Marquis Tualatin Assisted Living

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' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 5 sampled residents (#s 2 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 10/2021 with diagnoses including Arnold-Chiari syndrome (a congenital brain condition causing hydrocephalus), Type 2 diabetes mellitus, and abnormality of gait and mobility. Interviews with the resident and facility staff were conducted during the survey. Resident 5's service plan, dated 03/18/26, was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Number of staff needed to assist with transfers; * Updated fall prevention interventions; * Home health services from an outside provider; and * Staff escort to medical appointments. The need to ensure the service plan reflected residents' current care needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (Administrator) and Staff 2 (RN, Health Services Director) on 05/20/26 at 12:45. They acknowledged the findings 2. Resident 2 was admitted to the facility in 05/2025 with diagnoses including macular degeneration and dementia and had recently been admitted to hospice services. Observations of Resident 2, interviews with the resident and staff, and review of the resident’s clinical record from 03/02/26 through 05/17/26 were completed during the survey. The 03/30/26 service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas: * Ambulation with an assistive device; * Toileting assist; and * Level of assistance required for personal hygiene and grooming tasks. The need to ensure the service plan reflected Resident 2’s current needs and provided clear instruction to staff regarding the delivery of services was reviewed with Staff 1 (Administrator) and Staff 2 (RN, Health Services Director) on 05/20/26 at 12:55 pm. They acknowledged the findings.

Resident # 2 and #5 SP have been udated to reflect the identified needs. 100% audit will be completed of all current resident's Service Plans to ensure accuracy. Any areas of non-compliance will be immediately corrected. An in-service will be provided to ALF IDT to ensure the team is adequately updating their department's Service plan to reflect residents care. Facility Administrator will complete a weekly audit of all residents due for Serivce Plan reviews for 4 weeks and then quarterly thereafter. Administrator will address any areas of non-complaiince with the appropriate IDT to immediately correct any areas of inaccurate Service Plans. Administrator will be audit results to QA review to address areas of non-compliance.

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 a significant change of condition assessment was completed by an RN, including findings, resident status, and interventions made as a result of the assessment, for 3 of 3 sampled residents (#s 3, 4, and 5) who had significant weight changes. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 04/2025 with diagnoses including congestive heart failure and chronic kidney disease. During the acuity interview on 05/18/26, the resident was identified as having edema and being on weekly weights. Review of the resident’s clinical record, including weight records from 06/2025 through 05/18/26, observations of the resident, and interviews with staff and the resident identified the following: * 02/06/26 – 172.4 pounds; and * 03/06/26 – 158.8 pounds. Between 02/06/26 and 03/06/26, the resident lost 13.6 pounds, or 7.9% of his/her total body weight, in 30 days, which was a severe weight loss. There was no documented evidence an RN had completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment. Observations of the resident on 05/19/26 at 10:55 am revealed s/he had edema in both lower legs and was wearing Tubi Grips (compression stockings). The resident reported staff weighed him/her every morning and assisted in putting compression stockings on every morning and removing them every evening. Weight records indicated that Resident 4 was weighed daily beginning 03/14/26. Between 03/14/26 and 05/18/26 the resident’s weight fluctuated between 145 pounds and 169.4 pounds. The resident was observed on 05/19/26 eating 100% of his/her lunch independently. In an interview on 05/19/20 at 2:37 pm, Staff 2 (RN, Health Services Director) provided additional documentation, but there was no RN assessment which addressed the resident’s significant weight loss. The need to ensure all significant weight changes were assessed by an RN, with findings, resident status, and interventions made as a result of the assessment documented, was discussed with Staff 1 (Administrator) and Staff 2 on 05/20/26 at 11:15 am. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 10/2021 with diagnoses including Arnold-Chiari syndrome with hydrocephalus (congenital brain condition) Type 2 diabetes mellitus, and abnormality of gait and mobility. Review of the resident’s clinical record, including weight records from 02/2026 through 05/18/26, observations of the resident, and interviews with staff and the resident identified the following: * 02/14/26 – 252 pounds; and * 03/14/26 – 239 pounds. Between 02/14/26 and 03/14/26, the resident lost 13 pounds, over 5% his/her total body weight, in 30 days, which was a significant weight loss. There was no documented evidence an RN had completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment. An interview conducted on 05/19/26, at 3:00 pm, with Staff 2 (RN/Health Services Director) confirmed that no RN assessment was completed for Resident 5’s weight loss. During the survey Resident 5 was observed eating in the dining room with over 75% of meal eaten, and review of the record showed Resident 5 had regained six pounds since the significant weight loss was identified. The need to ensure an RN conducted and documented an assessment of a resident's significant change of condition was discussed with Staff 1 (Administrator) and Staff 2 on 05/20/26 at 12:45 pm. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 10/2024 with diagnoses including hypertension and dementia. The resident's (add dates) clinical record was reviewed. Weight records identified the following: * 10/03/25 – 98.4 pounds; and * 04/03/26 – 112 pounds. Between 10/2025 and 04/2026, Resident 3 gained 13.6 pounds, or 13.8% of his/her total body weight in six months which constituted a severe weight gain. On 05/20/26, survey requested Resident 3 be weighed. The facility reported his/her weight was 105.2 pounds. Observations and interviews with staff indicated the resident was independent with dining and ate meals in his/her room. There was no documented evidence the RN completed a timely assessment of the resident following the identified weight gain between 10/03/25 and 04/03/26, which included findings, resident status, and interventions made as a result of the assessment. An interview conducted on 05/19/26, at 3:50 pm, with Staff 2 (RN/Health Services Director) confirmed that no RN assessment was completed for Resident 3’s weight gain. The need to ensure the RN assessed residents with significant changes of condition in a timely manner and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 2 on 05/20/26 at 12:30 pm. They acknowledged the findings.

Resident 3, 4 and 5 Weight assessment has been completed by RN, interventions and follow up implemented as indicated. 100% audit will be completed of all residents currently flagging for a weight exception. RN will complete an ALF Weight Change Evaluation for these residents falling outside of their physician-set parameters. An in-service will be provided to IDT, including RN regarding weight exception process including monthly weight audit, ALF Weight Change Evaluation and requirement per facility policy and procedures. RN or designee will complete monthly audit and review all residents who flag for a weight exception. RN or designee will complete an ALF Weight Change Evaluation for any residents who have not previously flagged for a weight exception to determine if there is a significant change and implementation of weight change documentaton per policy. RN will bring a summary of each month's weight audit to QA review to address any areas of non-compliance.

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

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was completed for each resident before admission for 1 of 1 sampled resident (# 6) and 3 of 3 unsampled residents whose ABST evaluations were reviewed. Findings include, but are not limited to: The facility’s ABST was reviewed during the survey and the following was identified: Review of the ABST for four newly admitted residents showed the following: * Resident 6 was admitted to the facility in 03/2026. The ABST was not completed for Resident 6 until 10 days after admission; and * ABST data was not entered for an additional three unsampled residents before admission to the facility. The need to ensure residents’ ABST data was completed prior to move-in was discussed with Staff 1 (Administrator), and Staff 2 (RN, Health Services Director) on 05/20/26 at 11:45 am. They acknowledged the findings.

Resident 6 ABST has been updated. 100% audit has been completed of all residents ABST to ensure updated and accurate to resident(s) needs. RSC re-inserviced and education provided on ABST regulatory rule of completing the ABST evaluation for all new move-ins prior to their move-in date. Administrator or RSC will complete new resident's ABST evaluation for all new residents based on the Move-in Evaluation prior to the resident moving in, updated with Service Plan quarterly reviews and PRN. Administrator or designee will audit weekly for 4 weeks then quarterly thereafter, to ensure that all new move-ins and post quarterly SP, to ensure compliance. Administrator is responsible for monitoring and ensuring compliance and will bring audit results to QA reivew to address any areas of non-compliance.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled staff (#s 7, 11, 13, and 17) demonstrated competency in all assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 05/19/26 and 05/20/26, and the following was identified: Staff 7 (MT) was hired 10/14/24, Staff 11 (CG) was hired 10/31/25, Staff 13 (CG) was hired 10/13/25, and Staff 17 (MT) was hired 08/13/25. There was no documented evidence Staff 7, 11, 13, and 17 demonstrated competency in their assigned job duties within 30 days of hire. On 05/20/26 at 11:15 am, the need to ensure all direct care staff demonstrated competency in their assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (RN, Health Services Director). They acknowledged the findings, and no additional documentation was provided.

100% audit will be completed for all ALF employees to ensure all caregivers and medication techs have a fully completed orientation checklist in their personnel file. Any areas of non-compliance will be immediately corrected. Staffing Director will be re-inserviced and education provided on training records required to adequately demonstrate compentecy within 30 days of hire. Staffing Director will ensure that all new hires will complete job specific orientation within 30 days of hire. Administrator, or designee, will audit all new hire's weekly for 4 weeks and then quarterly thereafter. Administrator, or designee, will bring audit results to QA review and any areas of non-comliance will be addressed.

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

Based on interview and record review, it was determined the facility failed to ensure staff were provided fire and life safety training on alternate months of the fire drills and that the fire drills included documentation of the required elements per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety documentation from 11/2025 through 05/2026 was reviewed on 05/18/26 through 05/20/26. The following was identified: a. There was no documented evidence all staff were provided fire and life safety training every other month. b. Fire drill documentation did not include one or more of the following required elements: * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Escape route used; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. The facility was combining fire drills between post-acute rehabilitation and assisted living. The fire drills documented did not indicate if the required elements were completed in assisted living. On 05/19/26 at 1:15 pm, Staff 5 (Maintenance Director) acknowledged the documentation did not clearly state what elements of the fire drill were applicable to the assisted living. The need to provide fire and life safety training for all staff on alternate months of fire drills, as well as the need to address all required elements in fire drill documentation, was discussed with Staff 1 (Administrator) and Staff 2 (RN/Health Services Director) on 05/20/26 at 12:30 pm. They acknowledged the findings.

Annual Fire & Life Safety in-service calendar will be completed with fire and life safety education topics to be covered on opposite months from fire drills. Current fire drill documentation form will be audited and edited to ensure all required elements are included on the form. Maintenance Director and IDT will be in-serviced on ALF Fire and Life Safety regulations including required education, staff and resident participation, and proper documentation on fire drill forms. Administrator will audit monthly for 3 months for fire drill compliance and education on oppositie months. Results will be brought to QA review and any areas of non-compliance will be addressed.

Based on interview and record review, it was determined the facility failed to immediately investigate an injury of unknown cause and document that it reasonably concluded the injury was not the result of abuse, or report the injury to the local SPD office, for 1 of 1 sampled resident (#2) with an injury of unknown cause. Findings include, but are not limited to: Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia. Review of Resident 2's clinical records during the survey noted the following: * 02/20/23 - "Skin tear observed on right arm...HH Certified Nurse Aide reported she found it when providing shower for [resident]." The facility lacked an investigation into the injury of unknown cause which reasonably concluded and documented the injury was not the result of abuse. The injury was not reported to the local SPD office. The need to immediately investigate injuries of unknown cause to reasonably rule out abuse and neglect or report the injury to the local SPD office was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23. They acknowledged the findings. The survey team requested the facility submit the report. Documentation was provided prior to survey exit.

1.  Upon notification of findings, facility completed documentation and notification to SPD for Resident 2's 2/20/23 skin tear and Facility RN reviewed resident's service plan to ensure accuracy. 2.  All direct care staff will be in-serviced on when/how/what to report to the RN/Administrator. Facility RN or designee will complete a prompt investigation for resident injuries.  Any injuries that present as an "injury of unknown source" will be immediately reported to SPD on the designated form. 3. Administrator will review all injuries incidents weekly for 4 weeks and then monthly for 90 days to ensure any injury that is "Injury of unknown origin" is reported to APS, per regulation. Ongoing incidents will be reviewed during the monthly QA process to ensure accurate and timely investigations were completed and any injuries of unknown source were reported to SPD. 4.  Administrator is responsible for ensuring monitoring and compliance.

Based on observation, interview and record review, it was determined the facility failed to consistently determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition, ensure the determined actions were made part of the resident's record, note progress of the condition until resolved and monitor the resident consistent with his or her evaluated needs and service plan for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 6) who experienced changes of condition which required monitoring. Findings include, but are not limited to: 1. The sampled residents' records were reviewed for changes of condition. In response to some change of condition events, staff documented in a progress note that the resident was placed on "alert." There was then documentation by staff that the resident's condition was monitored and, at some point, the monitoring was discontinued by the facility RN with a note indicating the resident's condition had returned to baseline or had resolved. However, there were no documented instructions for staff in the resident's record indicating what actions or interventions had been put in place following the change of condition. In an interview on 04/13/23, Staff 2 (RN) explained that when a resident was placed on alert charting, instructions for staff were documented in the facility's electronic records system. She acknowledged, however, that when the alert was discontinued, the electronic system did not retain a record of the actions or interventions the facility had initially developed for the resident in response to the change of condition. She further acknowledged that if no monitoring was documented in the progress notes, it indicated the facility failed to place the resident on alert charting, i.e. the facility failed to determine, document and communicate to staff what actions or interventions were needed for the resident in response to the change of condition. She acknowledged this system did not meet the rule requirements. The need to ensure the facility had a system to make staff instructions or interventions part of the resident's record following a change of condition was reviewed with Staff 1 (Administrator) on 04/14/23. She acknowledged the deficiencies with the facility electronic record system. 2. Resident 1 was admitted to the facility in 08/2014 with diagnoses including Alzheimer's disease, cerebellar stroke syndrome and cerebral infarction. Review of the record indicated Resident 1 experienced the following changes of condition which required monitoring: * 02/13/23 - Scratched self on left arm causing bleeding; * 02/21/23 - Due to itchiness, scratched face resulting in a "gash" that was bleeding; and * 02/23/23 - Was found by staff outside in the parking lot, confused and looking for his/her car to go home. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed for the resident or monitored and documented on the resident at least weekly until the conditions were determined to be resolved. The facility failed to monitor Resident 1's service plan to determine if information regarding his/her risk for leaving the building unsupervised was accurate or whether additional interventions needed to be developed to ensure the resident's safety. The need to ensure the facility determined, documented and communicated to staff what actions were needed in response to a resident's change of condition, and that the resident was monitored with weekly progress noted until the condition resolved, was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23 and 04/13/23, respectively. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 08/2015 with diagnoses including late onset Alzheimer's disease, adjustment disorder and atrial fibrillation. Review of the record indicated Resident 4 experienced the following changes of condition which required monitoring: * 02/10/23 - Non-injury fall in the resident's room; * 03/13/23 - Non-injury fall while walking to his/her room from the dining room; * 03/15/23 - Fall resulting in injuries to left biceps and right elbow area; * 03/18/23 - Was found by staff outside in the parking lot, confused and looking for his/her spouse; and * 04/05/23 - Minor skin wound across top of left ankle from refusing to allow staff to remove his/her compression stockings at bedtime. There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed for the resident or monitored and documented on the resident at least weekly until the conditions were determined to be resolved. The facility failed to monitor Resident 4's service plan to determine if information regarding his/her risk for leaving the building unsupervised was accurate and instructions for staff regarding what to do if the resident refused to allow compression stockings to be removed were adequate, or whether additional interventions needed to be developed to ensure the resident's health and safety. The need to ensure the facility determined, documented and communicated to staff what actions were needed in response to a resident's change of condition, and that the resident was monitored with weekly progress noted until the condition resolved, was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23 and 04/13/23, respectively. They acknowledged the findings. 6. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia. The resident's 01/11/23 through 04/11/23 progress notes were reviewed and revealed the following: * 03/28/23 - "Patient eye is red and had a lot of gooey green [discharge] in it;" and * 01/18/23 - "...Resident had a quite a bit of green [discharge] coming out of [his/her] left eye." In an interview on 04/14/23, Staff 2 (RN) stated the facility contacted the resident's primary physician regarding the eye condition on 04/11/23, 15 days after it was discovered. Staff 2 confirmed the facility failed to monitor the resident's condition noting any progress at least weekly. The lack of monitoring of Resident 2's change of condition was discussed with Staff 1 (Administrator) on 04/14/23. She acknowledged the findings. 4. Resident 3 was admitted to the facility in 11/2021 with diagnoses including hypoxemia and personal history of venous thrombosis and embolism. Observations of and interviews with the resident, interviews with staff, review of the resident's service plan dated 04/04/23, and progress notes dated 02/02/23 through 04/09/23 were reviewed. a. The following short-term change of condition lacked documentation of progress, at least weekly, through resolution: * 03/01/23 - Emergency department visit for kidney stones. b. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly and documentation of resolution: * 02/07/23 - Rash on right side of groin; * 02/08/23 - Increased confusion; * 02/10/23 - Left leg pain; * 02/20/23 - Pain in left arm and shoulder; * 02/22/23 - Pain in the right big toe; and * 03/28/23 - New finasteride prescription.   The need to ensure short-term changes of condition had actions or interventions documented in the resident record, the determined actions or interventions were communicated to staff on all shifts and progress was noted, at least weekly, until resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23. They acknowledged the findings. 5. Resident 6 was admitted to the facility in 06/2022 with diagnoses including multiple sclerosis. Observations of and interviews with the resident, interviews with staff, review of the resident's service plan dated 02/24/23, progress notes dated 01/13/23 through 04/11/23 and fall investigation reports were reviewed. a. The following short-term changes of condition lacked documentation of progress, at least weekly, through resolution: * 02/26/23 - Fall. b. The following short-term changes of condition lacked documentation of the actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly and documentation of resolution: * 02/07/23 - Death of resident's best friend; * 02/12/23 - Missed all evening medications; * 02/20/23 - New trazadone prescription and change in duloxetine dosage; * 03/10/23 - Decrease in trazadone; * 04/05/23 - Skin tear from fall; * 04/05/23 - Nosebleed; and * 04/07/23 - New tamsulosin prescription. The need to ensure short-term changes of condition had actions or interventions documented in the resident record, the determined actions or interventions were communicated to staff on all shifts and progress was noted, at least weekly, until resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23. They acknowledged the findings.

1.  Facility RN has completed a review of residents 1, 2, 3, 4 and 6 to ensure each change of condition has been resolved and service planned appropriately. 2.  All direct care staff will be in-serviced on alert charting and documentation of resident's change of condition.  Resident Services Coordinator will be in-serviced on Temporary Service Plans and will complete a daily audit of all new alerts from the previous working day and open temporary service plans.  Facility RN or designee will review documentation and remove from alert when resolved. 3.  Residents placed on alert charting will be reviewed daily during stand up process and will be audited weekly for four weeks and quarterly thereafter by the facility RN to ensure alert charting and temporary service plan is in place per policy. 4.  Facility RN is responsible for ensuring monitoring and compliance.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed, communicate the interventions or actions to staff with weekly progress noted through resolution for 2 of 2 sampled residents (#s 7 and 8) who experienced short term changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the facility in 01/2022 with diagnoses including aphasia and hypertension. The resident's clinical record, including progress notes, and incident reports, were reviewed and interviews were conducted. The following change of condition was identified: On 06/27/23 a fall was noted in the progress notes. The following information was identified: *06/30/23 - "Resident is presenting with pain since [his/her] fall. Resident has remained in apartment all shifts, and opted into getting [his/her] dinner delivered to [his/her] room. Resident is still protecting [his/her] arm." Review of the available facility records revealed there was no documented evidence the facility, determined and documented actions or interventions were needed with instruction to staff nor was there evidence the resident had been monitored at least weekly through resolution. Resident 8's change of condition was discussed with Staff 1 (Administrator) on 07/20/23. She acknowledged the findings. 2. Resident 7 was admitted to the facility in 04/2017 with diagnoses including kidney failure and a total hip replacement. Review of the record from 06/13/23 to 07/20/23 identified the following short term change of condition. A progress note dated 07/04/23 documented that "medtech went to the resident saw caregiver talking to resident about a skin tear on his left knee. When asked if it hurts, he replied no. The area of the skin discolored bruise". There was no documented evidence the facility determined what action or intervention was required for the resident, communicated actions or interventions to staff and there was no evidence of weekly monitoring through resolution. Resident 7's change of condition was discussed with Staff 1 (Administrator) on 07/20/23. She acknowledged the findings.

1. Resident # 8's fall intervention Service Plan has been updated and short-term change of condition has resolved.  Resident # 7's skin tear has resolved without complications. 2. Resident Services Coordinator will be re-inserviced on Temporary Service Plans and will complete a daily audit of all new alerts from the previous working day and open temporary service plans.  Med Techs, Caregivers & RSC will be re-inserviced on Alert Charting policy and procedures, including skin tears. 3. Facility RN or designee will review documentation and remove from alert when resolved. 4. Residents placed on alert charting will be reviewed daily (M-F) during stand-up process and will be audited weekly for four weeks and quarterly thereafter by the facility Admin, RN or designee to ensure alert charting and temporary service plan is in place per policy. 5. Facility RN is responsible for ensuring monitoring and compliance.

2. On 04/14/23 at 11:20 am, a medication cart was observed in the first floor hallway outside the staff work area. The cart appeared to be unlocked and no staff were present. Upon inspection, the cart was unlocked and contained resident prescription medications and wound care supplies. At approximately 11:22 am, Staff 2 (RN) came out of a nearby office. The surveyor informed her of the unlocked medication cart - she immediately locked it. The need to ensure medications were stored in locked containers in a secure environment was discussed with Staff 1 (Administrator) on 04/14/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all medications administered by the facility were stored in locked containers in a secure environment such as a medication room or medication cart. Findings include, but are not limited to: 1. On 04/13/23 at 8:36 am, a medication cart was observed to be unlocked and located in an open and unlocked medication room on the first floor. Further inspection by this surveyor confirmed the medication cart held prescription medications for residents in the facility. At approximately 8:41 am Staff 2 (RN) and Staff 6 (CG) returned to the medication room. This surveyor informed both staff members the medication cart was unlocked and left in an unlocked and open medication room with no staff present. Staff 2 immediately shut and locked the door of the medication room. The need to ensure medications were stored in locked containers in a secure environment was discussed with Staff 2 on 04/13/23. She acknowledged the findings.

1.  All Medication Techs will be in-serviced on safe storage and securing medications. 2.  Daily audits will be completed by RSC or designee for 30 days and monthly thereafter to ensure med carts and med rooms are kept secured.  Any issues of non-compliance will be immediately addressed by the Faciltiy RN or Administrator. 3.  Daily audits will be reviewed during the monthly QA process.  Any issues of non-compliance will be addressed by the Administrator. 4.  Administrator is responsible for ensuring monitoring and compliance.

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications, for 1 of 1 sampled resident (#1) who was prescribed a PRN psychotropic medication requiring non-drug interventions be attempted prior to administration. Findings include, but are not limited to: Resident 1 was admitted to the facility in 08/2014 with diagnoses including Alzheimer's disease, cerebellar stroke syndrome and cerebral infarction. Review of the record indicated Resident 1 was prescribed lorazepam intensol (to treat anxiety or agitation) 2mg/ml, administer 0.25 ml (0.5 mg) by mouth or sublingually as needed every 2 hours. The orders noted Resident 1 was on hospice and staff should call the RN or hospice before administering. The MAR, reviewed between 04/01/23 and 04/10/23, indicated staff administered the lorazepam PRN on 04/07/23 and 04/08/23. There was no documented evidence the staff attempted non-drug interventions with ineffective results or contacted the RN or hospice prior to administering the medication. The need to ensure there were non-pharmacological interventions to attempt, documentation that the interventions were attempted and ineffective and documentation the RN or hospice were contacted prior to administering Resident 1's PRN psychotropic medication was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23. They acknowledged the findings and Staff 2 stated the facility had to develop a method for documenting non-pharmacological interventions on the electronic MAR.

1.  Resident 1 PRN Lorazepam order has been reviewed and continues to be appropriate. 2.  Med techs will be in-serviced on the process for PRN psychotropic medication administration which includes linking the non-pharmacological interventions attempted prior with the EMAR note for administration of the medication, to chart interventions tried and/or notifications made prior to medication administration. 3.  RN or designee will audit PRN psychotropics administered to ensure Med Tech documentation demonstrates PRN non-pharmacological interventions or required notifications are completed prior to administration.  Audits will be completed daily during stand-up process for 90 days.  Areas of non-compliance will be reviewed during the monthly QA process and addressed by the Administrator. 4.  Facility RN is responsible for ensuring monitoring and compliance.

Based on interview and record review, it was determined the facility failed to update the Acuity-Based Staffing Tool (ABST) following a significant change of condition and no less than quarterly, for 3 of 6 sampled residents (#s 1, 3 and 4). Findings include, but are not limited to: The facility used the Oregon Department of Human Services ABST. Review of the data for Residents 1, 3 and 4 indicated the ABST for each resident had not been updated since their records were originally created on 06/01/22. Residents 1 and 4 had experienced significant changes of condition on 01/18/23 and 03/14/23, respectively. The need to ensure ABST records were updated no less than quarterly and following a significant change of condition was reviewed with Staff 1 (Administrator) on 04/14/23. She acknowledged the findings.

1.  Resident 1, 3 and 4 have all been reviewed in ABST to ensure care needs are up to date and appropriate. Administrator was not aware of the requirement to click into a question if no changes were necessary to show that ABST was reviewed. 2.  Administrator will complete 100% review of current residents during the next scheduled service plan reiview to ensure ABST has been opened, reviewed and changes made if indicated.  Adminstrator will in-service RSC on process of using ABST during service plan reviews quarterly and/or with significant changes, via opening and clicking into the resident's infomration to update and/or to demonstrate that a review was completed. 3.  Administrator will audit Service Plan ABST Update log weekly post Service Plan reviews for 4 weeks and then monthly for 90 days to ensure ongoing compliance. 4.  Administrator will responsible for monitoring and ensuring compliance.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired direct care staff (#s 8, 9 and 10) completed pre-service orientation and pre-service dementia training before providing care and services to residents and failed to ensure 2 of 2 long term staff (#s 1 and 14) completed training addressing infectious disease prevention by 07/01/22. Findings include but are not limited to: a. Staff training records were reviewed with Staff 1 (Administrator) on 04/13/23 and identified the following: Staff 8 (CG), hired on 01/21/23, lacked documented evidence pre-service orientation training was completed in the following areas before providing care to residents: * Resident rights and values of community based care; and * Infectious disease prevention. Staff 9 (CG), hired on 01/09/23, lacked documented evidence pre-service orientation training was completed in the following areas before providing care to residents: * Resident rights and values of community based care; * Abuse reporting requirements; and * Infectious disease prevention. Staff 10 (MA), hired on 12/29/22, lacked documented evidence pre-service orientation training was completed in the following areas before providing care to residents: * Resident rights and values of community based care; * Infectious disease prevention; and * Fire safety and emergency procedures. b. Staff 8, 9 and 10 lacked documentation the following pre-service dementia training was completed prior to providing care to residents: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering and use of person-centered care. c. Staff 1, hired 05/14/07, and Staff 14 (Cook), hired 03/03/21, lacked documentation infectious disease prevention training was completed prior to 07/01/22.      The need to ensure newly hired direct care staff completed pre-service orientation and pre-service dementia training before providing care to residents and long term staff completed infectious disease prevention training prior to 07/01/22 was discussed with Staff 1 on 04/13/23. She acknowledged the findings.

1.  Employees 8, 9 and 10 have all completed required pre-service trainings.  Employees 1 and 14 have completed the required infectious disease training.  Administrator to audit 100% of current staff to ensure all have completed the required pre-service orientation/dementia/infection control. 2.  Administrator has re-inserviced Staffing Director on pre-service requirements.  Staffing Director will ensure that all new hires complete PreDay1 (general job orientation) and pre-service infection control and pre-service dementia (direct care staff) prior to providing care to residents. 3.  Administrator or designee, will review employee file compliance on a weekly basis for 90 days, then quarterly after.  Areas of non-compliance will be reviewed during monthly QA process and will be addressed by the Administrator. 4.  Staffing Director is responsible for monitoring and ensuring compliance.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 8, 9 and 10) demonstrated competencies in all required training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 04/13/23. Staff 8 (CG), hired on 01/21/23, and Staff  9 (CG), hired on 01/09/23, failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First Aid and abdominal thrust training. Staff 10 (MA), hired on 12/29/22, failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas: * Providing assistance with ADL's; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. The need to ensure newly hired direct care staff had documented evidence of demonstrated competency in all assigned job duties prior to working independently with residents was reviewed with Staff 1 (Administrator) on 04/13/23. She acknowledged the findings.

1.  Employees 8, 9 and 10 have completed 30 day orientation competencies.  Staffing Director to complete 100% audit of current staff to ensure all staff have completed job specific orientation with demonstrated competency.  Administrator has audited job specific orientation materials to ensure all required topics are covered and include competency demonstrated. 2.  Staffing Director will ensure that all new hires complete job specific orientation within 30 days of hire including demonstrated competency.  Staffing Director will ensure all required elements are completed and included in the documentation of new hire's performance during training period.   3.  Administrator or designee, will review employee file compliance on a weekly basis for 90 days, then quarterly after. 4.  Staffing Director is responsible for monitoring and ensuring compliance.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired direct care staff (#17) demonstrated competencies in assigned job tasks before working unsupervised.  This is a repeat citation. Findings include: Records of training for staff hired after 06/13/23 were reviewed on 07/20/23. Training records for Staff 17 (Med Aide), hired on 06/27/23, failed to show that appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments), had observed and evaluated the individual's ability to perform safe medication and treatment administration independently before administering medications unsupervised. The need to ensure newly hired direct care staff had documented evidence of demonstrated competency in all assigned job duties prior to working unsupervised with residents was reviewed with Staff 1 (Administrator) on 07/20/23. She acknowledged the findings and stated the staff would demonstrate competency before administering medications.

1. Employee # 17 has completed both job specific orientation and required training within 30 days of hire.  Staffing Director has documented this employee's demonstrated satisfactory perfomance in administering medications. 2. Staffing Director will ensure that all new hires complete job specific orientation within 30 days of hire including demonstrated competency.  If job duties include medication administration, Staffing Director will ensure documentation of observation and evaluation of the individuals's ability to safely administer medications unsupervised prior to the employee working independently. 3. Administrator or designee, will review employee file compliance weekly for 4 weeks, then quarterly after. 4. Staffing Director is responsible for monitoring and ensuring compliance.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 3 of 3 long term staff (#s 11, 12 and 13) whose training records were reviewed. Findings include, but are not limited to: Annual in-service training records were reviewed with Staff 1 (Administrator) on 04/13/23. Staff 11 (MA), hired on 01/05/17, Staff 12 (CG), hired on 06/12/19 and Staff 13 (CG), hired on 02/06/17, lacked documented evidence of a minimum of 12 hours of in-service training annually, based on their hire dates, on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, and at least six hours of dementia care training, The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 1 on 04/14/23. She acknowledged the findings.

1.  Employees 11, 12 and 13 have completed the required annual inservicing, per OARs.  Staffing Director to complete 100% audit of all direct care staff to ensure all have completed the required number of annual inservicing hours prior to anniversary of hire date.  All direct care staff will be up to date on required hours by date of alleged compliance. 2.  Facility will hold monthly staff meetings as well as require monthly in-servicing through Oregon Care Partners to ensure all required hours of training are completed for each direct care staff. 3.  Staffing Director will track each direct care staff's completed in-servicing hours to ensure compliance. 4.  Staffing Director is responsible for monitoring and ensuring compliance.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Fire drill and fire and life safety training records from 10/11/22 to 04/11/23 were reviewed with Staff 3 (Maintenance Director) on 04/13/23. The following deficiencies were identified: 1. The facility failed to show documented evidence fire drills were conducted every other month. Fire drills conducted and recorded on 02/08/23 and 04/04/23 lacked the following information: * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. 2. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) on 04/14/23. She acknowledged the findings.

1.  Administrator to make 2023 Inservicing calendar to include every other month fire drills with resident participation and staff education on alternating months.  A fire drill will be conducted on 5/23/23 to include resident participation in relocating. 2.  Maintenance will conduct every other month fire drills and will ensure that residents participate and doucmentation is completed on fire drill form. 3.  Administrator or designee will audit every month for 90 days to ensure compliance with completing drills and staff education and documentation addressing any problems that occurred during training and residents who chose /or could not participate in the training. 4.  Maintenance Director is responsible for monitoring and ensuring compliance.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed with Staff 3 (Maintenance Director) on 04/13/23. There was no documented evidence residents were 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 of the building or within the fire safe area in the event of an actual fire. The need to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed at least annually was discussed with Staff 1 (Administrator) on 04/14/23. She acknowledged the findings.

1.  All current residents will receive education on facility fire safety procedures, evacuation methods, and responsibilities during fire drills. 2.  Fire and Life Safety training will be provided to all new residents within 24-hours of admission and reviewed annually thereafter. Documentation supporting this training will be maintained. 3.  Administrator or designee will audit every month for 90-days, then quarterly thereafter to ensure compliance. 4.  Maintenance Director is repsonsible for monitoring and ensuring compliance.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed within 24 hours of admission in fire and life safety procedures as required by the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to: Fire and life safety records were reviewed on 07/20/23, Staff 1 (Administrator) was interviewed, and the following were identified: There was no documented evidence residents were instructed within 24 hours of admission on general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. On 07/20/23, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission as required by the OFC was discussed with Staff 1. The findings were acknowledged.

1. All current residents will receive education on facility fire safety procedures, evacuation methods, and responsibilities during fire drills.  Upon reciept of education, each resident will sign an acknowledgement form. 2. Fire and Life Safety training will be provided to all new residents within 24-hours of admission and reviewed annually thereafter. Documentation supporting this training will be maintained. 3. Administrator or designee will audit every week for 4 weeks and then quarterly thereafter to ensure compliance. 4. Maintenance Director is repsonsible for monitoring and ensuring compliance

Based on observation and interview, it was determined the facility failed to ensure covers, grates or screens of wall heaters did not exceed 120 degrees Fahrenheit when they were installed in locations that were subject to incidental contact by residents or with combustible material. Findings include, but are not limited to: During an environmental walk-through on 04/12/23, the metal surface on the wall heaters located in apartments with one or two bedrooms exceeded 120 degrees F when turned on. On 04/12/23, Staff 3 (Maintenance Director) observed the surveyor test the wall heater in room 360, acknowledged it measured approximately 220 F, and confirmed that all of the cadet wall heaters in the one bedroom and two bedroom units were the same style, and all exceeded 120 F. The need to ensure residents could not come into incidental contact with wall heaters that exceeded 120 degrees F was discussed with Staff 1 (Administrator). She acknowledged the findings and the wall heaters were disabled prior to survey exit on 04/14/23.

1.  All cadet wall heaters were disabled from use prior to survey exit.  PTAC units will remain functional in the apartments. 2.  Power will remain off to the wall heaters.  Access to re-enabling heaters is not available to residents or families. 3.  Maintenance Director or designee will spot check heaters for 4 weeks and then monthly for 90 days to ensure the wall heaters have not been enabled for use. 4.  Maintenance Director is responsible for monitoring and ensuring compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to: Refer to C 270, C 372 and C 422.

The findings of the re-licensure survey conducted 04/11/23 through 04/14/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 04/14/23, conducted 07/20/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 04/14/23, conducted 10/09/23, 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.