal service, not being served their meals timely; and * 01/07/25 - Group interview, several residents voiced concerns of meals being served late. Observations made during the survey found residents who ate meals in the main dining room and who were delivered meals to their apartments, consistently receiving their meals up to an hour outside of the posted meal end times. In an interview with Staff 1 (Administrator) and Staff 2 (District Director of Operations) on 01/08/25 it was reported the facility was unaware of the issues regarding garbage pick-up and ongoing resident concerns in this area. Staff 2 stated she was aware of the resident concerns regarding dining services and spoke to changes in staffing in the dietary department, however she was unable to show the facility had an effective system for resolving resident grievances. On 01/09/25, the need to ensure the facility had an effective method for responding to and resolving resident complaints was discussed with Staff 1 (Administrator) and Staff 2 (District Director of Operations). They acknowledged the findings.

1. Residents received education on reporting grievances at the Town Hall meeting on 1/28/2025. Copies of this procedure are available for residents at the information station. Town Hall meetings are scheduled bi-weekly to continue with adequate follow up and resolution of resident concerns. 2. Resident concerns will be added to the grievance binder and followed up on within 72 hours. These grievances can be raised to any associate who will add to the grievance binder. 3. Resident grievances will be updated and reviewed a minimum of twice weekly and this will continue as part of standard operations. 4. Executive Director is responsible for this plan of correction.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.

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.

Based on observation, interview, and record review, it was determined the facility failed to ensure the residents were treated with dignity and respect in a homelike environment related to meal service for residents who chose to receive meals in their apartments. Findings include, but are not limited to: During meal service observations from 01/06/25 through 01/09/25, meals delivered to resident apartments were served in disposable clamshell to go containers, drinks were served in styrofoam cups, and utensils were plastic. The meals served to residents in the dining room were served on ceramic dishes with stainless steel flatware. On 01/09/25, the need to ensure residents were treated with dignity and respect in a homelike environment related to meal service was discussed with Staff 1 (Administrator), Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations/RN), and (Staff 4 (Area Nurse Manager/RN). They acknowledged the findings.

1. Powered hot cart, plate covers and ceramic plates have been ordered for room tray delivery. 2. Once hot cart arrives, current associates will be provided education on room tray delivery and proper holding temperatures as well as the system for collecting dishware from resident units. 3. Dining Service Manager will provide oversight to room tray delivery system. The Dining Service Manager will verify associates are using non-disposable ware as part of the weekly dining audit. This will continue as part of standard operations. 4. Dining Service Manager and Executive Director are responsible for this plan of correction.

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.

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

Based on interview and record review, it was determined the facility failed to report physical injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injuries were not the result of abuse, and failed to notify the local SPD office immediately of any incident of suspected abuse, for 2 of 2 sampled residents (#s 4 and 6) with injuries of unknown cause or incidents of suspected abuse. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 05/2024 with diagnoses including major depressive disorder, tension-type headache, and combined systolic (congestive) and diastolic (congestive) heart failure. Resident 6 was unavailable for interview due to hospitalization starting on 01/07/25 following two falls sustained on 01/06/25 and 01/07/25. A review of the resident's clinical record between 10/18/24 and 01/06/25 and staff interviews identified the following: * The service plan dated 11/08/24 indicated the resident "states [s/he] does have some forgetfulness at times… does have some confusion at times and lack of concentration since stroke…"; and * A progress note dated 12/07/24 stated: “This morning around [his/her] eye was deep purple.” The incident on 12/07/24 represented an injury of unknown cause. There was no documented evidence the facility immediately investigated the injury to rule out abuse, nor reported it to the local SPD office as suspected abuse. In an interview with Staff 3 (District Director of Clinical Operations) on 01/08/25, she acknowledged the incident of injury of unknown cause was not reported immediately to the local SPD office. On 01/09/25 at 4:16 pm, Staff 1 (Administrator) provided documentation the incident had been reported to the local SPD office during the survey. The need to ensure resident incidents were immediately investigated by the facility to reasonably conclude and document that the physical injury was not the result of abuse, and reported to the local SPD office as needed was discussed with Staff 2 (District Director of Operations), Staff 3, and Staff 4 (Area Nurse Manager/RN) on 01/09/25 at 1:15 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 08/2024 with diagnoses including history of transient ischemic attack (TIA), epilepsy, anxiety disorder, and chronic pain. Resident 4’s record and progress notes dated 10/01/24 through 01/06/25, were reviewed and identified the following: Resident 4 had a physician's order to administer 1 ml morphine sulfate oral solution every six hours for pain. The following medication errors were noted: * A progress note dated 11/02/24 noted, “placing on alert for missed morphine this morning.” “[Resident 4] was in a lot of pain.” “MD, family, and LPN notified.” “Will monitor.” * A progress note dated 11/06/24 noted, “[Resident 4] is on alert for missed 6 pm dose of morphine.” * A progress note dated 12/08/24 noted, “[Resident 4] is on alert for missed morphine.” “Awaiting on med script from [the] doctor.” “Will continue to monitor.” * A progress note dated 12/09/24 noted, “[Resident 4] is on alert for missed morphine [and] it has been 24 hours since [s/he] had [his/her] morphine.” [S/he] is showing signs of adverse reactions to the missed medication.” * A progress note dated 12/09/24 noted, the resident was sent to the emergency department and was admitted to the hospital with ischemic bowels, gastroenteritis, and opiate withdrawal.” “APS notified of opiate withdrawal.” * A progress note dated 12/15/24 noted, “[Resident 4] is on alert for missed morphine.” “[S/he] has been asking for morphine [and] has been in a lot of pain trying to manage with Tylenol and has been really hard to transfer.” The facility had reported the missed pain medication on 12/09/24 to their local SPD office; however, there was no documented evidence the facility reported the missed medication on 11/02/24, 11/06/24, and 12/15/24. During an interview on 01/09/25 at 12:30pm pm, Staff 4 (Area Nurse Manager/RN) confirmed that the missed pain medication on 11/02/24, 11/06/24, and 12/15/24 had not been investigated and had not been reported. The missed pain medication constituted possible neglect with a risk of harm, which needed to be reported to the local SPD office. Survey requested the facility report the incidents, and confirmation was received at 5:18 pm on 01/09/25. On 01/09/25 at 3:24pm, Staff 15 (Resident Care Coordinator) verified the issue with Resident 4’s pain medication had been resolved, and the resident was receiving his/her pain medication as ordered. The need to promptly investigate and report medication errors that could have a negative effect on the resident, was discussed with Staff 1 (Administrator), Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations/RN) and Staff 4 on 01/09/25. They acknowledged the findings.

1. Report to APS for resident #4 and resident #6 was completed during survey as requested. 2. Incidents from the last 30 days have been reviewed to assure incidents were reported as required to Adult Protective Services. Incidents will be reviewed 4-5 days a week during regular scheduled clinical meeting. This review will include ensuring that all incidents have proper investigation and that they are reported to APS as appropriate. 3. Clinical meeting will continue a minimum of 4-5 times each week as part of standard facility operations. 4. Executive Director is responsible for this plan of correction.

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

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

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and were implemented by staff for 4 of 7 sampled residents (#s 2, 4, 6 and 7). Findings include, but are not limited to: 1. Resident 7 moved into the facility in 11/2022 with diagnoses including multiple sclerosis. The resident's 01/02/25 service plan was reviewed, interviews with staff and the resident were conducted, and observations were made. The resident's service plan was not reflective of needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas: *Assistance required with transfers; and *Diet and drink texture. The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was reviewed on 01/09/25 at 9:45 am with Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations/RN) and Staff 4 (Area Nurse Manager/RN). They acknowledged the findings. 2. Resident 2 was admitted to the facility in 09/2018 with diagnoses including anxiety, aphasia, and osteoporosis. Resident 2’s current service plan, dated 12/11/24, was not followed or was not reflective of the resident's care needs in the following areas: a. The service plan documented “2 person: requires a two person assist for transferring during all transfers” and “Resident is a two person assist with transfers and with getting dressed and toileting due to increased pain”. Observations on 01/07/25 showed a caregiver completed Resident 2’s toileting, dressing and transfers alone. In interview, the caregiver stated they always transferred Resident 2 by themself. Observations on 01/08/25 showed a different caregiver transferring Resident 2 and completing dressing and toileting alone with no other staff. On 01/08/25 that caregiver also stated they always completed Resident 2’s ADL care alone. b. Resident 2 had a signed physician order for PRN supplemental oxygen. Resident 2’s service plan did not include any information about how the supplemental oxygen would be delivered if it was needed, or when it would be used. Observations of Resident 2’s room on 01/07/25 and 01/08/25 did not show any evidence of an oxygen tank or concentrator. The need to ensure resident service plans provided instructions for staff, were reflective of care needs, and were followed was discussed with Staff 4 (Area Nurse Manager/ RN), Staff 2 (District Director of Operations), and Staff 3 (District Director of Clinical Operations/RN). They acknowledged the findings. 3. Resident 6 was admitted to the facility in 05/2024 with diagnoses including major depressive disorder, tension-type headache, and combined systolic (congestive) and diastolic (congestive) heart failure. Interviews with facility staff were conducted. Resident 6 was unavailable for interview due to hospitalization starting on 01/07/25 following two falls sustained on 01/06/25 and 01/07/25. The current service plan dated 11/08/24 was reviewed. Resident 6's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions to staff on addressing issues related to resident’s alcohol dependency; * Instructions on what types of skin impairments to report and to whom; * Instructions for signs and symptoms of infection to report while monitoring incision site with staples; * Incorrect reference to resident not having history of dehydration; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Instructions for bleeding precautions and interventions while on anticoagulation therapy; * Instructions on to whom to report weight gain or loss; * Presence of depression, thought disorders, behavioral and mood problems; * How a person expresses pain or discomfort; * How a person expresses anxiety; * Personality, including how the person copes with change or challenging situations; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * How a person expresses memory loss; and * Behavioral problems. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations), and Staff 4 (Area Nurse Manager/RN) on 01/09/25 at 1:15 pm. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 08/2024 with diagnoses including history of transient ischemic attack (TIA), epilepsy, anxiety disorder, and chronic pain. Interviews with the resident and facility staff were conducted. The current service plan dated 11/13/24 was reviewed. Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Instructions on signs and symptoms of seizure activity to report while on anti-seizure therapy; * Instructions on what types of skin impairments to report and to whom; * Personality, including how the person copes with change or challenging situations; * Number of staff needed to assist with activities of daily living; * Number of staff needed to assist with emergency evacuations; * Instructions to staff on providing care to resident with a recent history of stroke; * Instructions to staff on providing care to resident with frequent episodes of urinary tract infection; and * Incorrect reference to resident requiring walker assistance with mobility. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations), and Staff 4 (Area Nurse Manager/RN) on 01/09/25 at 1:15 pm. They acknowledged the findings.

1. Service plans for residents #2, #4, #6, and #7 have been updated 2. Executive Director and licensed nurse will complete review of remaining resident service plans to validate that they are reflective of resident’s needs and provide clear directions to staff. 3. Service plans will be created with input of direct care team members along with other department associates. 4. Executive Director and/or designee are responsible for this plan of correction.

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

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

Based on interview and record review, it was determined the facility failed to ensure resident service plans were developed by a service planning team that consisted of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee, a licensed nurse if the resident shall need or is receiving nursing services or experiences a significant change of condition, and at least one other staff person who is familiar with or who is going to provide services to the resident, for 3 of 6 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 2, 3, and 4's most recent service plans were reviewed during the survey. Each service plan lacked documented evidence it was developed and reviewed by the resident and other required members of his/her Service Planning Team. The need to ensure resident service plans were developed with a Service Planning Team was reviewed with Staff 4 (Area Nurse Manager/ RN), Staff 2 (District Director of Operations), and Staff 3 (District Director of Clinical Operations/RN). They acknowledged the findings.

1. The service plans for residents identified during survey were updated and reviewed with residents and their representatives, if requested. 2. Service plans will be developed with a service planning team which may include Executive Director, dining staff, care staff, other associates of the community, resident and family as applicable. If resident or family declines a care conference they will be provided with a paper copy of their service plan. 3. Executive Director and/or designee will conduct random audits of 4 resident service plans weekly for the next 30 days to confirm the service planning team is meeting regularly. 4. The Executive Director is responsible for this plan of correction.

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated, referred to the RN for an assessment and the service plan updated as needed for 2 of 2 sampled residents (#s 4 and 6), and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 3 of 6 sampled residents (#s 3, 4, and 6) who experienced changes of condition. Resident 4 continued to experience a significant decline in multiple ADLs and increased pain. Resident 6 experienced an overall health decline and multiple falls with injuries and continued to decline in health status with multiple hospitalizations. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 05/2024 with diagnoses including major depressive disorder, tension-type headache, and combined systolic (congestive) and diastolic (congestive) heart failure. Resident 6's progress notes, dated 10/18/24 through 01/06/25, service plan dated 11/08/24, additional temporary care plans, after-visit summaries to emergency department (ED) and physician visits, significant change of condition evaluation dated 11/07/24, nurse change of condition follow-up note dated 12/06/24, and incident reports were reviewed. Between 10/30/24 and 01/02/25, the resident experienced the following: * On 11/06/24 at 8:30 pm, Resident 6 had an unwitnessed fall in his/her room and was sent to the ED for a fractured nose and dizziness. The incident report noted Resident 6 “drink[s] 5-6 shots every night of whiskey”; * On 12/03/24, Resident 6’s metoprolol succinate (to control blood pressure and heart rate) was increased from 25 mg orally daily to 50 mg orally daily; * On 12/05/24 at 5:15 pm, Resident 6 had an unwitnessed fall in his/her room and was sent to the ED for laceration of right eyebrow, requiring sutures, dizziness, atrial fibrillation and chest pain; * On 12/09/24, the resident was sent out for “tightness in chest and back, couldn’t talk, low blood pressure, dizzy, and incontinence”. S/he was admitted to the hospital for “diarrhea and falls at home” from 12/09/24 through 12/13/24. During hospitalization, Resident 6 underwent cardioversion procedure to regulate heart rhythm; * On 12/19/24, the resident was sent out after “PT [Physical Therapist] checked his/her blood pressure and it was 80/40.” Resident 6 was seen in the ED for generalized weakness, mild dehydration and hypotension (low blood pressure); * On 12/20/24, metoprolol succinate was decreased from 50 mg orally daily to 25 mg orally nightly; * On 12/23/24 at 6:45 pm, Resident 6 had an unwitnessed fall in his/her room and was sent to the ED for face laceration requiring staples, fall, and alcohol intoxication with complications; * On 12/23/24, metoprolol succinate was discontinued during the physician’s visit; and * Progress note dated 01/03/25 stated, “Resident was seen at [hospital]… for low bp and possible dehydration. Upon observation at ED, they dx with afib and near syncope.” There was no documented evidence the facility determined what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved for multiple hospitalizations occurring between 11/07/24 through 01/06/25 to minimize further injury falls and hospitalization. During an interview on 01/09/25 with Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations), and Staff 4 (Area Nurse Manager/RN), they acknowledged the pattern of multiple hospitalizations constituted a change in the resident's current status. There was no documented evidence the facility evaluated the multiple hospitalizations in relation to the resident's condition, referred to the RN for assessment and updated the service plan after the significant change of condition. The failure of the facility to evaluate the resident placed the resident at risk for continued decline. The need to ensure the facility had a system in place to evaluate the resident's changes in condition and refer to the RN when appropriate, and determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved was discussed with Staff 2, Staff 3 and Staff 4 on 01/09/25. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 08/2024 with diagnoses including history of transient ischemic attack (TIA), epilepsy, anxiety disorder, and chronic pain. Resident 4's progress notes dated 10/02/24 through 01/06/25, service plan dated 11/13/24, and temporary care plans were reviewed and identified the following changes of condition: * A progress note dated 11/02/24 noted, “Placing on alert for missed morphine this morning.” “[Resident 4] is in a lot of pain.” * A progress note dated 12/09/24 noted, “[Resident 4] is on alert for missed morphine, [and] it has been 24 hours since [s/he] had [his/her] morphine.” [S/he] is showing signs of adverse reactions to the missed medication.” * A progress note dated 12/14/24 noted, “[Resident 4] came back from the hospital.” “[S/he]” is not at baseline, [s/he] has slurred speech and confusion and is not able to bear much weight when transferring.” * A progress note dated 12/15/24 noted, “[Resident 4] is on alert for missed morphine.” “[S/he] has been asking for morphine [and] has been in a lot of pain trying to manage with Tylenol and has been really hard to transfer.” * A progress note dated 12/16/24 noted, the resident was sent to the emergency department due to “blood in [his/her] urine, was weak, clammy and in pain all over.” * A progress note dated 12/19/24 noted, “Resident 4” has increased weakness tonight.” “The resident was unable to hold [their] own weight, so it took two of us to transfer [her/him].” * A progress note dated 12/24/24 noted, “[Resident 4] has been needing more assistance with transfers and showers, caregivers are reporting that the resident is not able to bear [their] own weight, decreased in balance, increased in drowsiness and reports of confusion.” There was no documented evidence the facility determined actions or interventions specific to each change of condition, communicated the determined actions or interventions to staff or monitored and documented on the progress of the condition at least weekly until resolved. In an interview on 01/09/25 at 12:30 pm with Staff 4 (Area Nurse Manager/RN), she acknowledged the resident experienced a significant functional decline. There was no documented evidence the facility consistently evaluated the resident’s condition, referred significant change of condition to the RN, and updated the resident’s service plan as needed. The facility’s failure to evaluate the resident placed the resident at risk for continued decline. The need to ensure changes of condition were identified, reported to the RN if determined to be a significant change of condition, interventions determined, documented, and communicated to staff with monitoring occurring per the resident's evaluated needs was discussed with Staff 1 (Administrator), Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations/RN) and Staff 4 on 01/09/25. They acknowledged the findings. 3. Resident 3 moved into the facility in 09/2022 with diagnoses including chronic obstructive pulmonary disease (COPD) and heart failure. The resident's 10/24/24 service plan and progress notes and temporary service plans dated 10/06/24 to 01/06/25 were reviewed, and interviews with staff were conducted. The following short-term change of condition, documented in the progress notes, lacked actions or interventions communicated to staff on all shifts and/or were not monitored at least weekly to resolution: * 10/06/24 Pain and bruising to right leg following injury outside of the facility; * 10/07/24 New medication (antibiotic); * 10/07/24 New order from hospice, bed pans; * 10/11/24 Right knee wound; * 11/05/24 Redness and bleeding of skin in abdominal region; * 12/08/24 New medication (eye drops); * 12/11/24 Flu and pneumonia vaccine; and *01/03/25 Changes to how resident received medications. The need to ensure the short term changes of condition had actions or interventions determined, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was reviewed on 01/09/25 at 9:45 am with Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (Area Nurse Manager/RN). They acknowledged the findings.

1. Service plans for residents #3, #4, and #6 were updated. 2. Medication Technicians will be re-educated on Alert Charting Guidelines & Temporary Service Plan (TSP) development which includes resident specific detail on the TSP and expectations for documentation in the resident record. Current associates will be educated on recognizing and reporting changes in condition. Area Nurse Manager RN and Clinical Specialist LN have completed Change of Condition training through Oregon Care Partners. 3. Clinical meeting will occur 4-5 times weekly to review residents with changes in condition and to confirm documentation is reflective of monitoring through resolution. 4. Health and Wellness Director, Health and Wellness Coordinator, and/or Executive Director are responsible for this plan of correction.

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

OAR 411-054-0045 (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.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, or updated the service plan for 2 of 4 sampled residents (#s 4 and 6) who experienced a significant change of condition. Residents 4 and 6 were put at risk for serious harm due to the facility's failure to address a decline in health condition or treat ongoing pain. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 05/2024 with diagnoses including major depressive disorder, tension-type headache, and combined systolic (congestive) and diastolic (congestive) heart failure. Resident 6's progress notes, dated 10/18/24 through 01/06/25, service plan dated 11/08/24, additional temporary care plans, after visit summaries to emergency department, significant change of condition evaluation dated 11/07/24, Nurse change of condition follow-up note dated 12/06/24, and incident reports were reviewed. Resident 6's clinical records and interviews with staff indicated the resident had experienced an overall decline in physical status, including onset of chest pain, severe episodes of recurrent major depressive disorder, exacerbation of alcohol dependency, increased dizziness, change in ambulation status, and increase in ADL assistance. Resident 6 had five visits to the emergency department from 12/05/24 to 01/02/25 including two visits related to falls with injuries. Resident 6 was admitted to the hospital on 01/07/25 following a fall sustained on 01/06/25 and a subsequent fall sustained on 01/07/25 and therefore was unavailable for interview. The pattern of falls and a decline in physical condition were a change in the resident's current status and represented a significant change of condition for which an RN assessment was required. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status and interventions made as a result of the assessment. On 01/09/25 at 1:15 pm Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations), and Staff 4 (Area Nurse Manager/RN)) confirmed there had been no change of condition assessment completed for the resident after 11/07/24. The failure to ensure the RN conducted an assessment of the resident's significant change of condition with documented findings, resident status and interventions made as a result of the assessment put the resident at risk for continued injury falls and multiple hospitalizations. The need to ensure the facility RN assessed all significant changes of condition was discussed with Staff 2, Staff 3, and Staff 4 on 01/09/25. They acknowledged the findings. Refer to C 270, Example 1. 2. Resident 4 was admitted to the facility in 08/2024 with diagnoses including history of transient ischemic attack (TIA), epilepsy, anxiety disorder, and chronic pain. A review of Resident 4’s 11/13/24 service plan and progress notes from 10/02/24 through 01/06/25 identified the following: * A progress note, dated 12/14/24, indicated Resident 4 had returned from the hospital and that the resident was not at baseline, s/he had slurred speech, confusion, and was unable to bear much weight when transferring; * A progress note dated 12/15/24 noted the resident was really hard to transfer; * A progress note dated 12/19/24 documented that the resident had increased weakness that evening and was unable to hold their own weight and that it took two staff to transfer; and * A progress note dated 12/24/24 indicated the resident had been needing more assistance with transfers and showers, caregivers reported that the resident was unable to bear their own weight, decreased in balance, increased in drowsiness, and reported of confusion. Resident 4’s physical and cognitive decline constituted a significant change of condition for which an assessment by the facility RN was required. There was no documented evidence the RN had assessed the resident’s status, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition. An interview with Staff 4 (Area Nurse Manager/RN) on 01/09/25 at 12:30 pm confirmed that no RN assessment had been completed. The facility failure to assess the resident's condition and develop interventions as a result of the assessment, put the resident at risk for further functional decline. On 01/09/25, the need to ensure an RN assessment was completed for significant changes of condition that included findings, resident status, and interventions was discussed with Staff 1 (Administrator), Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations/RN), and Staff 4. They acknowledged the findings. Refer to C 270, Example 2.

1. The RN has conducted an assessment of resident #4 and #6 and documentation is present in the resident record. 2. Area Nurse Manager RN and Clinical Specialist LN have completed Change of Condition training through Oregon Care Partners. 3. Clinical meeting will occur 4-5 times weekly to review residents with changes in condition, assure community RN is notified and assure documentation is reflective of monitoring through resolution. 4. Health and Wellness Director and Executive Director are responsible for this plan of correction.

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.

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

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record and all medication and treatment orders were carried out as prescribed for 3 of 8 sampled residents (#s 3, 4, and 7 ) whose medications and treatments were reviewed. Findings, include, but are not limited to: 1. Resident 3 moved into the facility in 09/2022 with diagnoses including chronic obstructive pulmonary disease (COPD) and heart failure. The resident's 10/24/24 service plan, 12/01/24 through 01/06/25 MAR/TAR, current physician’s orders, and progress notes and temporary service plans dated 10/06/24 to 01/06/25 were reviewed, and interviews with staff were conducted. The following was identified: a. The resident had a signed physician’s order which stated “Staff may leave resident scheduled medication to take at [his/her] leisure and then will check to make sure [s/he] has taken all of [his/her] medication in an hour.” The resident’s morning medications were scheduled to be administered at 8:00 am. On three occasions, outside provider notes from hospice documented that the resident had his/her morning medications in his/her room and had not yet taken them: 10/27/24 at 11:00 am, and 11/25/24 and 12/15/24 at 11:30 am. There was no documented evidence that staff had been checking to make sure the resident took his/her medications an hour after leaving the medications in his/her room, as prescribed by the physician. During an interview on 01/09/25, Staff 3 (District Director of Clinical Operations/RN) confirmed there was nowhere on the MAR for staff to document that they had returned to check on the resident to make sure the medications had been taken. b. On 01/08/25 it was observed that the resident had an OTC medication “Better Lungs” and multiple inhalers in his/her room. The resident did not have a signed physician’s order for the OTC medication. The resident did not have a signed physician’s order to keep the inhaler in his/her room. During an interview with Staff 5 (Health and Wellness Director/LPN) on 01/08/25 at 2:08 pm, she stated she spoke with the resident’s hospice team and they confirmed that the resident should not have OTC medications or inhalers in his/her room. c. The resident had a signed physician’s order for Voltaren gel 1% (for pain) to be applied to the resident’s lower back and right knee. Review of the administration notes showed that staff documented applying the gel to the residents right and left knees. There was no documented evidence that staff was applying the gel to the resident’s lower back as ordered. During interviews on 01/07/25 and 01/08/25, staff stated they applied the gel to wherever the resident complained of pain, which was usually his/her knees. The need to ensure written, signed orders were documented in the resident's facility record and medication and treatment orders were carried out as prescribed was reviewed on 01/09/25 at 9:45 am with Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations/RN) and Staff 4 (Area Nurse Manager/RN).They acknowledged the findings. 2. Resident 7 moved into the facility in 11/2022 with diagnoses including multiple sclerosis. The resident's 01/02/25 service plan, 12/01/24 through 01/06/25 MAR/TAR, current physician’s orders, and progress notes and temporary service plans dated 10/06/24 to 01/06/25 were reviewed, and interviews with staff were conducted. The following was identified: a. The resident had a signed physician’s order which instructed staff to take the resident’s weight weekly “to make sure there is no weight loss” and “send weight to PCP monthly”. There was no documented evidence that the resident’s weight records were faxed monthly to the resident’s PCP. On 01/08/25 at 2:08 pm, Staff 5 (Health and Wellness Director/LPN) confirmed that there was no documentation of the order above being followed. The need to ensure written, signed orders were documented in the resident's facility record and medication and treatment orders were carried out as prescribed was reviewed on 01/09/25 at 9:45 am with Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations/RN) and Staff 4 (Area Nurse Manager/RN). They acknowledged the findings. 3. Resident 8 was admitted to the facility in 07/2012 with diagnoses including type 2 diabetes mellitus. Facility staff administered insulin to the resident two times daily. Review of Resident 8's medical record, current physician orders, dated 12/10/24, and MAR from 12/01/24 through 01/09/25 revealed Humulin N suspension 100 unit/ml (to control blood glucose level) was ordered to “…inject 22 units subcutaneously in the morning for diabetes. If resident is not eating breakfast for the day give 12 units of insulin in the morning AND inject 15 units subcutaneously in the evening. If resident is not eating give 7 units of insulin in the evening.” In an interview on 01/09/25 at 9:45 am, the resident stated s/he always ate meals in the room and staff administered insulin injections prior to eating meals. The timing of administration of insulin injections was confirmed by review of the facility medication administration record. The insulin injections were administered prior to meal delivery times as observed by the survey team during the survey visit. During the interview on 01/09/25 at 10:58 am, Staff 14 (MT), Staff 19 (CG), and Staff 20 (MT) stated the facility does not keep track of timing or amount of food intake. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations), and Staff 4 (Area Nurse Manager/RN) on 01/09/25 at 1:15 pm. They acknowledged the findings.

1. Physicians have been contacted for resident #3 and #8 to clarify medication orders. Resident #7 eMAR has been updated to prompt physician notification of weights monthly as ordered by the provider. Medication Technicians were educated on not leaving medications at bedside and observing residents take medication as ordered. 2. Remaining resident orders will be reviewed to identify any that may require further nursing clarification or clarification with the provider for accuracy. . 3. Clinical meeting will occur 4-5 times weekly to validate resident orders and transcription within the eMAR. 4. Health and Wellness Director and Executive Director are responsible for this plan of correction.

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview, and record review, it was determined the facility failed to ensure MARs were accurate, included medication-specific instructions, and had resident-specific parameters and instructions for PRN medications for 2 of 6 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2018 with diagnoses including anxiety, aphasia, and osteoporosis. The resident's 12/11/24 to 01/06/25 MAR and prescriber orders signed 12/12/24 were reviewed and revealed the following: * Resident 2 had a signed prescriber’s order for PRN oxygen “give 2 liters 02 via nasal canula as needed”. The PRN oxygen was not listed on Resident 2’s 01/2025 MAR; * Resident 2 had a prescriber’s order for a scheduled lidocaine 4% patch to be applied one time a day for pain relief. Resident 2’s MAR listed the medication time as 11:00 am with the instruction “ask resident if s/he needs a lidocaine patch” although the patch was not prescribed as a PRN; and * Resident 2 had a prescriber’s order for a PRN lidocaine 4% patch to be applied “for 12 hours then remove at QHS (hour of sleep) for 12 hours”. Resident 2’s MAR listed the medication as “apply to affected area every 12 hours as needed for pain remove after 12 hours” without the instruction to remove at hour of sleep and leave off for 12 hours. The requirement to keep an accurate MAR for all medications prescribed and document resident specific parameters and instructions for PRN medications that include specific instructions was discussed with Staff 4 (Area Nurse Manager/ RN), Staff 2 (District Director of Operations), and Staff 3 (District Director of Clinical Operations/RN). They acknowledged the findings. 2. Resident 3 moved into the facility in 09/2022 with diagnoses including chronic obstructive pulmonary disease (COPD) and heart failure. Review of the resident's 12/01/24 to 01/06/25 MARs and physician orders dated 12/17/24 revealed the following PRN medications lacked resident-specific parameters for administration: a. PRN medications for pain: * Morphine sulfate oral solution 20 mg/5 ml; and * Oxycodone 5 mg. b. PRN medications for shortness of breath: * Morphine sulfate oral solution 20 mg/5 ml; and * Albuterol Sulfate Inhaler. c. PRN medications for nausea: * Haloperidol oral concentrate 2 mg/ml; and * Ondansetron 4 mg. There were no parameters or instructions for staff related to when PRN oxygen via nasal cannula should be administered. The need to ensure the MAR was accurate and PRN medications contained resident-specific parameters and instructions for administration was reviewed on 01/09/25 at 9:45 am with Staff 2 (District Director of Operations), Staff 3 (District Director of Clinical Operations/RN) and Staff 4 (Area Nurse Manager/RN). They acknowledged the findings.

1. The physician orders for resident #2 have been clarified with the provider and orders for resident #3 have nursing clarification present. 2. Remaining resident medication orders will be reviewed for presence of resident-specific parameters for administration to eliminate judgement by the unlicensed medication technician. 3. Clinical meeting will occur 4-5 times weekly to assure resident orders contain resident specific parameters and instruction. A summary of current orders will be sent to the resident’s provider quarterly as part of community operations procedure. 4. Health and Wellness Director and Executive Director are responsible for this plan of correction.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted.

Based on interview and record review, it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) that met the regulation. Findings include, but are not limited to: In an interview on 01/06/25, Staff 2 (District Director of Operations) stated the facility’s ABST (Service Alignment) had been approved by the department; however, would not be fully implemented until 01/31/25. The facility was unable to provide documented evidence that all 22 of the required ADLs were individually addressed for each resident, nor was the amount of staff time needed for each of the 22 ADL elements. On 01/09/25, the need to ensure the facility fully implemented an ABST that met the regulation was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (District Director of Clinical Operations/RN), and Staff 4 (Area Nurse Manager/RN). They acknowledged the findings.

1. An Acuity Based Staffing Tool has been approved by ODHS and finalized by 1/28/2025 2. Executive Director and licensed nurse will be educated on new ABST on or before 2/7/2025 3. This tool will reviewed weekly to verify that posted staffing plan and staff schedule align with staffing patterns indicated by ABST tool and system. 4. The Executive Director is responsible for this plan of correction.

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted.

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

Based on interview and record review, it was determined the facility failed to ensure all staff completed the department approved LGBTQIA2S+ training prior to 12/31/24 for 10 of 10 sampled staff (#s 9, 16, 21, 22, 23, 24, 25, 26, 27 and 28). Findings include, but are not limited to: Staff training records were reviewed on 01/09/24. The following was identified: There was no documented evidence Staff 9 (Med Tech) hired 04/18/18, Staff 16 (Caregiver) hired 08/01/14, Staff 21 (Server), hired 11/14/24, Staff 22 (Caregiver), hired 10/29/24, Staff 23 (Caregiver), hired 10/22/24, Staff 24 (Caregiver), hired 10/08/24, Staff 25 (Caregiver) hired 08/06/19, Staff 26 (Resident Engagement Coordinator), hired 01/07/15, Staff 27 (Housekeeper), hired 11/29/22 and Staff 28 (Dining Room Manager), hired 02/08/16 completed the department approved LGBTQIA2S+ training by 12/31/24. On 01/09/25, the need to ensure all staff completed the department approved LGBTQIA2S+ trainings by 12/31/24 was discussed with Staff 1 (Administrator) and Staff 2 (District Director of Operations). They acknowledged the findings.

1. Staff meetings were held to complete Providing Inclusive Care LGBTQIA2S+ specific training provided by Oregon Care Partners on 1/16/2025 and presented in group format. 2. Associates not present at the live training were provided with a link to the Oregon Care Partner training with a deadline of 2/28/2025 to complete the training. 3. The Providing Inclusive Care training for newly hired associates will be included in the community training checklist for new associates to complete prior to resident contact. The Business Office Manager will review new associate training checklist records for completion of pre-service training prior to being assigned on the job training as part of standard operations. 4. Executive Director and Business Office Manager are responsible for this plan of correction.

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

OAR 411-054-0300 (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.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are nor limited to: Tour of the facility on 01/06/25 found the following in need of cleaning and repair: 1st Floor * Resident room doors and door frames had black scuffs, scrapes, chipped paint and gouges including rooms 109, 110, 113, 117, 129, 132, 136, 139, along with health center door and exit door by north stairwell; * Room 113 had a large hole in the wall above the baseboard, holes and scrapes to closet door, bathroom door, doorframe, bedroom and bathroom walls and baseboards, chipped laminate on bathroom counter, a build-up of brown and grey debris in bathroom ceiling vent, and the refrigerator was dented at its base; * Rooms 121 and 135 bathroom ceiling vents had build-up of brown and grey debris and the bathroom sink in room 135 was slow to drain; * Hallway wall by mechanical room had scrapes and black scuffs; * First floor laundry room had holes in the walls, doors had black scuffs and scrapes, floor had a build-up of brown and grey debris in one corner, broken ceiling tile, cabinet surface had chipped paint and there was a laundry basket on the floor with brown matter on its surface; and * Dining room walls and baseboards had multiple black scuffs, scrapes and chipped paint and there were multiple brown stains on the carpet. 2nd floor * Resident room doors and door frames had black scuffs, scrapes, chipped paint and gouges including rooms 219, 220 and 229; * Hallway ceiling lights had black debris inside their covers; * Hallway windows had cobwebs on their surfaces; * Second floor laundry room door had black scuffs on its base and the door hinge of the handwashing sink lower cabinet was broken; * Room 221 bathroom ceiling vent had a build-up of brown and grey debris and ceiling heat lamp was missing a cover; * Carpets in the hallway near room 223 and room 224 had brown stains; and * Wall near room 230 had black scuffs. During a facility tour on 01/08/25, the areas in need of cleaning and repair were discussed with Staff 1 (Administrator) and Staff 6 (Maintenance). They acknowledged these findings.

1. Repairs began on resident rooms and areas identified during survey following survey exit on 1/6/2025. This included areas of quick repair such as painting. 2. Community walk through was conducted to determine any other common areas or resident apartments in need of cleaning and repair and work orders were created in electronic work order system for tracking. New equipment or flooring was ordered as needed. Residents and associates will be provided with education regarding maintenance order request process by 2/15/2025 3. Maintenance Manager will conduct weekly walkthrough of common areas and a sample of resident apartments to identify areas in need of cleaning or repair. This will continue as part of standard operations. 4. The Executive Director and Maintenance Manager are responsible for this plan of correction.

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.

OAR 411-054-0300 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction. (a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit. (b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules). (c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans.

Based on observation and interview, it was determined the facility failed to maintain hot water temperatures in residents’ units within a range of 110 - 120 degrees Fahrenheit. Findings include, but are not limited to: On 01/06/25, the surveyor measured hot water temperatures in five resident units. Water temperatures ranged between 96.4 - 109 degrees Fahrenheit. The facility failed to maintain hot water temperatures in resident units within a range of 110 - 120 degrees Fahrenheit. On 01/08/25, the need to ensure water temperatures in resident units were maintained within the required range was discussed with Staff 1 (Administrator) and Staff 6 (Maintenance Director). They acknowledged the findings.

1. Water temperatures are taken in a sample of 6 apartments weekly as part of standard operations. A review of temperatures from 60 days prior to survey entrance showed that only 1 of 48 room water temperatures taken were below 110 degrees and this temperature was 109.5 degrees. Survey team was offered to review this documentation. 2. New water thermometer probes were purchased and a mixing valve for the hot water heater was adjusted. 3. Water temperatures in a sample of resident apartments will continue to be monitored weekly as part of standard operations to verify temperatures are consistent with expected ranges. 4. The Executive Director and Maintenance Manager are responsible for this plan of correction.

OAR 411-054-0300 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction. (a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit. (b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules). (c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.  Findings include, but are not limited to: On 11/30/23 at 11:10 am the following were observed: * Boxes were stored on the kitchen floor (paper towels and disposable containers), on the floor of walk in refrigerator (meat and two stacks of liquid eggs) and the floor of walk in freezer (stacks of multiple boxes of food); * The dishwasher temperatures were not meeting minimum required temperature. Three dishwashing cycles were run without appropriate temperatures being reached for wash and rinse.  The facility called for immediate service; and *One staff was not wearing any hair restraint. The findings were discussed with Staff 1 (Kitchen Manager) and Staff 2 (Executive Director) on 11/30/23. The findings were acknowledged.

C-240 Boxes stored on ground.        1-Deliveries are to be dispursed immediately.        2-Needs to be put on cart if not able to.        3- DSM and DM to audit bi weekly to ensure all is being followed        4- Dining Service Manager and Dining Director C-240 Dishwasher Tempature       1-ECO-LAB contacted to ensure temp is accurate- ED has also asked about the Santitiation piece of the machine.        2-Needs to be checked daily        3- DSM and DM to audit bi weekly to ensure all is being followed        4- Dining Service Manager and Dining Director C-240- Hair protection-        1-All staff have been given hair nets or hats to ensure proper coverage        2- checked daily and staff to sign uniform policy        3- DSM and DM to audit bi weekly to ensure all is being followed        4- Dining Service Manager and Dining Director Staff training will be completed and signed by staff 1-20-24 ED and DSD.

The findings of the kitchen inspection, conducted 11/30/23, 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 11/30/23, conducted on 02/08/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was stored in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to: 1. On 10/26/22 at 9:50 am, the kitchen was observed to need cleaning in the following areas: *The shelf below the prep table against the walk ins, had dried on food debris; *The shelf under the mixer had dried food debris; *The oven doors had buildup of food splatters/grease, back of stove had grease buildup, wall behind had drips and splatters of food/grease; *The steamer had splatters/drips on front of door, grease/dust on top; *The shelves below the steam table had drips and dried debris; *The cutting board on steam table had deep cuts and dark matter; *Uncovered disposal containers on low shelf very near floor were exposed to potential contamination, shelf had dried debris; *Floors throughout the kitchen underneath counters and racks had food debris and black matter; *Food splatters inside microwave; *Carts had spills and food debris; and *Two garbage cans were uncovered when not in use. 2. Food was not stored appropriately in the following areas: *The walk-in refrigerator had rack with individual servings of pudding, fruit and plates of cottage cheese and fruit uncovered and undated; *The walk-in freezer had individual servings of ice cream/sherbet not dated, open and undated bag of a breaded product; and *The dry storage had open bags of Panko crumbs, brown sugar, flour and lentils stored in an open bin. The areas above were discussed with Staff 1 (Executive Director) and Staff 2 (Kitchen Manager) on 10/26/22. The findings were acknowledged.

1: All areas in kitchen have been  deep cleaned. -Shelves have been degreased. -Cutting board is being replaced. -Relocated to go containers to include a safe storage free from debri and cleanliness. -Ensuring dry storage is cleaned and organized -Ensuring walk in and freezer cleaned and organized. All food dated. -Hired Summit flooring company to come and steam floors. Will be done prior to POC completion date. - WIll be having an after hours kitchen close cleaning party on the 23rd to ensure we have met all needs.   2.Dining Service Manager will be conducting a walk through monthly to ensure all affected areas are up to par. 3. ED will be conducting a bi-weekly kitchen audit to ensure deficent practice is met. 4. ED and Dining Service Manager will be responsible for ensuring deficant practice is met and continued.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was stored in accordance with the Food Sanitation Rules OAR 333-150-0000. This is a repeat citation. Findings include, but are not limed to: On 01/12/23 at 10:50 am the kitchen was observed to need cleaning in the following areas: * The shelf below the prep table against the walk in wall, had dried debris on the shelf and trays that held bottles and jugs of food items; * The oven doors and back of grill had drips/splatters and grease/food; * Front door and underneath the steamer; * Shelf below steam table had crumbs/debris; * Black cart near steam table had crumbs/debris; and * A standing fan near the microwave and steam table had heavy buildup of dust. The following food items were not stored properly: * In the dry storage area, open bags of rice, granulated sugar and panko crumbs were open to the air and risked being contaminated; and * A rolling cart holding desserts in the area near the walk in freezer were uncovered. The areas above were discussed with Staff 1 (Executive Director) and Staff 2 (Sales Manager) on 01/12/23. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to ensure the kitchen inspection survey plan of correction was implemented and satisfied the Department. Finding include, but are not limited to: Refer to C240.

The findings of the kitchen inspection, conducted 10/26/22, 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 333-150-000.

The findings of the first revisit to the kitchen inspection of 10/26/22, conducted 01/12/23 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 second revisit to the kitchen inspection of 10/26/22, conducted 05/08/23 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 interview and record review, it was determined the facility failed to ensure complete and accurate records were maintained for 3 of 5 sampled residents (#s 2, 5 and 6) whose records were reviewed.  Findings include, but are not limited to: A survey team conducted a re-licensure survey from 8/3/21-8/6/21. During the survey process it was determined the facilities electronic software program, Point Click Care had the capability of allowing the user to choose what date to use when initiating documentation of various required evaluations including, but not limited to: post fall evaluations, self-medication evaluations, changes of condition evaluations, smoking evaluations, new move in evaluations and skin observation forms. Resident 2, 5 and 6's Point Click Care (PCC) electronic clinical records reviewed between 5/11/21- 8/3/21, included a review of progress notes, MAR's, skin observations, new move in evaluations and change of condition evaluations. The following records were determined to have inaccurate records: 1. Resident 2's change of condition evaluation with an effective date of 7/15/21 was signed by Staff 2 (RN) on 8/3/21; and Resident 2's skin observation form and smoking evaluation with an effective date of 7/26/21 was signed by Staff 2 on 8/3/21. 2. Resident 5's reevaluation, smoking evaluation, with an effective date of 5/14/21 was signed on 8/3/21; and Resident 5's self-administration of medications review with an effective date of 5/14/21 was signed on 8/5/21. During an interview on 8/5/21 with Resident 5, it was reported Staff 2 had completed a self-administration medication review with the resident that same day. 3. Resident 6 was reviewed for initial new move- in evaluation. The effective date of the form was 6/4/21 and was signed by Staff 3 (Health and Wellness Director) on 8/3/21. During an interview on 8/5/21 with Staff 8 (Regional Clinical Director) and Staff 9 (Regional Director of Operations), the surveyor and Staff 8 and 9 used PCC's training module to determine the cause of the discrepancies in the effective dates and the signed dates. Staff 8 and 9 acknowledged the need to ensure their staff were trained on the proper use of the PCC system which included saving, signing and locking the documents in a timely manner. The findings were reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Health and Wellness Director), Staff 8 (Regional Clinical Director) and Staff 9 (Regional Director of Operations) on 8/6/21. They acknowledged the findings.

1.  Education has been provided to the clinical team on Point Click Care operations and the need to lock forms once complete which electronically signs and dates the form. 2.  Point Click Care forms in process queue will be reviewed in conjunction with the routine clinical meeting to assure forms are completed and locked timely. 3.  Executive Director and/or designee will randomly audit records weekly for 30 days then monthly thereafter for compliance. 4.  Executive Director is responsible for compliance.

Based on interview and record review, it was determined the facility failed to conduct immediate investigations of injuries of unknown cause to rule-out the possibility of abuse or report the injuries to the local Seniors and People with Disabilities (SPD) office, for 2 of 2 sampled residents (#s 2 and 4) with documented injuries of unknown cause. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 2019 with diagnoses including dementia without behaviors. A home health provider collaboration note dated 6/28/21 documented the discovery of four new bruises on his/her right arm, and that Resident 4 could not explain how the bruises occurred. The discovery of the unexplained bruises constituted an injury of unknown origin. The facility documented the home health note was reviewed on 6/30/21, however, there was no evidence the facility had conducted an immediate investigation to rule out the possibility of abuse or neglect. On 8/5/21, the above incident was reviewed with Staff 2 (RN), no further information was provided. The facility's failure to report incidents of suspected abuse/neglect or injuries of unknown cause, or to conduct an immediate investigation of an injury of unknown cause and document that abuse was ruled out, was reviewed with Staff 1 (Executive Director), and Staff 8 (Regional Clinical Director) on 8/6/21, they acknowledged the findings. 2. Resident 2 was admitted to the facility in 4/2015 with diagnoses including chronic pain syndrome. During the acuity interview on 8/3/21, Resident 2 was identified as having skin issues. Staff 3 (Health and Wellness Director) documented in a progress note dated 6/23/21 "This nurse provided wound care to residents pin point size wound on right posterior elbow". This represented an injury of unknown cause. There was no documented evidence the facility immediately investigated and documented the injury was not the result of abuse. The facility did not report the injury to the local SPD office as suspected abuse. During an interview with Resident 2 and observations of the resident's right elbow on 8/4/21 identified the wound had healed. The need to ensure allegations of abuse and injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1 (Executive Director) on 8/5/21. He acknowledged the finding.

1. Residents in sampling have all incidents reviewed, with abuse ruled out and appropriate follow through. 2. Executive Director will review incident documentation for the past 60 days to assure proper investigation was completed. Any incidents without known cause, or otherwise meet reporting criteria will be reported to APD. All staff will receive training on abuse and neglect by RN Consultant. 3. Review of falls, injury, and other incidents will be reviewed during routine clinical meeting to monitor effective follow up investigation, or APD reporting occurred. Executive Director will review all incident reports to determine effective follow up and to determine whether the incident meets APD reporting criteria. APD reporting will occur within 24 hours as appropriate. 4. The Executive Director is responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure the kitchen followed food handling practices and was clean and in good repair in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 8/3/21 and 8/4/21 identified the following deficiencies: 1. The following areas were in need of cleaning and repair: *Cutting board had gouges and was discolored creating an uncleanable surface; *The oven, stove, and flat top grill had thick buildup of black matter, debris and food matter; *Multiple walls and ceiling tiles had grease splatter and food build up; and *The fryer had multiple food items floating in it and a thick layer of grease build up on the edges. 2. The dry storage area had multiple opened food packages that were not properly sealed and not dated. 3. The walk-in refrigerator had multiple opened foods that were not properly covered and not dated. 4. On 8/3/21, observations revealed the facility had received a food supply shipment which had food boxes placed on the floors of the dry storage, walk in fridge, and walk in freezer. This prevented survey from being able to fully observe these areas. The surveyor informed Staff 1 (Executive Director) the storage areas would be observed on 8/4/21 to allow the facility time to put away the shipment. On 8/4/21 the boxes were still being stored on the floor of the dry storage, walk in fridge and walk in freezer. On 8/4/21, the need to ensure the kitchen followed food handling practices and was clean and in good repair was discussed with Staff 1 (Executive Director) and Staff 5 (Dining Services Manager). They acknowledged the findings.

1. Dry storage all opened and not properly sealed or in containers were thrown out on day of survey. Walk-in refrigerator any opened foods and not dated were destroyed on day of survey.  Food supply from shipments were properly stored on day of survey Cutting board gouges were removed and resurfaced on 8/16/21. The oven, stove and flat top grill were cleaned by outside contractor on 8/17/21-8/18/21. Walls and ceiling tiles professionally cleaned by outside contractor. The fryer was professional cleaned by outside contractor on 8/17/21-8/18/21. 2.  The Dietary Manager will implement daily, weekly, and monthly cleaning assignments.  The Dietary Manager will educate all dining associates on proper food storage and how to complete work orders for items in need of repair. 3.  The Dietary Manager and/or a designee will verify that cleaning schedule is being implemented and completed daily, weekly, and monthly.  The Dietary Manager and/ or designee will verify that food is properly stored through random audits a minimum of 4 times weekly. 4. The Dietary Manager and Executive Director are responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were accurate, reflective of the resident's needs, and were followed, for 3 of 5 sampled residents (#s 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1.  Resident 3 was admitted to the facility in 2015 with diagnoses including Parkinson's Disease and kidney disease. Resident 3's record revealed that between 6/30/21 and 7/7/21, the resident lost seven pounds, a significant weight loss. The service plan created on 7/16/21 did not mention the weight loss or interventions for weight loss. The need to ensure resident service plans were reflective of current care needs  was reviewed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 8 (Regional Clinical Director) on 8/6/21, they acknowledged the findings. 2. During the survey, observations were made of Resident 5 and the resident and caregiving staff were interviewed. Resident 5's service plan dated 5/12/21, was not reflective of the resident's current status in the following areas: * Staff administration of medications; * Resident performed insulin injections; * Resident ate all meals in the room; and * Bathing assistance. 3. During the survey, observations were made of Resident 2 and the resident and caregiving staff were interviewed. Resident 2's service plan dated 6/17/21 , was not updated after a change of condition evaluation on 7/15/21 and was not reflective of the resident's current status in the following areas: * Independent in administering nebulizer; * Needing wound care; and * Needing daily blood pressure, pulse, and weight monitoring. On 8/5/21 the need to ensure the service plans were reflective of resident care needs and updated after changes of condition was discussed with Staff 1 (Executive Director). He acknowledged the findings.

1. The service plan for Resident 3 has been updated to reflect weight loss and hospice involvement.  The service plan for Resident 5 has been updated to reflect administration of medication, meals and bathing assistance.  The service plan for Resident 2 has been updated to reflect nebulizer treatment, wound care, blood pressure/pulse/weight monitoring.   2.  Resident service plans will be reviewed to confirm that each is reflective of current status. Resident changes in condition will be discussed during daily stand up and reviewed by clinical team during clinical meetings to assure interventions are developed if needed.  Appropriate updates will be made to service plans and documentation will be reflected in the resident's record.  Licnesed nurse or designee will conduct a record review and obtain feedback from associates working with the resident as part of the service plan review. 3.  The Executive Director and/or designee will randomly audit resident service plans weekly for 60 days to assure ongoing compliance. 4. The Executive Director will be responsible.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 5 of 5 sampled residents (#s 2, 3, 4, 5 and 6) whose service plans were reviewed.  Findings include, but are not limited to: Resident 2, 3, 4, 5 and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. On 8/6/21, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director). He acknowledged the findings.

1.  The service plans of Resident 2, 3, 4, 5 and 6 will be reviewed and updated to include evidence of those who participated in the development of the service plan. 2.  Executive Director and Health & Wellness Director will review regulation to assure understanding.  Service plans will be developed with input from a team not limited to Executive Director, Nurses, Caregivers/Medication Technicians, Programs/Dining, Resident and additional members of the resident's choosing. Resident's participation if not possible will be documented to reflect the facility's attempts to determine resident's preferences. 3.  Follow Up audit will occur weekly by Executive Director or designee for next 30 days and monthly thereafter. 4. Executive Director will monitor for compliance.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short term changes of condition, including resident-specific instructions communicated to staff on each shift and monitored at least weekly through resolution for 1 of 1 sampled resident (#2) who had changes of condition related to skin issues and medication changes. Findings include, but are not limited to: Resident 2 was admitted to the facility in April 2015. During acuity the Resident was identified as having a history of falls and skin issues. Records dated 5/11/21 through 8/3/21 which included progress notes, service plans, temporary service plans (TSP) and the resident's 7/1/21 through 8/3/21 MARs were reviewed. The resident experienced the following short term changes of condition: * 5/3/21 new medication for Doxycyline (Antibiotic); * 5/20/21 PICC (peripherally inserted central catheter) removed with new dressing on inner right arm; * 6/8/21 skin tear to third right knuckle on left hand; * 6/23/21 skin tear to right posterior elbow; * 7/1/21 new medication Clopidogrel Bisulfate (blood thinner); and * 7/8/21 right leg wound. There was no documented evidence the facility documented what actions or interventions were needed, communicated to staff or monitored at least weekly through resolution for the above short term changes of condition. During an interview with Staff 2 (RN) and Staff 3 (Health and Wellness Director) on 8/5/21, Staff 2 indicated there were no TSP's for the above changes of condition and stated she had no further information to provide. The need to monitor short-term changes of condition at least weekly to resolution with clear direction to staff was discussed with Staff 1 (Executive Director), Staff 2, Staff 3, Staff 8 (Regional Clinical Director) and Staff 9 (Regional Director of Operations) on 8/5/21. They acknowledged the findings.

1. Resident 2's history of falls and skin issues has been reviewed and record updated to include interventions to address fall risk. 2.  Resident records for those with a known pattern of falls and skin issues will be reviewed to assure proper evaluation, preventative measures and documentation included in the resident record. Current staff will be educated to proper reporting for changes in condition and associated documentation. Medication Technicians will be educated on the community alert charting policy and associated documentation.  Resident changes in condition will be discussed during daily staff stand up meetings and reviewed by the clinical team during clinical meetings to assure interventions are developed if needed appropriate updates are made to service plans and documentation reflected in the resident record. 3. The Executive Director and/or Designee will audit resident records weekly for 60 days to assure ongoing compliance. 4. The Executive Director will be responsible to review for ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure the facility RN was notified of a significant change of condition, completed an assessment which included developing interventions based on the condition of the resident, and updated the service plan within 48 hours of a significant change of condition for 1 of 2 sampled residents (#3). Findings include, but are not limited to: Resident 3 was admitted to the facility in 2015 with diagnoses including Parkinson's disease and kidney disease. A review of the resident's clinical records indicated the resident had lost seven pounds between 6/30/21 (125 lbs.) and 7/7/21 (118 lbs.), over 5% of his/her body weight in one week. This represented a significant change of condition. Review of Resident 3's service plan dated 7/16/21 referenced weight fluctuations, but not the recent weight loss and there were no nutritional interventions. In interview on 8/5/21, Staff 2 (RN) stated the weight tracking system had not "flagged" the weight loss and no RN assessment was completed. The need for an RN assessment, including resident status, developing interventions, documenting the findings and updating the service plan was reviewed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 8 (Regional Clinical Director) on 8/6/21, they acknowledged the findings.

1.  The weight record for Resident 3 has been reviewed, RN assessment completed with notation in the record and service plan updated to reflect current needs and interventions. 2.  Remaining resident weight records will be reviewed for weight loss and associated documentation for any significant changes.  Incidents over the last 30 days will be reviewed in order to indentify any resident in need of a change of condition assessment by the RN. All staff will be educated on proper reporting for changes in condition and associated documentation. Resident changes in condition will be discusssed during routine stand up meeting and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed, appropriate updates are made to service plans and documentation of RN assessment is reflected in the resident record. 3.  The Executive Director and/or designee will randomly audit resident records weekly for 60 days to assure compliance. Thereafter random audit to assure compliance. 4.  The Executive Director and Registered Nurse are responsible for monitoring.

2. Resident 4's signed physician orders and 7/1/21 through 8/3/21 MAR were reviewed. The following deficiencies were identified: Resident 4's signed physician order dated 12/11/20 for documented "morphine sulfate solution 20 mg/ml - Prior to giving Morphine, provide soft music, food/drink or 1:1 staff intervention. If not effective within 5 minutes, proceed to give Morphine." The July 2021 MAR did not include the parameter of attempting non-pharmacy interventions from the physician order. The 7/21 MAR documented the morphine was given twice on 7/3/21 without evidence the parameter was followed. On 8/6/21, the need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 8 (Regional Clinical Director) on 8/6/21, they acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 5 sampled residents (#s 4 and 6) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 6's signed physician orders and 7/1/21 through 8/3/21 MAR were reviewed. The following deficiencies were identified: *The resident had a signed physician orders to take 6mg of Warfarin (anticoagulant)  on 7/7/21, and the MAR indicated that 7.5mg was administered; and *The resident had a signed physician order on 7/1/21 to start Vitamin D3 (supplement) and it was not administered until 7/7/21. On 8/6/21, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Executive Director). He acknowledged the findings.

1.  The physician orders and MAR for Residents 4 & 6 have been reconciled to assure accuracy. 2.  An audit will be conducted on remaining resident orders to assure accuracy. Physician orders will be reviewed and sent to resident healthcare provider for review and signature every quarter. Medication Technicians will be inserviced on following physician orders, ancillary order entry, and the transcription process.  Health & Wellness Director, Health & Wellness Coordinator, Resident Care Coordinator or their designee will provide the triple check on new orders as part of the routine clinical meeting to assure accuracy. 3.  Executive Director, Health & Wellness Director  and/or designee will randomly audit orders weekly for 60 days then monthly thereafter for compliance. 4.  Executive Director is responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate for 2 of 5 sampled residents (#s 2 and 6) whose MARs were reviewed. Findings include, but are not limited to: 1.  Review of Resident 6's 7/1/21 through 8/3/21 MAR identified multiple blanks on the MAR for multiple medications. The facility failed to have any documentation if the medications were administered or not. In an interview with Staff 2 (RN) and Staff 3 (Health and Wellness Director) on 8/5/21, they acknowledged the inaccuracy due to the blanks on the MAR. On 8/6/21, the need to ensure residents' MARs were accurate was discussed with Staff 1 (Executive Director). He acknowledged the findings. 2.  Resident 2's MAR's from July 1, 2021 through August 3rd, 2021 were reviewed and identified the following: Ipratroplum-Albuterol Aerosol Solution (for COPD) was not initialed as administered on 7/5/21. The need to ensure MAR's were accurate to include initials for when medications were administered was discussed with Staff 1 (Executive Director) on 8/5/21. He acknowledged the findings.

1. The blanks on the MAR for Residents 2 and 6 were reviewed and investigated. 2.  Remaining resident MARs will be reviewed for accurate documentation.  Additional education was provided for current Medication Technicians on August 19, 2021 regarding the importance of accurate and timely documentation when administering medications.  A MAR audit will be conducted in conjunction with the routine clinical meeting to assure accurate documentation. 3.  Executive Director, Health & Wellness Director and/or designee will randomly Medication Records weekly for 60 days then monthly thereafter for compliance. 4.  Executive Director is responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat resident's behavior had written, resident-specific parameters and non-pharmacological interventions for staff to attempt prior to administering a PRN psychoactive medication for 1 of 1 sampled resident (#4) who was prescribed PRN medications to address behaviors. Findings include, but are not limited to: Resident 4 was admitted to the facility in 2019 with diagnoses including dementia without behaviors. In 2020 Resident 4 was prescribed Lorazepam 0.5 mg every 4 hours "as needed for anxiety, agitation, sob [shortness of breath], increased behaviors, restlessness" and "prior to giving Lorazepam, provide soft music, food/drink or 1:1 staff intervention". The facility MAR did not include resident-specific parameters for staff indicating for what behaviors the medication should be considered for and did not include the non-pharmacological interventions from the physician order for staff to attempt prior to using the medication. In interview on 8/5/21, Staff 15 (MT) confirmed she was not aware of the specific behaviors the PRN was for, or the non-pharmacy interventions to attempt, and confirmed that information was not part of the facility MAR. The need to ensure there were parameters and non-drug interventions to attempt prior to administering a PRN psychoactive medication, and that staff were aware of the non-drug interventions was reviewed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 8 (Regional Clinical Director) on 8/6/21, they acknowledged the findings.

1.  Resident 4 psychotrophic medication was reviewed with Hospice for updates and physician direction and the MAR updated to reflect accurately. 2.  Remaining residents with orders for as needed psychotrophic medication has been completed. Parameters, common side effects and non-pharmacological interventions have been added to the resident's medication record where needed.  Current Medication Technicians have received additional education concerning the use of non-pharmacological interventions and the documentation of these interventions prior to medications use on August 19, 2021.  Psychotropic medication orders and administration will be reviewed during the routine clinical meeting for appropriate documentation. 3.  Executive Director, Health & Wellness Director  and/or designee will randomly audit orders weekly for 60 days then monthly thereafter for compliance. 4.  Executive Director is responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to: On 8/3/21, the facility's fire and life safety records were requested for review, and sampled residents were interviewed about the fire and life safety instruction they had received. An unsampled resident initiated contact with the survey team on 8/5/21 to state they had not received fire safety instruction and were concerned about how they would evacuate from the 2nd floor in case of an emergency. Interviews and record reviews showed no documented evidence of the following general fire and life safety requirements: * Evidence that  each resident was instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; * Evidence alternative exit routes were used during fire drills; * Evidence residents participated in fire drills and training to assess ongoing evacuation capabilities of both residents and staff; and * Documentation of interventions and resolution related to resident evacuation concerns identified during fire drills. The need to ensure all general fire and life safety requirements were implemented and followed was discussed with Staff 1 (Executive Director) and Staff 4 (Maintenance Manager) on 8/6/21.  They acknowledged the findings.

1. All residents were provided with a map detailing out evacuation options. This is placed on the back of their apartment door for easy review. A resident town hall meeting was held on 9/2/21 to instruct all residents on emergency procedures. 2. Residents will be educated in emergency procedures a minimum of annually during a resident council meeting. Attendance will be taken at this meeting. In addition, residents will be instructed on evacuation procedures and asked to sign and date the evacuation map showing their acknowledgement and understanding of this instruciton. 3. Review of maps for resident signature and date as well as resident attendance at resident council will be reviewed a minimum of quarterly to insure all residents receive instruction a minimum of annually. 4. The Maintenance Director and the Executive Director are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: The facility was toured on 8/3/21. The following issues were identified: * Torn and fraying carpet in the hallway in front of room 209; * There were dark spots and stains on the carpet in rooms 107, 111, 113, 119, 120, 127, 133 and 217; * Additionally, room 119 had torn and fraying carpet that exposed the sub floor underneath, multiple gouges and holes in the walls throughout the apartment, toilet seat was broken, gouges and exposed wood around the interior of the entrance door, closet door trim, bathroom door trim, gouges and scrapes on the refrigerator door  and kitchen counter had exposed wood. The areas needing repair were reviewed with Staff 1 (Executive Director) and Staff 4 (Maintenance Director) on 8/3/21 and 8/6/21. They acknowledged the areas needing cleaning and repair.

1. Carpets that had frayed edges were cut and glued so that there were no trip hazards in hallway on 8/6/21.  Stained carpets are being evaluated for removal or deep cleaned options. Some residents given options to move to other rooms so that rooms can be restored. Room 119 declined two other available rooms on 8/25/21 as they would need to move temporarily in order for flooring to be replaced. Room 107 and 111 both declined moves on 8/21/21 2. Maintenance Director completed an audit on all apartments on 8/15/21 and all areas in need of cleaning or repair was entered into electronic work order system for processing. All staff and residents will be educated on how to request maintenance support for items in need of cleaning and repair on 9/17/21. 3. Maintenance Director or designee will audit a minimum of 5 apartments a week for 30 days to insure that items in need of repair or cleaning are being reported and followed up. Maintenance Director or designee will audit a minimum of 10 apartments per month as part of community ongoing quality assurance program. 4. Maintenance Director and Executive Director are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. This is a repeat citation. Findings include, but are not limited to: The facility was toured on 12/20/21 at 11:50 am. The following issues were identified: * Torn and fraying carpet in the hallway in front of rooms 116 and 209; * Dark spots and stains on the carpet in resident rooms 111, 113, 120, 127 and 217; * Hallway carpet was stained or soiled across from room 239, outside the elevator on the second floor and at the top of the lobby staircase on the second floor; and * There were holes and deep gouges in several walls in resident room 113. The areas needing cleaning or repair were reviewed with Staff 4 (Maintenance Manager) on 12/20/21 and with Staff 17 (Executive Director) on 12/21/21. They acknowledged the areas needed cleaning or repair.

1.  All areas in need of repair or cleaning identified during survey were placed into community electronic work order system.  Maintenance Manager will  review this system  and complete work orders as assigned. 2. Executive Director and Maintenance Manager will complete a full audit of facility interior by 1.14.2022 . All areas in need of cleaning or repair were placed into community electronic work order system. Residents and staff will be educated on work order submission process by 1.22.22. 3. Regional Maintenance Technician and Maintenance Supervisor will review electronic work order system a minimum of twice monthly to review that work orders are being completed timely. 4. Executive Director and Maintenance Supervisor are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: All hallway windows on the second floor had horizontally openings with sills lower than 36 inches. The windows had an internal locking system in the window frames that failed to operate properly, allowing the windows to be fully opened. In an interview with Staff 4 (Maintenance Director) all resident windows were designed with the same locking systems. Staff 4 tested a random selection of resident rooms concluding the locking systems previously installed were no longer operating as they should. The need to ensure windows lower than 36 inches and above the first floor included a locking mechanism to prevent accidental falls was discussed with Staff 1(Executive Director) and Staff 4 on 8/3/21. They acknowledged the findings and Staff 4 began installing new locking mechanisms before survey exited the building on 8/6/21.

1. all windows above the first floor were equipped with locking devices to prevent opening further than 6 inches at time of survey. 2. all associates will be educated on the need for all 2nd floor apartment windows to have locking devices on 9/17/21 at mandatory all staff meeting. Staff will be educated on how to properly report any windows missing locking devices. 3. Maintenance Director or designee will conduct random audits of 5 apartments per month to insure locking devices are in place as part of ongoing quality assurance program. 4. Maintenance Director and Executive Director are resonsible for this plan of correction.

The findings of the re-licensure survey conducted 8/3/21 through 8/6/21 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 and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 08/03/21, conducted 12/21/21, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 08/06/21, conducted 02/24/22, 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.