Waverly Place Assisted Living

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:

During the change of ownership survey, conducted 03/17/25 through 03/20/25, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.

Refer to deficiencies in the report.

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.

This Rule is not met as evidenced by:

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.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to:

During the survey, conducted 03/17/25 through 03/20/25, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.

In an interview at 11:30 am on 03/20/25, Staff 1 (ED) confirmed that there was not a current quality improvement program being conducted to evaluate services and resident outcomes.

The need to ensure the facility developed and conducted ongoing quality improvement programs was reviewed with Staff 1, Staff 2 (RCC), and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

Refer to the deficiencies in the report.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

(9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

This Rule is not met as evidenced by:

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

(9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to promptly investigate incidents of abuse or suspected abuse, and/or report incidents and injuries of unknown cause to Seniors and People with Disabilities (SPD), for 4 of 6 sampled residents’ (#s 1, 3, 4, and 7) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2020 with diagnoses including aortic stenosis, congestive heart failure, chronic obstructive pulmonary disease. The resident was receiving hospice services.

During the survey the resident was observed to be bedbound and dependent on staff for cares, although interviews with Witness 1 (family member) and Staff 20 (CG) reported that a month prior the resident was independent with all mobility, ambulating using a walker and independent with ADL cares.

Interviews with staff, and review of the resident's 03/13/25 service plan and available interim service plans, progress notes, hospice visit notes, and incident investigations from 12/29/24 through 03/17/25 were completed. The following was identified:

* 01/16/25 Bruise to lateral right calf;

* 02/15/25 Three skin tears to the right posterior ankle;

* 03/07/25 Fall with right leg pain;

* 03/09/25 Three skin tears to the left posterior ankle;

* 03/11/25 Fall with abrasion to the left lower back, “bump” to the left temple, “bleeding/bump” to the left side of the head, and skin tear to the left lower leg; and

* 03/13/25 Bruise found to forehead.

During an interview with Staff 1 (ED) on 03/18/25 she reported there were no incident investigations completed to rule out abuse for the 5 injuries of unknown cause and fall with injury, and none of the incidents had been reported to the local SPD office.

The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office, and all injuries of unknown cause were immediately reported to the local SPD office unless an immediate investigation reasonably concluded that the injury was not the result of abuse was discussed with Staff 1 on 03/18/24, and with Staff 1 and Staff 2 (RCC) on 03/20/25 at 10:40 am. They acknowledged the findings.

The facility was instructed to report the falls with injuries and injuries of unknown cause to the local SPD office on 03/18/25. Documentation of all reporting requested was received from the facility by 4:00 pm on 03/18/25.

2. Resident 7 was admitted to the facility in 06/2024 with diagnoses including Parkinson’s disease and mild cognitive impairment.

Interviews with staff, and review of the resident's 07/08/24 service plan, interim service plans, progress notes, and incident investigations from 12/17/24 through 03/17/25 were completed. The following was identified:

Resident 7 was identified on the service plan to have mild cognitive impairment and to be impulsive. The resident was observed ambulating with a walker in the dining room during survey with one person contact assist with a gait belt.

*12/17/24 Bruising observed on the resident’s “thigh and knee”. There was no investigation completed and the bruising was not reported to the local SPD.

The need to ensure injuries of unknown cause were reported to the local SPD office, was discussed with Staff 1 (ED) on 03/19/25 and with Staff 2 (RCC) on 03/20/25 at 10:40 am. They acknowledged the findings.

The facility was instructed to report the injury of unknown cause to the local SPD office on 03/19/25 at 1:00 pm. Documentation of all reporting requested was received from the facility by 1:35 pm on 03/19/25.

3. Resident 3 was admitted to the facility in 01/2022 with diagnoses including congestive heart failure, history of cerebral infarction (stroke) and was receiving hospice services.

The resident's 12/17/25 through 03/16/25 progress notes, interim service plans and incident reports were reviewed, and interviews with staff were conducted. The following incidents were identified:

*01/26/25: Progress notes stated “[Caregivers] were assisting [Resident 3] back to [his/her] wheelchair. They asked [him/her] to let go of the bar and when [s/he] did not as [s/he] transferred [s/he] got a skin tear on [his/her] right forearm.”

*02/03/25: Resident 3 was found lying on the floor in his/her room and was unable to state what had occurred. Staff documented an abrasion to Resident 3’s forehead and pain in his/her right shoulder. Later that day, staff documented that the resident’s “right wrist has a deep purple bruise on it.”

*02/05/25: Incident report stated the resident was found in front of a table in his/her room, and s/he was unable to tell staff what had happened. The resident had bleeding from his/her brow line next to his/her eye and a skin injury to his/her right knee.

*02/09/25: Injury of unknown cause, “some scratches above [his/her] left eye.”

*02/21/25: Progress notes stated the resident “was getting up to go to the bathroom” but “did not know how [s/he] ended up on the floor.” Resident 3 sustained injuries including bleeding and skin abrasion to his/her right knee.

*03/15/25: Resident was found face down on the floor in his/her apartment, fully clothed, at 11:54 pm. Injuries included bruising around the resident’s left eye, swelling to the left side of his/her forehead, an abrasion and bruising on the left side of his/her face and an abrasion on his/her left hand. Throughout the next 15 hours, staff also documented a significant decline in Resident 3’s cognition, ability to speak, ability to swallow, and overall mobility.

There was no documented evidence the incidents of abuse, or suspected abuse, were immediately reported to the local SPD office or that the injuries of unknown cause were immediately investigated, and abuse ruled out.

During an interview on 03/18/25 at 10:26 am, Staff 1 (ED) confirmed no investigations occurred for the six incidents listed above, and no reporting to the local SPD office had occurred.

The facility was instructed to report the incident and all injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office. Documentation of all reporting requested was received from the facility by 3:43 pm on 03/18/25.

The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office, and all injuries of unknown cause were immediately reported to the local SPD office unless an immediate investigation reasonably concluded that the injury was not the result of abuse, was reviewed with Staff 1, Staff 2 (RCC), and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

4. Resident 1 was admitted to the facility in 09/2024 with diagnoses including arthritis, anxiety, and depression. In an acuity interview on 03/17/25, the resident was identified as requiring staff assistance with basic ADL tasks.

Review of the resident’s clinical record revealed the following:

* On 01/25/25, a progress note identified a “quarter sized bruise on the top of [his/her] left hand near [his/her] wrist.”

When interviewed by the surveyor at 1:20 pm on 03/18/25, the resident could not recall how the bruise had occurred.

There was no documented evidence the facility immediately investigated the injury to rule out abuse or neglect. The facility did not report the injury to the local Seniors and People with Disabilities (SPD) office.

On 03/18/25 at 1:45 pm, the need to ensure all injuries of unknown cause were immediately reported to the local SPD office unless an immediate investigation reasonably concluded that the injury was not the result of abuse was discussed with Staff 1 (ED). Staff 1 acknowledged the findings and stated the injury would be reported to the local SPD office. Verification the facility had self-reported the incident to the local SPD office was received by the survey team on 03/19/25.

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure the evaluation described the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level and/or that the evaluation was the foundation that the facility used to develop the resident's service plan, including data relevant to the residents' needs and current condition, for 3 of 6 sampled residents (#3, 4 and 6) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2022 with diagnoses including congestive heart failure and history of cerebral infarction (stroke).

The resident’s most recent evaluation, dated 12/26/24, was reviewed, observations of the resident were made, and staff were interviewed. The evaluation date did not correspond with the resident’s service plan, dated 02/27/25. The following was identified:

a. The quarterly evaluation was not reflective of the needs and current condition of the resident in the following areas:

*Communication, including ability to understand and be understood;

*Mental health, including history of depression or mood problems;

*Environmental factors that impact the resident’s behavior, including noise; and

*Ability to manage medications.

The need to ensure the evaluation described the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level and that the evaluation was the foundation the facility used to develop the resident's service plan, including data relevant to the residents' needs and current condition, was reviewed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 09/2023 with diagnoses including chronic pain syndrome and Parkinson’s disease.

The resident’s most recent evaluation, dated 02/06/25, was reviewed, the resident was observed, and staff and the resident were interviewed. The following was identified:

a. The quarterly evaluation was not reflective of the needs and current condition of the resident in the following areas, and/or was not used as the foundation for the resident’s service plan, with discrepancies noted in the following areas:

*Cognition including supervision and ability to safely leave the building unsupervised;

*Safety checks;

*Ability to use call system;

*Mental health status and presence of mood problems;

*Ability to lock/unlock door;

*Assistance required with ambulation, dental care, toileting, nighttime cares, grooming, ambulation and mobility;

*Pain including non-pharmacological interventions; and

*History of behaviors.

The need to ensure the evaluation described the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level and that the evaluation was the foundation that the facility used to develop the resident's service plan, including data relevant to the residents' needs and current condition, was reviewed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 10/2020 with diagnosis including aortic stenosis, congestive heart failure, chronic obstructive pulmonary disease, and was receiving hospice services.

Interviews with staff, review of the resident's 03/13/25 service plan, progress notes from 12/29/24 through 03/17/25, and most recent quarterly evaluation, dated 03/13/25, were completed.

The following elements on the evaluation were not updated to reflect the resident's condition and care needs:

* Memory, orientation, and confusion;

* Presence of depression, thought disorders, behavioral or mood problems;

* Presence of anxiety, history of treatment and effective non-drug interventions;

* Emergency evacuation ability;

* Nutritional habits, fluid preferences;

* Toileting, bowel and bladder management;

* Dressing, grooming, bathing and personal hygiene;

* Mobility, ambulation, transfers and assistive devices; and

* Skin condition.

The need to ensure the evaluation described the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level and that the evaluation was the foundation the facility used to develop the resident's service plan, including data relevant to the residents' needs and current condition was reviewed with Staff 1 (ED) and Staff 2 (RCC) at 10:40 am on 03/20/25. They acknowledged the findings.

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, updated quarterly and with a change of condition, reflective of residents' current care needs, provided clear direction regarding the delivery of services, and/or were implemented for 5 of 6 sampled residents (#s 1, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 10/2020 with diagnoses including aortic stenosis, congestive heart failure, chronic obstructive pulmonary disease and was on hospice services.

The resident's current service plan dated 03/13/25, was reviewed, observations were made, and interviews were conducted. There were no interim service plans available for review.

During the acuity interview on 03/17/25, staff reported that Resident 4 required the assistance of two people for transfers, required full ADL assist, had shortness of breath and used oxygen.

On 03/17/25 the resident was observed in bed with family members present at bedside. The head of the bed was elevated.

During an interview on 03/17/25, Witness 1 (Family Member) reported Resident 4 no longer got up from bed as s/he was too weak. Witness 1 reported that two staff assisted with turning, repositioning and providing incontinent cares. One staff assisted with all the other ADL tasks and the resident remained very short of breath. Witness 1 stated the resident was no longer eating but would on occasions take sips of the health shake brought by facility at each meal.

An interview with Staff 20 (CG) on 03/18/25 was completed. The care staff confirmed Resident 4 now needed two staff members to assist with bed mobility, transfers, dressing and toileting cares. Staff 20 stated the service plan was not reflective and lacked needed information.

The progress notes indicated multiple skin tears, wounds and bruises were present, that the resident was experiencing a lot of anxiety symptoms and was primarily bed bound due to weakness.

The service plan was not reflective of the resident's current condition and care needs, did not provide clear direction to staff, and/or was not implemented in the following areas:

* Anxiety, to include non-drug interventions;

* Cognitive status and level of confusion;

* Fall history;

* Safety checks seven times per shift;

* Increase safety checks to seven times a shift;

* Soft lighting in room at night;

* Bed bound;

* Activities of daily living to include bed mobility, transfers, dressing, grooming, hygiene, bathing and toileting assistance;

* Skin issues with treatment instructions for staff;

* Foods, fluids of preference or ability;

* Shortness of breath with interventions;

* Inability to use call pendant;

* Oxygen; and

* Evacuation ability.

The need to ensure service plans were reflective of the resident’s current needs, provided clear direction to staff and/or were implemented was discussed with Staff 1 (ED), and Staff 2 (RCC) on 03/20/25. They acknowledged the findings. No further information was provided.

2. Resident 5 moved into the facility in 06/2021 with diagnoses including schizophrenia and depression.

a. The resident's current service plan dated 11/04/24 was reviewed, observations were made, and interviews were conducted.

The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Memory, confusion, and decision-making ability;

* Activities of daily living; and

* Evacuation assistance.

b. The service plan was not updated quarterly after 11/04/24.

The need to ensure service plans were updated quarterly, reflective of the resident’s current needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) on 03/20/25. They acknowledged the findings. No further information was provided.

3. Resident 3 was admitted to the facility in 01/2022 with diagnoses including congestive heart failure and history of cerebral infarction (stroke).

The resident's current service plan available to staff, dated 02/27/25, and 12/17/24 through 03/16/25 progress notes were reviewed, interviews with staff were conducted, and observations of the resident were completed. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas:

*Assistance required with evacuation, ambulation, transfers, toileting, preparing for bed, and dressing;

*Ability to manage medications;

*Pain and non-pharmacological interventions;

*Role of hospice including service provision such as bathing;

*Activity preferences;

*Food preferences and dining habits;

*Communication ability;

*Grooming ability;

*Skin condition;

*Fall risk and/or interventions;

*Communication ability including hearing and vision; and

*Safety checks.

The need to ensure service plans were reflective and provided clear direction to staff was reviewed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 09/2023 with diagnoses including chronic pain syndrome and Parkinson’s disease.

During the acuity interview on 03/17/25, Staff 2 (RCC) and Staff 3 (Interim RCC) stated care staff accessed resident service plans via a binder outside of the medication room.

On 03/19/25 at 3:46 pm, Staff 3 confirmed that there was no service plan for Resident 6 currently available to care staff.

The need to ensure service plans were readily available to all staff was reviewed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings. A service plan was printed and made available to care staff as of 11:35 am on 03/20/25.

5. Resident 1 was admitted to the facility in 09/2024, with diagnoses including arthritis, anxiety, and depression.

Review of Resident 1’s service plan, dated 03/11/25, interim service plans, and interviews with staff and the resident indicated the service plan was not reflective or did not provide clear direction to staff in the following areas:

* Meals: food and fluid preferences;

* Activities: limitations and adaptations;

* Ambulation ability;

* Cognitive decline; and

* Pain issues.

On 03/20/25, the need to ensure service plans were reflective of current resident care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RCC). They acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and/or provided clear direction to staff regarding the delivery of services for 2 of 4 sampled residents (#s 9 and 12) whose service plans were reviewed. This is a repeat citation. Findings include but are not limited to:

1. Resident 9 moved into the facility in 09/2024 with diagnoses including chronic kidney disease stage 5 and peripheral vascular disease.
The resident's record, including the most recent service plan, dated 06/04/25, interim service plans, and progress notes dated 05/20/25 through 06/15/25, were reviewed. Observations were made, staff were interviewed, and the following was identified:

The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Level of assistance with ADLs;
* Mobility status;
* Use of a hospital bed with an air mattress; and
* Use of side rails, including safety precautions.

On 06/18/25, the need to ensure service plans provided clear direction to staff was reviewed with Staff 2 (RCC), Staff 4 (RN), Staff 5 (Memory Care Coordinator), and Witness 1 (RN Consultant). They acknowledged the findings.

2. Resident 12 was admitted to the facility in 03/2020 with diagnoses including neuropathy.

During the acuity interview on 06/16/25, Resident 12 was identified as having fractured his/her tibia in a fall and was a two-person transfer.

A review of the resident’s service plan, most recently updated on 06/11/25, was completed, observations of the resident were made, and interviews with the resident and staff were conducted. The following was identified:

* The service plan noted the resident had two transfer poles;
* There was no indication where the transfer poles were located in the resident’s apartment; and
* There were no instructions to staff regarding the use of or the precautions for the use of the transfer poles.

At 9:41 am on 06/17/25, the surveyor observed a transfer pole in the resident’s living room, on the left side of his/her recliner. Resident 12 reported s/he used it every time s/he got in or out of the recliner. S/he stated there was also a transfer pole next to his/her bed. At 10:00 am the transfer pole was observed on the left side of the resident’s bed. The surveyor attempted to move the pole and discovered it was loose. The surveyor checked the transfer pole beside the recliner, and it was not loose.

On 06/17/25 at 10:05 am, two staff were observed transferring the resident from his/her recliner to his/her wheelchair for toileting. At approximately 10:12 am, staff were observed transferring the resident back to his/her recliner from his/her wheelchair. During both transfers the resident used the transfer pole next to his/her recliner.

The need to ensure service plans included instructions to staff related to the provision of care was discussed with Staff 2 (RCC), Staff 4 (RN), Staff 5 (Memory Care Coordinator), and Witness 1 (RN Consultant) on 06/18/25 at 2:45 pm. They acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

Based on 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 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6). Findings include, but are not limited to:

Resident 1, 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.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director) and Staff 2 (RCC) during the survey. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure a risk agreement included all required elements for 1 of 1 sampled resident (#3) with a risk agreement. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 01/2022 with diagnoses including congestive heart failure and history of cerebral infarction (stroke).

The resident’s medical record was reviewed on 03/17/25, and the following was identified:

On 12/12/24, the facility’s previous RN completed an assessment regarding Resident 3’s ability to self-administer his/her own medication. The RN documented the resident was able to open containers and take medications without assistance, was able to distinguish time, and “[Resident] takes the med[ication] [his/her] son organizes them.” There was no documented evidence the resident was unable to self-administer his/her medications safely.

On 12/20/24, the RN completed an “Informed/Negotiated Risk Agreement” form, also known as a managed risk agreement, with Resident 3’s son.

The risk agreement document failed to address all required areas, including:

*Possible negative consequences to the resident or others;

*Description of the resident’s preference;

*Description of the services the facility should provide to accommodate the resident’s choice or minimize the potential risk;

*Inclusion of the final agreement on the resident’s service plan; and

*Evidence that the licensing policy analyst was consulted, and alternatives were reviewed before the resident signed the agreement.

There was no documented evidence that the facility involved the resident in developing the risk agreement.

During an interview on 03/18/25 at 9:30 am, Staff 1 (ED) stated the RN was no longer employed by the facility, and Staff 1 had been unaware of this risk agreement. Staff 1 stated she had no additional information and confirmed there was no documented evidence the resident was involved in the agreement or that the licensed policy analyst had been contacted.

The need to ensure risk agreements included all required elements was reviewed with Staff 1, Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

OAR 411-054-0036 (6) Service Plan: Managed Risk

(6) RISK AGREEMENT. When a resident's actions or choices pose a potential risk to that resident's health or well-being, the facility may utilize a risk agreement to explore alternatives and potential consequences with the resident.
(a) The facility must identify the need for and develop a written risk agreement following the facility's established guidelines and procedures. A risk agreement must include:
(A) An explanation of the cause of concern;
(B) The possible negative consequences to the resident or others;
(C) A description of the resident's preference;
(D) Possible alternatives or interventions to minimize the potential risks associated with the resident's current preferences and actions;
(E) A description of the services the facility shall provide to accommodate the residents' choice or minimize the potential risk; and
(F) The final agreement, if any, reached by all involved parties, must be included in the service plan.
(b) The licensing policy analyst must be consulted and alternatives reviewed before the resident signs the agreement.
(c) The facility must involve the resident, the resident's designated representative, and others as indicated, to develop, implement, and review the risk agreement. The resident's preferences shall take precedence over those of a family member.
(d) A risk agreement shall not be entered into or continued with, or on behalf of, a resident who is unable to recognize the consequences of their behavior or choices.
(e) The risk agreement must be reviewed at least quarterly.

This Rule is not met as evidenced by:

OAR 411-054-0036 (6) Service Plan: Managed Risk

(6) RISK AGREEMENT. When a resident's actions or choices pose a potential risk to that resident's health or well-being, the facility may utilize a risk agreement to explore alternatives and potential consequences with the resident.
(a) The facility must identify the need for and develop a written risk agreement following the facility's established guidelines and procedures. A risk agreement must include:
(A) An explanation of the cause of concern;
(B) The possible negative consequences to the resident or others;
(C) A description of the resident's preference;
(D) Possible alternatives or interventions to minimize the potential risks associated with the resident's current preferences and actions;
(E) A description of the services the facility shall provide to accommodate the residents' choice or minimize the potential risk; and
(F) The final agreement, if any, reached by all involved parties, must be included in the service plan.
(b) The licensing policy analyst must be consulted and alternatives reviewed before the resident signs the agreement.
(c) The facility must involve the resident, the resident's designated representative, and others as indicated, to develop, implement, and review the risk agreement. The resident's preferences shall take precedence over those of a family member.
(d) A risk agreement shall not be entered into or continued with, or on behalf of, a resident who is unable to recognize the consequences of their behavior or choices.
(e) The risk agreement must be reviewed at least quarterly.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated, referred to the RN for assessment and the service plan was updated as needed, and/or failed to 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 on all shifts, and document weekly progress until the condition resolved for 6 of 8 sampled residents (#s 1, 3, 4, 6, 7 and 8) who experienced changes of condition. Resident 3 experienced repeated falls with injuries including facial abrasions, and a decline in functioning which included changes to cognition, communication, swallowing, and mobility. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2022 with diagnoses including congestive heart failure and history of cerebral infarction (stroke).

The resident's most recent evaluation, dated 12/26/24, current service plan available to staff, dated 02/27/25, and 12/17/24 through 03/16/25 Progress Notes and hospice notes were reviewed, interviews with staff were conducted, and observations of the resident were completed. The following was identified:

a. Resident 3 experienced the following short term changes of condition:

*02/03/25: Resident 3 was found laying on the floor in his/her room and was unable to state what had occurred. Staff documented an abrasion to Resident 3’s forehead and pain in his/her right shoulder. Later that day, staff documented that the resident’s “right wrist has a deep purple bruise on it.”

*02/05/25: Incident report stated the resident was found in front of a table in his/her room, and s/he was unable to tell staff what had happened. The resident had bleeding from his/her brow line next to his/her eye and a skin injury to his/her right knee.

*02/21/25: Progress notes stated the resident “was getting up to go to the bathroom” but “did not know how [s/he] ended up on the floor.” Resident 3 sustained injuries including bleeding and skin abrasion to his/her right knee.

*03/15/25: Resident was found face down on the floor in his/her apartment, fully clothed, at 11:54 pm. Injuries included bruising around the resident’s left eye, swelling to the left side of his/her forehead, an abrasion and bruising on the left side of his/her face and an abrasion on his/her left hand. Throughout the next 15 hours, staff also documented a significant decline in Resident 3’s cognition, ability to speak, ability to swallow, and overall mobility.

There was no documented evidence the facility determined what resident-specific interventions were needed to mitigate the fall risk following each of the above falls; therefore, there was no documented evidence resident-specific interventions were communicated to staff on each shift.

The facility failed to develop interventions to reduce Resident 3's fall risk, and Resident 3 experienced repeated falls with injuries including facial abrasions, knee abrasions, and a decline in functioning which included changes to cognition, communication, swallowing, and mobility.

b. In the resident’s 12/26/24 quarterly evaluation, s/he was noted to self-administer his/her own medication, transferred independently, required stand-by assistance with dressing, and was continent of bowel and bladder.

The resident was admitted to hospice on 01/03/25 after being released from the hospital secondary to acute-on-chronic congestive heart failure and pneumonia.

Upon return to the facility on 01/03/25, the resident was no longer able to self-administer his/her own medication, utilized continuous oxygen and was incontinent of bladder at times. On 01/05/25, the resident was noted to require two-person assistance to transfer to his/her wheelchair. On 01/06/24, the resident was noted to be “assisted” by two care staff “throughout the shift.”

The change in the resident’s ADL needs constituted a significant change of condition. There was no documented evidence that the facility evaluated the resident, referred to the facility RN for assessment, and updated the service plan.

During an interview on 03/18/25 at 9:30 am, Staff 1 (ED) stated that the facility had an RN on staff during the time that the resident experienced the significant change of condition, and the RN left the facility as of 01/21/25. She confirmed there was no documented evidence that the facility evaluated the resident and referred to the RN for assessment.

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

*12/27/24 – Choking incident at dinner;

*01/04/25 – Change in medication;

*01/06/25 – Instructions from hospice stating resident had shoulder pain and is “[two] person assist to wheelchair”;

*01/06/25 – Change in medication;

*01/08/25 – Change in medication;

*01/26/25 – Skin tear to right forearm;

*01/29/25 – Hospital bed delivered;

*01/31/25 – Resident reporting discomfort, staff instructed to be “floating feet on pillows”;

*02/03/25 – Skin abrasion on forehead, bruising on right wrist, increased pain;

*02/04/25 – Change in medication;

*02/05/25 – Skin abrasion on forehead and right knee;

*02/06/25 – Change in medication;

*02/06/25 – Increased difficulty swallowing and new order to crush meds PRN;

*02/07/25 – “Reclining” wheelchair delivered;

*02/09/25 – Scratches above left eye;

*02/21/25 – Skin abrasion and bleeding to right knee;

*02/17/25 – Pain in feet;

*03/11/25 – Skin and treatment changes to right buttock; and

*03/14/25 – Per facility RN, resident “displaying signs of depression” and “is requesting individualized activities.”

The need to ensure the facility evaluated residents who experienced significant changes of condition, referred the resident to the facility nurse, documented the change and updated the service plan as needed; and determined and documented what action or interventions were needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 09/2023 with diagnoses including chronic pain syndrome and Parkinson’s disease.

The resident's progress notes dated 12/17/24 through 03/16/25 were reviewed, interviews with staff were conducted, and observations of the resident were completed. There was no current service plan or interim service plan documentation available for Resident 6.

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

*01/27/25 – New behavior, sexual behavior in public space;

*02/13/25 – New behavior, taking and hiding items from the public dining room; and

*03/03/25 – Skin concern on the right side of the resident’s face.

The need to ensure the facility determined and documented actions or interventions needed for short-term changes of condition, communicated the interventions to staff on all shifts and monitored the short-term changes of condition at least weekly through resolution was reviewed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 10/2020 with diagnoses including aortic stenosis, chronic obstructive pulmonary disease and congestive heart failure.

The resident's service plan available to staff dated 03/13/25 and MARs and progress notes dated 12/29/24 to 03/17/25 were reviewed, observations were made, and interviews with staff and the resident were conducted. There were no interim service plans available for review.

The following short-term changes 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:

* 01/04/25 - New medication (Vistaril);

* 01/16/25 - Bruise on the lateral right calf;

* 01/28/25 - Chest pain with hospitalization;

* 02/04/25 - Return from hospital with multiple medication changes;

* 02/06/25 - Hydrocodone changed from scheduled to as needed for pain;

* 02/14/25 - New medication (Omeprazole);

* 02/25/25 - Admit to hospice services from palliative care;

* 02/26/25 - Increased confusion;

* 02/26/25 - Hydrocodone discontinued, and acetaminophen ordered every 12 hours scheduled;

* 02/28/25 - Multiple medications discontinued;

* 03/07/25 - Fall with injuries: Two abrasions lateral right knee, and pain to the right knee and back of head;

* 03/08/25 - Unwitnessed fall;

* 03/09/25 - Three skin tears on left posterior ankle, and complaint of right leg pain;

* 03/09/25 - Left foot swelling, warm to touch;

* 03/11/25 - Fall with injuries: bump/bruise left side of temple between hairline and left eye, a bump on left side of head with an open wound, an abrasion to the lower left side of the back, and a skin tear on left outer lower leg above the ankle;

* 03/11/25 - Second fall, non-injury, resident asked to be checked on every 30 minutes;

* 03/13/25 - Medication changes: Discontinued scheduled nightly lorazepam and changed to lorazepam 0.5mg bid at 6:00 am and 6:00 pm;

* 03/13/25 - Bruise to the forehead;

* 03/15/25 - Skin tear to right side of knee; and

* 03/15/25 - Discontinuation of all medications except for comfort medications ordered by hospice.

The need to ensure all changes of condition had actions or interventions determined, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was discussed with Staff 1 (ED) and Staff 2 (RCC) at 10:40 am on 03/20/25. They acknowledged the findings.

4. Resident 1 was admitted to the facility in 09/2024 with diagnoses including arthritis, anxiety, and depression.

Review of Resident 1's progress notes, dated 12/17/24 through 03/17/25, revealed the resident experienced the following changes of condition:

* On 01/23/25, progress notes indicated the resident had a “non-injury fall”;

*On 01/24/25, notes indicated Resident 1 was experiencing back pain, tailbone pain, swelling in feet and legs, and increased weakness; and

*On 01/25/25, progress notes revealed the resident was complaining of headache, hip pain, and had a “quarter sized bruise on the top of [his/her] left hand near [his/her] wrist.”

There was no documented evidence these injuries had actions/interventions developed, or existing fall interventions were monitored for effectiveness. Remove evaluated language unless you are talking about significant change of condition.

On 03/20/25, the need to ensure the facility had a system for evaluating changes of condition, determining actions or interventions needed, and monitoring the conditions to resolution was discussed with Staff 1 (ED) and Staff 2 (RCC). They acknowledged the findings.

5. Resident 8 was admitted to the facility in 11/2024 with diagnoses including hypertension and depression.

The resident had non injury falls on 01/25/25 in the library, and on 02/08/25 in his/her room.

On 02/22/25 Resident 8 fell in the dining room during breakfast and suffered injuries including a fractured nose.

On 02/26/25 a progress note documented “due for care assessment.” The service plan was updated with “moderate risk” for falls and new fall interventions were developed.

On 02/26/25 the incident investigation from the 02/08/25 was completed, and noted “care plan was assessed 2/26/25 fall risk was added with preventative measures.”

Resident 8 was placed on "Alert Charting" after each fall, however, there was no documented evidence the facility reviewed the service plan to determine if the current fall interventions were adequate or whether additional interventions needed to be implemented after each fall until the 02/26/25 care plan update.

Resident 8 was placed on alert charting to monitor pain and bruising from the fall on 02/22/25. There was no documented evidence of further weekly monitoring after 02/26/25.

The facility failed to determine, document and communicate to staff what action or intervention was needed for the resident and there was no documented evidence the facility monitored and documented on the status of the 02/22/25 fall injuries at least weekly until resolved.

The need for a system of responding to falls that included determining and documenting what action/intervention was needed in a way that could be included in the resident's record, updating the resident's service plan as needed, reviewing the service-planned interventions for effectiveness and monitoring and documenting on the status of the condition at least weekly until resolved was reviewed with Staff 1 (Executive Director) and Staff 2 (RCC) on 03/20/25. They acknowledged the findings.

6. Resident 7 was admitted to the facility in 06/2024 with diagnoses including Parkinson’s disease and mild cognitive impairment.

The resident's service plan available to staff dated 07/08/24 and progress notes dated 12/17/24 to 03/17/25 were reviewed, and observations were made. There were no interim service plans available for review.

The following short-term changes 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:

*01/04/25 – Fall with scraped leg;

*01/30/25 – Fall with head strike;

*02/23/25 – Fall with facial redness;

*03/11/25 – Fall with head wound and wound to back of left hand; and

*03/16/25 – Fall with abrasion “rug burn” to left shoulder.

Resident 7 was placed on "Alert Charting" after each fall, however, there was no documented evidence these injuries had actions/interventions developed, or existing fall interventions were monitored for effectiveness.

The need to ensure all changes of condition had actions or interventions determined, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was discussed with Staff 1 (ED) and Staff 2 (RCC) at 10:40 am on 03/20/25. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed to include documented findings, resident status, and interventions made as a result of the assessment for 4 of 4 sampled residents (#s 2, 3, 4, and 5) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 11/2024 with diagnoses including hypertension and depression.

Weight records, dated 11/3/24 through 03/17/25, and progress notes, dated 11/03/24 through 03/17/25, were reviewed and indicated the resident experienced significant weight gain:

* 11/24/24: 125 pounds;

* 12/11/24: 132.6 pounds = 6% weight gain in 17 days;

* 01/25/25: 133.8 pounds; and

* 02/25/25: 131 pounds.

Between 11/24/24 and 12/11/24 the resident gained 7.6 pounds, or 6.08% of total body weight in 17 days. This weight change constituted a significant change of condition.

The facility RN did not assess the weight change but instead notified Resident 2’s physician. On 12/13/24 the physician responded, “will likely need evaluation for this weight gain.”

In interview on 03/20/25, Staff 1 (ED) and Staff 2 (RCC) confirmed the facility RN at the time did not complete an evaluation or assessment of the significant weight gain.

Observations of the resident between 03/17/25 and 03/20/25 showed the resident eating meals in the dining room. The resident was observed to eat over 75% of the observed lunch meals, without staff assistance.

A weight of 137 lbs was obtained on 03/20/25, at the request of the surveyor, and Staff 2 stated that weight gain would be assessed by an RN.

The need to ensure an RN assessment was completed for a significant change of condition, which documented findings, resident status, and interventions made, was discussed with Staff 1 and Staff 2 on 03/20/25 at 2:00 pm. They acknowledged the findings.

Resident 4 was admitted to the facility in 10/2020 with diagnoses including aortic stenosis, chronic obstructive pulmonary disease, and congestive heart failure.

During the acuity interview on 03/17/25, staff reported the resident had a change of condition with weight loss, cognitive and ADL decline.

Observations of Resident 4 during survey revealed s/he remained in bed with family at bedside.

On 03/17/25 during an interview, Witness 1 (Family member) reported that Resident 4 stayed in bed now. “She’s too weak to get up.” She reported assistance from two care staff was being provided with bed mobility, incontinent cares, dressing and transfers. One person full assist was provided by care staff for grooming and hygiene tasks. She stated that prior to a hospitalization in 02/2025 Resident 4 was independent with mobility using a walker, ate independently, and was independent with all ADL tasks.

Interviews with staff and review of the resident's 03/13/25 service plan, and 12/29/24 through 03/17/25 progress notes, were completed.

The service plan indicated the resident used a walker for mobility and staff were to anticipate all needs. There were no additional instructions related to mobility or ADL assistance needed.

Staff 20 (CG) reported that Resident 4 had declined, was not eating or drinking much, was significantly weaker, extremely confused, and had primarily remained in bed over the last two weeks. The resident was no longer able to walk, needed two persons assist for mobility, toileting, dressing, and one person full assist for all other ADL tasks.

Staff 4 (RN) completed an assessment for the resident’s significant change of condition on 03/07/25. The assessment included information that Resident 4 had declined with increased confusion, decreased oral intake, dysphagia, anxiety and depression which led to Resident 4 being admitted to hospice.

The RN assessment completed did not include the resident’s significant decline in strength and mobility, with increase assistance in all areas of care and mobility in the 03/07/25 assessment. Additionally, the interventions determined from the RN assessment were not implemented.

During an interview with Staff 4 on 03/18/25, he acknowledged the resident’s decline in mobility and ADLs, and indicated it was expected, as Resident 4 was on hospice.

The need to ensure an RN assessment was completed for significant changes of condition which included resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED), and Staff 2 (RCC) on 03/20/25. No further documentation was provided.

3. Resident 5 was admitted to the facility in 06/2031 with diagnoses including paranoid schizophrenia, hypothyroidism, and depression.

Weight records, dated 10/25/24 through 02/25/2025, and progress notes, dated 12/06/24 through 03/17/25, were reviewed and indicated the resident experienced significant weight gain:

* 11/25/24: 187 pounds;

* 12/09/24: 199.2 pounds = 6.50% weight gain in 14 days;

* 01/25/25: 191.2 pounds; and

* 02/25/25: 194.2 pounds.

Between 11/25/24 and 12/09/24 the resident gained 12.2 pounds, or 6.50% of total body weight in 14 days. This weight change constituted a significant change of condition.

There was no documented evidence the facility RN completed an assessment of the significant weight change.

In interview on 03/20/25, Staff 1 (ED), Staff 3 (RCC), and Staff 4 (RN) confirmed the facility RN at the time did not complete an assessment of the significant weight gain.

Observations of the resident between 03/17/25 and 03/20/25 showed the resident eating meals in the dining room. The resident was observed to eat over 75% of the observed lunch meals, without staff assistance.

The need to ensure an RN assessment was completed for a significant change of condition, which documented findings, resident status, and interventions made, was discussed with Staff 1, Staff 3 and Staff 4 at 10:40 am on 03/20/25. They acknowledged the findings.

Resident 3 was admitted to the facility in 01/2022 with diagnoses including type 2 diabetes and history of cerebral infarction (stroke).

The resident's most recent evaluation, dated 12/26/24, current service plan available to staff, dated 02/27/25, and 12/17/24 through 03/16/25 progress notes and hospice notes were reviewed, interviews with staff were conducted, and observations of the resident were completed. The following was identified:

In the resident’s 12/26/24 quarterly evaluation, s/he was noted to self-administer his/her own medication, transferred independently, required stand-by assistance with dressing, and was continent of bowel and bladder.

The resident was admitted to hospice on 01/03/25 after being released from the hospital secondary to acute-on-chronic congestive heart failure and pneumonia.

Upon return to the facility on 01/03/25, the resident was no longer able to self-administer his/her own medication, utilized continuous oxygen and was incontinent of bladder at times. On 01/05/25, the resident was noted to require two-person assistance to transfer to his/her wheelchair. On 01/06/24, the resident was noted to be “assisted” by two care staff “throughout the shift.”

The change in the resident’s ADL needs constituted a significant change of condition. There was no documented evidence that a timely RN assessment occurred for the significant change of condition.

The need to ensure all significant changes of condition were assessed timely by an RN was reviewed with Staff 1, Staff 2 (RCC) and Staff 4 at 11:35 am on 03/20/25. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure treatment orders were carried out as prescribed and failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all treatments the facility was responsible to administer for 2 of 2 sampled Residents (#s 3 and 4) whose treatment orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2022 with diagnoses including congestive heart failure and history of cerebral infarction (stroke).

Resident 3's current physician's orders, MAR dated 02/01/25 through 03/16/25, and progress notes dated 12/17/24 through 03/16/25 were reviewed. The following was identified:

a. The resident had a physician’s order for PRN albuterol sulfate (for shortness of breath) and PRN oxygen at 2 liters per minute (for shortness of breath). The orders were not carried out as prescribed, as the treatments were not included on the MAR and therefore unavailable for staff to administer as ordered.

b. On 02/21/25 and 02/23/25, unlicensed staff documented treating a wound on the resident’s right knee, including applying antibiotic cream, taping a pad over the wound, and changing the bandage. There was no documented evidence of a signed physician’s order for this treatment.

The need to ensure all treatments were carried out as prescribed and written signed physician orders were documented in the resident’s facility record was reviewed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 10/2020 with diagnoses including congestive heart failure and was on hospice services.

Resident 4's current physician's orders, MAR dated 02/01/25 through 03/16/25, and progress notes dated 12/29/24 through 03/16/25 were reviewed.

Two orders were received on 03/10/25 from the hospice provider for wound care:

* Left foot, third toe: “Cleanse with wound spray and gauze. Apply single layer of xeroform. Pad with cast cotton. Secure with opsite. Change prn dislodged or soiled and at least 2 x weekly;” and

* “Wound care right medial ankle skin tear: Cleanse with wound spray and gauze. Apply 2 layers of xeroform. Cover with cast cotton and secure with opsite. Change 2 x weekly and prn dislodged or soiled.”

Review of the 03/2025 MAR/TAR found neither treatment listed.

During an interview with Staff 16 (MT) on 03/18/25 at 1:50 pm, she reported the treatment orders were never put into the electronic MAR/TAR system.

On 03/18/25 at 2:00 pm Staff 4 (RN) reported the orders did not make it past the second check and verified the treatment orders were not implemented.

The need to ensure all treatments were carried out as prescribed was reviewed with Staff 1 (ED), and Staff 2 (RCC) at 10:40 am on 03/20/25. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as written for 1 of 4 sampled residents (#12). This is a repeat citation. Findings include, but are not limited to:

Resident 12 was admitted to the facility in 03/2020 with diagnoses including neuropathy.

A review of the resident’s 06/01/25 through 06/16/25 MAR and signed physician orders revealed the resident had the following orders for pain medication:

* Acetaminophen 500 mg, two tablets three times daily at 6:00 am, 2:00 pm, and 8:00 pm;
* Acetaminophen 500 mg tablets, one tablet by mouth every six hours as needed for pain; and
* Ibuprofen 600 mg, one tablet every 8 hours as needed for pain “if Tylenol not working.”

The MAR included the following parameters for ibuprofen:

* “Do not give within 1 hr of scheduled pain medication. Try 2nd.Unless unable to give Tylenol PRN, then give 1st [sic].”

The resident was administered ibuprofen on 06/07/25 at 7:33 pm and 06/08/25 at 9:48 pm. There was no record of acetaminophen being administered and being ineffective prior to the ibuprofen being administered. The 06/07/25 administration of ibuprofen occurred less than 30 minutes prior to a scheduled administration of acetaminophen.

In an interview on 06/18/25 at 10:58 am, Staff 18 (MT) reported ibuprofen was administered to the resident first, instead of administering acetaminophen first, because “it was helping more” than the acetaminophen.

The need to carry out physician orders as written was discussed with Staff 2 (RCC), Staff 4 (RN), Staff 5 (Memory Care Coordinator), and Witness 1 (RN Consultant) on 06/18/25 at 2:45 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to consistently notify the physician when a resident refused consent to an order, for 1 of 1 sampled resident (# 1) with documented refusals of ordered medications or treatments. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2024, with diagnoses of arthritis, anxiety, and depression.

Review of Resident 1’s MAR, dated 02/01/25 through 03/17/25, indicated the resident refused the following prescribed medications, topical treatments or taking of vital signs:

* Diclofenac sodium 1% gel - on 17 occasions;

* PEG3350 17 gram powder – on three occasions;

* Acetaminophen 325 mg – on two occasions;

* Carvedilol 3.125 mg – once; and

* Daily weight – once.

The facility failed to notify the prescribing physician of each of these refusals.

On 03/20/25, the need to ensure the physician was notified each time a resident refused consent to an order was discussed with Staff 1 (ED) and Staff 2 (RCC). They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions for PRN medications were included on the MAR and/or the MAR included all required components, including medication specific instructions, for 4 of 6 sampled residents (#s 1, 3, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 06/2021 with diagnoses including schizophrenia and depression.

The resident's 02/01/25 to 03/17/25 MAR was reviewed and revealed the following:

a. PRN medications for pain lacked resident-specific parameters for administration as follows:

* Acetaminophen 500 mg, one tablet every six hours as needed for pain; and

*Acetaminophen 500 mg, two tablets every six hours as needed for pain.

b. Haloperidol 2mg every day as needed for anxiety lacked information for staff as to how the resident would exhibit symptoms of anxiety.

The need to ensure medications contained resident-specific parameters and instructions for administration was discussed with Staff 1 (ED), Staff 2 (RCC), and Staff 4 (RN) at 10:40 am on 03/20/25. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 01/2022 with diagnoses including congestive heart failure and history of cerebral infarction (stroke).

The resident’s MAR, dated 02/01/25 through 03/16/25, and physician’s orders were reviewed. The following was identified:

a. The resident had two PRN medications for pain which did not have parameters for order of administration:

*Morphine Sulfate 20mg/ml (.25ml / 5 mg per dose); and

*Acetaminophen 650 mg.

b. The resident had two PRN medications for restlessness, agitation and/or nausea which did not have parameters for order of administration:

*Haloperidol 2.5 mg; and

*Lorazepam 0.5 mg.

The resident was administered PRN haloperidol and lorazepam at the same time on 3/11/25 with no notes regarding reason for administration.

c. The resident had two PRN medications for shortness of breath which did not have parameters for order of administration:

*Morphine Sulfate 20mg/ml (.25ml / 5 mg per dose); and

*Lorazepam 0.5 mg.

The need to ensure the MAR was accurate and that PRN medications included resident-specific parameters and instructions for administration was reviewed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 09/2023 with diagnoses including chronic pain syndrome and Parkinson’s disease.

The resident’s MAR dated 02/01/25 through 03/16/25 and physician’s orders were reviewed. The following was identified:

a. The MAR listed PRN docusate sodium (for constipation), “[one] to [three] capsules” by mouth every four hours as needed. There were no specific instructions to the unlicensed staff regarding how many capsules to administer to the resident.

b. The MAR listed PRN stimulant laxative plus (for constipation) “[one] to [four] capsules.” There were no specific instructions to the unlicensed staff regarding how many capsules to administer to the resident.

c. The resident had three PRN medications for constipation which did not include resident-specific parameters for order of administration:

*Docusate sodium 100 mg;

*Stimulant laxative plus 8.6-50 mg; and

*Milk of magnesia 400 mg/5 ml.

The need to ensure all PRN medications had resident-specific parameters and instructions was reviewed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

4. Resident 1 was admitted to the facility in 09/2024, with diagnoses including diverticulosis, anxiety, and depression.

Review of Resident 1’s MAR, dated 02/01/25 through 03/17/25, revealed the following:

a. There were two PRN pain medications prescribed for the resident. These were:

* Acetaminophen 325 mg, with instructions to try first when pain rating was 1-4 (0n 1-10 scale); and

* Acetaminophen-codeine 300-30 mg, to be used when pain rating was 5-10.

There were multiple administrations of both PRN medications, but no documentation of the pain levels.

b. The MAR included a routine medication for pain, diclofenac sodium 1% gel, with instructions to “apply 4 grams topically to affected area four times daily”. There were 16 administrations of this medication without documentation of the application site.

On 03/20/25, the need to ensure a complete and accurate MAR was kept, including PRN parameters and application sites for topical medications was discussed with Staff 1 (ED) and Staff 2 (RCC). They acknowledged the findings.

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.

This Rule is not met as evidenced by:

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure there was a self-administration evaluation and a physician order of approval for a resident to self-administer medication for 1 of 1 sampled resident (#10) who self-administered medication. Findings include, but are not limited to:

Resident 10 was admitted to the facility in 04/2023 with diagnoses including frequent urinary tract infections (UTIs).

The resident’s 06/01/25 through 06/16/25 MAR and signed physician orders were reviewed. Staff were interviewed. The following was identified.

* There was an order for estradiol 0.01% cream (to treat UTIs), place 1 gram vaginally three times weekly at bedtime.

* The MAR indicated staff did not administer this medication.

There was no documented evidence a self-administration evaluation had been completed determining the resident was able to safely self-administer medication.

There was no physician order of approval for the resident to self-administer the estradiol.

The need to have a current self-administration evaluation which determined the resident was able to safely self-administer medication, as well as to have a physician’s order of approval for self-administration, was discussed with Staff 2 (RCC), Staff 4 (RN), Staff 5 (Memory Care Coordinator), and Witness 1 (RN Consultant) on 06/18/25 at 2:45 pm. They acknowledged the findings.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds

(5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual care plan and service plan for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 6) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include but are not limited to:

The facility's ABST was reviewed during the survey 03/17/25 through 03/20/25.

Review of Residents 1, 2, 3, 4 and 6’s ABST revealed multiple ADLs were not reflective of the residents' evaluated care needs.

The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings. No further information was provided.

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in for 1 of 1 sampled resident (#2) and multiple unsampled residents, no less than quarterly at the same time of service plan update and/or with a significant change of condition for 5 of 5 sampled residents (#s 1, 3, 4, 5, and 6) and multiple unsampled residents, and failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. Findings include but are not limited to:

During the acuity interview on 03/17/25, Staff 3 (Interim RCC) confirmed the facility census was 70 residents.

1. The facility’s ABST data was retrieved at 8:03 am on 03/17/25 and reviewed during the survey 03/17/25 through 03/20/25. The following was revealed:

a. One sampled resident (#2) and five unsampled residents had no ABST data.

b. Of the 64 residents with ABST data, a total of 58 residents, including residents # 1, 3, 4, 5 and 6 and multiple unsampled residents, did not have evidence that the ABST was updated quarterly at the same time as the service plan update and/or with a significant change of condition. Of those 58 residents, 34 were most recently updated in 2023.

2. The facility’s posted staffing plan was documented as last updated on 02/20/25. The facility’s schedule and time cards dated 03/09/25 through 03/16/25 were reviewed. The following was identified:

The posted staffing plan for the facility was as follows:

* Day shift: 4 CG, 2 MT;

* Swing shift: 4 CG, 2 MT; and
* Night shift: 3 CG, 1 MT.

Review of the facility schedule and corresponding timecards from 03/09/25 through 03/16/25 revealed the facility failed to staff per the posted staffing plan on:

* Day shift: 75% of shifts;

* Swing shift: 50% of shifts; and

* Night shift: 37% of shifts.

The facility failed to staff per the posted staffing plan for a total of 54% of shifts during the reviewed time period.

The need to ensure residents’ ABST evaluations were updated before move-in, with significant changes of condition, and no less than quarterly with the service plan, and the need to ensure consistent staffing to meet or exceed the posted staffing plan was discussed with Staff 1 (ED), Staff 2 (RCC) and Staff 4 (RN) at 11:35 am on 03/20/25. They acknowledged the findings.

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

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

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) data for each resident was updated no less than every 90 days for multiple unsampled residents. This is a repeat citation. Findings include, but are not limited to:

The facility’s ABST data was reviewed on 06/17/25. It was determined that the data for 22 of the 62 residents in the facility at that time had not been updated within the last 90 days.

The need to update residents’ ABST data no less than 90 days to coincide with the quarterly service plan was discussed with Staff 2 (RCC), Staff 4 (RN), Staff 5 (Memory Care Coordinator), and Witness 1 (RN Consultant) on 06/18/25 at 2:45 pm. They acknowledged the findings.

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 12, 14, and 19) demonstrated satisfactory performance in all assigned duties within 30 days of hire or prior to beginning assigned duties. Findings include, but are not limited to:

There was no documented evidence staff demonstrated competency within 30 days of hire of the following required elements:

Staff 12 (MT) hired on 05/02/24:

*Conditions that require assessment, treatment, observation, reporting.

Staff 14 (MT) hired on 09/03/24:

*Documented medication training prior to starting duties; and

*First aid / abdominal thrust.

Staff 19 (CG) hired on 01/09/25:

*Role of service plans in providing individualized care;

*Changes associated with normal aging;

*ADL assistance;

*Identification, documentation and reporting of changes of condition;

*Conditions that require assessment, treatment, observation, reporting; and

*General food safety.

The requirements for documented demonstration of competence for employees were reviewed with Staff 6 (Business Office Manager) on 03/19/25. The requirement was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 03/20/25 at 3 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long term staff (#s 13 and 15) completed a minimum of 12 hours of annual in-service training as required. Findings include, but are not limited to:

There was no documented evidence staff completed the following:

Staff 13 (CG) hired on 06/04/19:

*12 hours of in-service training; and

*Infectious disease training within the last 2 years.

Staff 15 (CG) hired on 02/13/22:

*12 Hours on in-service training.

The requirement to complete and document annual training for staff was reviewed with Staff 4 (Business Office Manager) on 03/19/25. The requirement was reviewed with Staff 1 (ED) and Staff 2 (RCC) on 03/20/25 at 3:00 pm. They acknowledged the findings.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff

(6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF.

(a) Annual infectious disease training requires the following:
(A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training.
(B) Annual in-service training must be documented in the employee record.

(b) Biennial LGBTQIA2S+ training requires the following:
(A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff.
(i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite.
(ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility.

(B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either:
(i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or
(ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility.

(C) ORS 441.116 requires all LGBTQIA2S+ trainings address:
(i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus.
(ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status.
(iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status.
(iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns.
(v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination.
(vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training.
(vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state.

(D) The proposal for training submitted by a facility, entity, or individual shall include:
(i) The regulatory criteria described in paragraph (C) of this section as part of the proposal.
(ii) The following elements must be included in the proposal:
(I) A statement of the qualifications and training experience of the facility, individual or entity providing the training;
(II) The proposed methodology for providing the training either online or in person.
(III) An outline of the training.
(IV) Copies of the materials to be used in the training.
(iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision.

(c) Annual Home and Community-Based Services (HCBS) training requires the following:
(A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations.
(B) Annual in-service training must be documented in the employee record.
(C) These annual trainings will be required as of April 1, 2025.

(7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF.
(a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually 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, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire.
(b) Requirements for annual in-service dementia training:
(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.
(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.
(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.
(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.
(E) The facility shall determine the competency of direct care staff in dementia care in the following ways:
(i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19).
(ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff.
(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency.

(8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

This Rule is not met as evidenced by:

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff

(6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF.

(a) Annual infectious disease training requires the following:
(A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training.
(B) Annual in-service training must be documented in the employee record.

(b) Biennial LGBTQIA2S+ training requires the following:
(A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff.
(i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite.
(ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility.

(B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either:
(i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or
(ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility.

(C) ORS 441.116 requires all LGBTQIA2S+ trainings address:
(i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus.
(ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status.
(iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status.
(iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns.
(v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination.
(vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training.
(vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state.

(D) The proposal for training submitted by a facility, entity, or individual shall include:
(i) The regulatory criteria described in paragraph (C) of this section as part of the proposal.
(ii) The following elements must be included in the proposal:
(I) A statement of the qualifications and training experience of the facility, individual or entity providing the training;
(II) The proposed methodology for providing the training either online or in person.
(III) An outline of the training.
(IV) Copies of the materials to be used in the training.
(iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision.

(c) Annual Home and Community-Based Services (HCBS) training requires the following:
(A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations.
(B) Annual in-service training must be documented in the employee record.
(C) These annual trainings will be required as of April 1, 2025.

(7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF.
(a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually 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, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire.
(b) Requirements for annual in-service dementia training:
(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.
(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.
(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.
(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.
(E) The facility shall determine the competency of direct care staff in dementia care in the following ways:
(i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19).
(ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff.
(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency.

(8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

This Rule is not met as evidenced by:

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

Six months of fire drill records were reviewed on 03/17/25, and revealed the following:

a. Fire drills lacked documentation of one or more of the following components:

* The escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time-period needed;

* Number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

In an interview on 03/17/25, Staff 1 (ED) acknowledged the documentation lacked one or more of the required components.

b. The facility failed to provide fire and life safety instruction to staff on alternate months.

In an interview on 03/17/25, Staff 1 confirmed staff were not provided fire and life safety instruction on alternating months.

The need to ensure fire drills were conducted according to Oregon Fire Code with all required components documented and fire and life safety instruction to staff was provided on alternating months was discussed with Staff 1 and Staff 2 (RCC) on 03/20/25. They acknowledged these findings.

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents were provided fire and life safety training within 24 hours of admission according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Facility Fire and Life Safety records from 10/2025 to 03/2025 were reviewed on 03/17/25. The following was identified:

The facility fire and life safety records lacked documented evidence residents were provided training and instruction on fire and life safety within 24 hours of admission to the facility.

The need to ensure residents were instructed on fire and life safety procedures within 24 hours of admission to the facility was discussed with Staff 1 (ED) on 03/20/25 at 10:40 am. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:

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

Refer to C260, C303, and C363.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common areas were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

A tour of the facility on 03/19/25 at 10:30 am revealed the following:

The 3rd floor laundry room sink used by residents, had water that when turned on, was hot to the touch. The hot water temperature, taken by the surveyor with a digital thermometer, was 132 degrees Fahrenheit.

Room 335, Room 235, the second-floor laundry room, and the first-floor public restroom used by residents were tested and found to be between 125 and 129 degrees Fahrenheit.

On 03/19/25 at 10:45 am, Staff 1 (ED) observed the water temperature in the 3rd floor laundry room sink, along with the surveyor, and acknowledged the water temperature exceeded 120 Fahrenheit. Staff 1 stated she would work with Staff 9 (Maintenance Director) to ensure the temperatures were lowered to within the correct range and monitored.

On 03/19/25 at 3:45 pm water temperatures were tested again and found to be within the required range.

The need to ensure hot water temperatures were monitored and maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 1 and Staff 2 (RCC) on 03/20/25. They acknowledged the findings.

OAR 411-054-0200 (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.

This Rule is not met as evidenced by:

OAR 411-054-0200 (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.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 08/22/2023, 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 08/22/23, conducted 11/01/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 08/22/23 revealed the following:a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:* Can opener blade and casing;* Commercial meat slicer; * Industrial and table top mixer;* Open stainless steel shelving throughout kitchen; * Floors underneath shelving and equipment;* Walls behind equipment;* Service/utility carts;* Dish machine top;* Walls in dry storage area;* Walls behind and near the dish machine;* Fan over steam table and range;* Ceiling vent; and * Walk in freezer floor.b. Commercial meat slicer and industrial stand mixer were not covered when not in use. c. Green and white cutting boards were found with deep scoring and staining. d. Exterior and interior of the oven, range top, and grease trap of grill were found with food debris build up and grease. Convection oven interior and exterior were found with food debris build up and grease. e. Kitchen staff were observed handling clean dishes after handling dirty dishes without washing or sanitizing hands.f. Ice machine was observed with visible black and pink substances on interior of machine.g. Cafe bar straws were stored without cover or individual wrappers. Disposable single service straws and utensils were stored with food contact portions open to potential contamination.h. Tables in the dining area were set with cutlery with food surface contact areas exposed to potential contamination.i. Ready to eat food items were observed on plate without cover or serving utensil in the cafe bar.Staff 2 (Dining Services Director) and the Surveyors toured the kitchen. Staff 2 acknowledged the above findings.The areas in need of cleaning, repair and attention were reviewed with Staff 1 (Administrator) and Staff 2 on 08/22/23 at 1:10 pm. They acknowledged the findings.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 04/27/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 12/01/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and observation it was confirmed the facility failed to have medical and other records kept confidential except as otherwise provided by law. Findings include: During an onsite interview on 12/1/2022, Staff #5 (S5) stated that it is typical for the facility to post service plans on a cork board outside the medication room for staff to read and acknowledge the new or updated service plans. S5 stated that this is not a new process and has been done for some time now. During an unannounced site visit on 12/1/2022, Compliance Specialist (CS) observed 5 service plans on a cork board near the medication room out in the open for anyone to see and read. On 12/1/2022, these findings were reviewed and acknowledged by S1. Plan of Correction: S1 stated they will remove the service plans after CS leaves and put them in an area of only staff to obtain.

Based on interview, observation, and record review it was confirmed that the facility failure to have awake qualified direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents. Findings include: During separate interviews on 12/1/2022, Staff #4 (S4) stated that their current staffing levels are 2 Med Tech (MT) and 4 Caregivers (CG) for day and swing shift and 1 MT and 2 CG for NOC shift. Resident #2 (R2) stated that call light response times are long. During an unannounced site visit on 12/1/2022, Compliance Specialist (CS) observed 2 MT and 3 CG working. A review of the staff schedule for October and November 2022, the posted staffing plan, facility ' s Acuity Based Staffing Tool (ABST), call light logs for 11/20/2022-11/24/2022, shower schedule for 11/28/2022-12/4/2022, and service plan and progress notes for Residents #1-3 (R1, R2 and R3). The call light logs indicate 11 occurrences in a four-day time frame where the call lights exceeded the facility ' s 15-minute response time. The longest wait time being 46 minutes. The posted staffing plan stated 1 MT and 3 CG for day and swing shift and 1 MT and 1 CG on NOC shift. The ABST tool has inaccurate numbers stating that on day shift for each day the facility needing 303.5 hours of care resulting in 40 caregivers needed. The staff schedule for October shows multiple occurrences where the facility is understaffing per their indicated staffing levels. On 12/1/2022, these findings were reviewed and acknowledged by Staff #1 (S1). Plan of Correction: Facility retrain and remind staff at change of shift regarding call light response times. Regular auditing of the call light logs to ensure staff are responding timely.

Based on interview, observation, and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During separate interviews on 12/1/2022, Staff #4 (S4) stated that their current staffing levels are 2 Med Tech (MT) and 4 Caregivers (CG) for day and swing shift and 1 MT and 2 CG for NOC shift. Staff #1 (S1) and S4 were unable to express how they use their Acuity Based Staffing Tool (ABST) to generate their current staffing levels based on the amount of caregiving time indicated in the tool. Resident #2 (R2) stated that call light response times are long. During an unannounced site visit on 12/1/2022, Compliance Specialist (CS) observed 2 MT and 3 CG working. A review of the staff schedule for October and November 2022, the posted staffing plan dated 8/15/2019, facility ' s Acuity Based Staffing Tool (ABST), call light logs for 11/20/2022-11/24/2022, shower schedule for 11/28/2022-12/4/2022, and service plan and progress notes for Residents #1-3 (R1, R2 and R3). The call light logs indicate 11 occurrences in a four-day time frame where the call lights exceeded the facility ' s 15-minute response time. The longest wait time being 46 minutes. The posted staffing plan stated 1 MT and 3 CG for day and swing shift and 1 MT and 1 CG on NOC shift. The staffing plan had not been updated since 2019. The ABST tool has inaccurate numbers stating that on day shift for each day the facility needing 303.5 hours of care resulting in 40 caregivers needed. The ABST for Resident #3 (R3) stated that the resident does not need any assistance with showers and bathing. Review of R3 service plan and the shower schedule showed that R3 receives assistance with showers 3 times a week. The staff schedule for October shows multiple occurrences where the facility was understaffing per their indicated staffing levels. On 12/1/2022, these findings were reviewed and acknowledged by S1. Plan of Correction: The facility will reevaluate their ABST to reflect to correct hours of care provided to the residents and correct time needed for residents' current needs. They will change their posted staffing plan as needed once the hours are changed and staff accordingly.

Based on interview and record review it was determined that the facility failed to keep clean and in good repair all interior and exterior materials and surfaces, and all equipment necessary for the health, safety, and comfort of the resident. Findings include: During separate interviews on 12/1/2022, Staff #1-3 (S1, S2 and S3) stated that the dishwasher and disposal were down for a few days, however the facility did call a company to fix the equipment. S2 stated that there is a practical to use the triple sinks for washing dishes. The triple sinks have the soap and sanitation chemicals needed to ensure dishes are clean when washing dishes by hand. S2 stated the memory care side also has a dishwasher and that they are able to wash the dishes there if needed. A review of the receipt for Roto-Rooters stated that on 11/11/2022 the dishwasher and disposal were repaired. On 12/1/2022, these findings were reviewed and acknowledged by S1. Plan of correction: Both the dishwasher and garbage disposal have been fixed and working in good repair since 11/11/2022.

The findings of the kitchen inspection, conducted 11/28/2022, 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 11/28/22, conducted 02/07/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 11/28/22 revealed splatters, spills, drips, dust and debris noted on: - Can opener blade and casing; - Stand mixer; - Interiors of drawers; - Open stainless steel shelving throughout kitchen; - Underneath shelving and equipment; - Floors throughout kitchen; - Plate warmer; - Service/utility carts; - Dish machine top; - Walls behind and near the dish machine; - Baking rack in main kitchen area; - Walls and outlet by food prep area; - Fan over steam table and range - Vents in ceiling; - Walk in freezer floor. * Exterior of the range, range top, grease trap of grill were found with grease and food debris build up. Left oven cover in need of repair.* White cutting boards found with deep scoring and staining. (small portable and long attached on/near steam table).* Dish washing racks were observed stored on the floor. * Kitchen staff was observed serving food with long painted and/or acrylic nails and not wearing gloves.* Kitchen staff observed in kitchen and doing prep and service items without hair being restrained.* Kitchen staff was observed prepping ready to eat food (applesauce in bowls) after touching potentially contaminated items (drawers/fridge handles/etc) directly after returning from dining room service tray delivery without washing hands.* Staff 3 was working in kitchen with expired food handlers card (9/30/2022)Staff 2 (Dietary Manager) and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings.The areas in need of cleaning, repair and attention were reviewed with Staff 1 (Administrator). He acknowledged the findings.

The findings of the re-licensure survey, conducted 10/04/21 through 10/06/21, 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 10/06/21, conducted 1/12/22 through 1/13/22, 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.

2. Resident 5 was admitted to the facility in 10/2019 with diagnoses including diabetes and congestive heart failure.Observations of the resident on 10/04/21 and 10/05/21, interviews with staff, and review of the resident's current service plan and evaluation dated 09/16/21 were conducted during the survey. The quarterly evaluation was not reflective in the following areas:* Current skin conditions;* Significant weight gain; and* Compression stockings.The need to ensure quarterly evaluations were accurate and included documented changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/05/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in move-in evaluations and to ensure quarterly evaluations were completed on time and were reflective of the resident's current care needs for 2 of 5 sampled residents (#s 1 and 5) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2021 with diagnoses including atrial fibrillation and anxiety.The resident's move-in evaluation, dated 06/07/21, was reviewed during survey. The following required elements were not addressed:* Physical health status, including a list of current diagnoses, a list of medications and PRN use, and visits to health practitioner(s), ER, hospital, or nursing facility in the past year;* Personality, including how the person copes with change or challenging situations;* How a person expresses pain or discomfort;* Complex medication regimen; and* Environmental factors that impact the resident's behavior, including noise, lighting, and room temperature.The need to address all required elements in the move-in evaluation was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 10/2019 with diagnoses including congestive heart failure and diabetes.Observations of the resident on 10/04/21 and 10/05/21, interviews with staff, and review of the resident's current service plan, dated 09/14/21, were conducted during the survey. The service plan was not reflective of the resident's status and lacked clear instructions to staff in the following areas:* Use of compression stockings;* Home health nursing services;* Significant weight gain; and* Current skin conditions to the left shin, abdominal fold, and under the left chest.The need to ensure service plans were reflective of the resident's current status and provided clear instructions for staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/05/21. They acknowledged the findings.
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 direction to staff for 5 of 5 sampled residents (#s 1, 3, 4, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 10/2018 with diagnoses including osteoarthritis and dementia.Observations of Resident 3 on 10/05/21, review of clinical records, and interviews with staff indicated Resident 3's current service plan, dated 10/04/21, was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following care areas:* Use of a motorized wheelchair for mobility;* Medication administration responsibility; and* Transfer assistance needs.The need to ensure service plans were reflective of residents' current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/06/21. They acknowledged the findings.
3. Resident 7 was admitted to the facility in 10/2018 with diagnoses including heart failure and cognitive impairment. Resident 7's service plan was reviewed and caregiving staff and the resident were interviewed. The service plan, dated 07/16/21, was not reflective of the resident's current status and lacked clear instructions to staff in the following areas:* Hospice services provided;* Weight changes;* Direct feeding assistance needed; and* Symptoms of anxiety.On 10/06/21, the need to ensure service plans were reflective of the residents' current care needs and included clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.
4. Resident 1 was admitted to the facility in 06/2021 with diagnoses including atrial fibrillation and anxiety.Resident 1's current service plan, dated 07/01/21 and updated 08/11/21 and 09/01/21, was reviewed, and caregiving staff and the resident were interviewed. The service plan did not provide clear instructions to staff for "monitoring, guidance, and occasional redirection" related to his/her poor memory and judgment. The need for service plans to include clear direction to staff about the provision of care was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.5. Resident 4 was admitted to the facility in 02/2020 with diagnoses including diabetes with neuropathy and chronic kidney disease.The resident's current service plan, updated 09/16/21, was reviewed and caregiving staff and the resident were interviewed.The service plan was not reflective of Resident 4's current status and/or did not provide clear instructions to staff in the following areas:* Transfer status;* Assistance with self-administration of special medications;* Home health services;* Hallucinations;* Obsessive-compulsive behavior;* Communication difficulty; and* Poor memory and judgment.The need to ensure service plans reflect the current care needs of the resident and include clear direction to staff regarding the provision of care was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident-specific instructions communicated to staff on each shift, weekly progress notes until the condition resolved, and/or the facility failed to refer significant changes of condition to the facility RN for 5 of 5 sampled residents (#s 1, 3, 4, 5 and 7) who had changes of condition. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 10/2019 with diagnoses including diabetes and congestive heart failure. A progress note dated 09/14/21 revealed a "yeast type of rash" under the left chest. There was no documentation of weekly monitoring of the skin condition to resolution. The need to ensure changes of condition were monitored at least weekly to resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/05/21. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 01/2018 with diagnoses including osteoarthritis and dementia.Clinical records were reviewed during survey and indicated the resident experienced the following changes of condition:* Progress notes stated the resident developed a blood blister on 07/09/21. An RN progress note dated 08/09/21 indicated the blister had resolved. There was no documented evidence the blister was monitored between 07/09/21 and 08/09/21.* An RN progress note dated 08/09/21 stated the resident developed a right groin rash. There was no documented evidence the rash was monitored from 08/09/21 through 09/02/21.The need to ensure residents who experienced changes of conditions were monitored at least weekly through condition resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/06/21. They acknowledged the findings.
3. Resident 7 was admitted to the facility in 10/2018 with a diagnoses including heart disease and cognitive impairment.Review of Resident 7's clinical records indicated the resident experienced a change of condition related to an 11.8% weight loss from 06/23/21 to 07/21/21. There was no documented evidence the facility identified the significant weight loss, determined what interventions or actions were needed or referred the resident's significant weight loss to the facility RN for further evaluation.On 10/06/21 the need to ensure changes of conditions were monitored, resident-specific actions and interventions were developed and communicated to staff, and the resident service plan was updated was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.
4. Resident 1 was admitted to the facility in 06/2021 with diagnoses including atrial fibrillation and anxiety.Progress notes from 07/18/21 through 10/03/21, weight records dated 06/24/21 through 09/14/21 and the resident's current service plan were reviewed, and staff and the resident were interviewed.Resident 1's weight records indicated the following:* 06/24/21 - 116 pounds;* 07/14/21 - 120 pounds;* 08/03/21 - 124 pounds; and* 09/14/21 - 125.5 pounds.As of 09/14/21 Resident 1 had gained 9.5 pounds, or 8.19% of his/her total body weight, in a three month period. Staff 2 (RN) reported she had not been informed of the resident's weight gain.There was no documented evidence the resident's weight was being monitored.The need to monitor changes of condition through resolution was discussed with Staff 1 (Administrator), Staff 2, and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.5. Resident 4 was admitted to the facility in 02/2020 with diagnoses including diabetes with neuropathy and chronic kidney disease.Progress notes dated 07/12/21 through 09/29/21, weight records from 04/02/21 through 09/20/21, and medical provider after visit summaries from 07/13/21, 07/22/21, and 09/14/21 were reviewed, and caregiving staff and the resident were interviewed. Resident 4 experienced the following changes of condition:* 09/11/21 - Staff documented the resident was placed on alert "due to losing mobility caused by stiffness and pain" in his/her right arm;* 09/15/21 - The resident returned to the facility from the ER;* 09/20/21 - Resident 4 weighed 166 pounds, a loss of 25.6 pounds since 06/02/21, or 13.36% of his/her total body weight. The resident had experienced weight fluctuations from 04/02/21 through 09/20/21; and* 09/27/21 - Staff documented the resident was on alert for "starting new medication Nitrofurantoin for infection."There was no documented evidence any of these changes of condition were monitored through resolution. On 10/06/21 the need to monitor all short-term changes of condition through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

2. Resident 5 was admitted to the facility in October 2019 with diagnoses including diabetes and congestive heart failure. Weight records and progress notes dated 7/22/21 through 10/4/21 were reviewed and indicated the resident experienced an 8.5 pound unplanned weight gain between 8/19/21 and 9/23/21. The gain of over 6% of total body weight constituted a significant change of condition.The facility failed to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment.Observations of the resident on 10/04/21 and 10/05/21 showed the resident eating in the dining room independently. Resident 5 was weighed on 10/5/21 at 135.7 pounds, which was 0.7 pounds higher than the 9/23/21 weight.The need to ensure an RN assessment was completed and included the required components of documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/5/21. They acknowledged the findings.
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 4 of 4 sampled residents (#s 1, 4, 5 and 7) who experienced a significant change of condition. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 10/2018 with a diagnosis of heart failure. Weight records, dated 6/23/21 through 7/21/21, indicated the resident experienced a 19.3 pound weight loss. This constituted an 11.8% severe weight loss in a month and required an RN assessment. There was no documented evidence a thorough RN assessment was completed, and no interventions were developed or implemented as a result of the RN assessment.On 10/06/21, the failure to conduct an RN assessment for a significant change of condition was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.
3. Resident 1 was admitted to the facility in 06/2021 with diagnoses including atrial fibrillation and anxiety.Progress notes from 07/18/21 through 10/03/21, weight records dated 06/24/21 through 09/14/21 and the resident's current service plan were reviewed, and caregiving staff and the resident were interviewed.a. On 08/10/21 the resident experienced a witnessed fall resulting in a fractured elbow and sacrum. Following the fractures, the resident required more assistance with ADLs than prior to the fall.There was no documented evidence an RN had completed a significant change of condition assessment when the resident experienced the fractures.The need to ensure an RN assessed all significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/06/21. They acknowledged the findings. Staff 1 stated the facility RN had quit prior to the fall and they had not yet hired a replacement on 08/10/21, the date of the resident's fall.b. Resident 1's weight records indicated the following:* 06/24/21 - 116 pounds;* 07/14/21 - 120 pounds;* 08/03/21 - 124 pounds; and* 09/14/21 - 125.5 pounds.As of 09/14/21 Resident 1 had gained 9.5 pounds, or 8.19% of his/her total body weight, in a three month period, which constituted a significant weight gain.There was no documented evidence a significant change of condition assessment had been completed by the RN.On 10/05/21 survey requested Staff 2 (RN) to weigh the resident. The RN reported the resident's weight was 119 pounds. This was a loss of 6.5 pounds, or 5.18% of his/her total body weight, in three weeks. Staff 2 stated she had not been informed of the resident's weight changes. The need for an RN to complete an assessment for all significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 and Staff 5 (RCC) on 10/06/21. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 02/2020 with diagnoses including diabetes with neuropathy and chronic kidney disease.Progress notes dated 07/12/21 through 09/29/21, weight records from 04/02/21 through 09/20/21, and medical provider after visit summaries from 07/13/21, 07/22/21, and 09/14/21 were reviewed, and staff and the resident were interviewed. Weight records revealed:* The resident lost 25.6 pounds between 06/02/21 and 09/20/21, or 13.36% of his/her total body weight. This was a severe weight loss.* The resident gained 9.5 lbs., or 8.19% of his/her total body weight, in a three month period between 06/24/21 and 09/14/21, which was a significant gain.There was no documented evidence the RN completed a significant change of condition assessment for either of these weight changes.During survey Staff 2 (RN) was requested to obtain a current weight for Resident 1. On 10/05/21 she reported the resident weighed 200 pounds. This was a gain of 15.4 pounds, or 8.34% of his/her total body weight, in three weeks. Staff 2 (RN) stated she had not been informed of the resident's weight fluctuations.The need to ensure an RN assessed all significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#5) who received insulin injections by unlicensed staff. Findings include, but are not limited to:Delegation records for Resident 5, reviewed with Staff 2 (RN) on 10/04/21, indicated the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 13 (MA), Staff 16 (MA) and Staff 18 (MA), including:* Nursing assessment and condition of the client to determine if the client's condition was stable and predictable;* The rationale for deciding the task of nursing care could be safely delegated to unlicensed persons; and* Frequency the client should be reassessed, including rationale.The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (Administrator) and Staff 2 on 10/05/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#6) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:Resident 6's signed physician orders, dated 08/10/21, included the following orders:* Oxycodone/APAP Tab 5-325 mg as needed every eight hours for pain. Review of the Controlled Substance Disposition logs and the resident's 09/01/2021 through 09/30/2021 MAR identified the following:* A 09/24/21 dose of Oxycodone/APAP at 1:41 pm was reflected in the disposition log but not on the MAR.On 10/06/21, the need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

3. Resident 3 was admitted to the facility in 10/2018 with diagnoses including dementia.Resident 3's current physician orders and MARs dated 09/01/21 through 10/04/21 were reviewed and indicated the following:* Staff documented an order for daily Ativan (a medication for anxiety) was not administered to the resident, because the medication was not available, on four occasions in September. During an interview on 10/05/21, Staff 2 (RN) and Staff 5 (RCC) stated they investigated the medication error and concluded the staff members (who documented the medication was not available) were not aware where this medication was stored. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/06/21. They acknowledged the findings.
2. Resident 5 was admitted to the facility in 10/2019.Current physician orders, the 09/01/21 through 09/30/21 MAR, and the medical record for Resident 5 were reviewed.Progress notes revealed Resident 5 reported to Staff 2 (RN), on 09/14/21, a new rash under the left chest area.During an interview on 10/05/21 at 9:05 am, Staff 5 (RCC) reported the rash was being treated twice a day with the same medicated cream used on the resident's lower abdomen rash. The signed physician orders dated 08/11/21 included Lotrisone cream to be applied twice daily to "underbelly fold" for yeast. There was no signed order for the Lotrisone cream to be applied to the rash located below the left chest area. The need to ensure there were physician or other legally recognized practitioner orders specific for all wound care provided was discussed with Staff 1 (Administrator) and Staff 2 on 10/05/21. 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 and were documented in the resident's facility record for 3 of 5 sampled residents (#s 1, 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 06/2021 with diagnoses including atrial fibrillation and anxiety.The resident's 09/01/21 through 09/30/21 MAR, physician orders, and 07/18/21 through 10/03/21 progress notes were reviewed, and Staff 2 (RN) was interviewed. Resident 1 was prescribed warfarin (a blood thinner) for atrial fibrillation.Staff 2 documented in a progress note on 09/08/21 the resident had not been administered his/her warfarin since 08/27/21. The note indicates the RN investigated further and discovered an error was made when an 08/12/21 order for warfarin was entered on the MAR. An order from the anticoagulation clinic was obtained on 09/08/21 and the resident received warfarin that day.There was no documented evidence the facility administered warfarin to the resident as prescribed from 08/28/21 through 09/07/21, a total of 11 days. The need to follow physician orders as prescribed was discussed with Staff 2 (RN) on 10/04/21, 10/05/21 and 10/06/21 and with Staff 1 (Administrator) and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included clear instructions for 2 of 5 sampled residents (#s 1 and 5) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 10/2019 with diagnoses including diabetes and received daily insulin injections by unlicensed staff.Review of Resident 5's 09/01/21 through 09/30/21 MAR revealed the resident had orders to check CBGs (blood glucose levels) before breakfast and in the evening daily. The MAR lacked clear instruction to staff on when to notify the physician and/or RN of abnormal CBGs or when to hold the insulin for low CBGs. The need to ensure there were clear instructions on the MAR about when to notify the physician and/or RN of abnormal CBGs and when to hold the insulin for low CBGs was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/05/21. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 06/2021 with diagnoses including osteoarthritis.Review of the resident's 09/01/21 through 09/30/21 MAR identified multiple blanks where staff had not initialed for administration of Hydrocodone/APAP.On 10/06/21 the need to ensure accurate MARs was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 11/2018 with diagnoses including anxiety.Review of the resident's 09/1/21 through 09/30/21 MAR showed the following psychotropic medication:* Clonazepam 0.5 mg (a psychotropic medication), one tablet a day as needed for anxiety.The facility administered the Clonazepam to the resident on 14 occasions between 09/1/21 and 09/21/21. The medication was discontinued on 09/22/21.The MAR did not contain resident-specific parameters for staff describing how the resident expressed anxiety. Additionally, there was no documentation of what non-drug interventions were attempted and ineffective prior to administration of the medications. The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and that non-drug interventions were attempted and documented as ineffective prior to administration of the medication was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/05/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had resident-specific parameters and non-drug interventions were attempted prior to administering the medication for 2 of 2 sampled residents (#s 2 and 7) who were prescribed PRN medication to address behaviors. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 10/2018 with diagnoses including anxiety.Review of the resident's 09/1/21 through 09/30/21 MAR showed the following psychotropic medications:* Haloperidol 5 mg (a psychotropic medication), one tablet every 6 hours as needed for anxiety.* Lorazepam 0.5 mg (a psychotropic medication), one tablet every 4 hours as needed for anxiety.The MAR did not contain resident-specific parameters for staff describing how the resident expressed anxiety. On 10/06/21, the need to ensure there were resident-specific descriptions of how the resident expressed anxiety was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff (#16) completed all required pre-service orientation prior to beginning their job responsibilities. Findings include, but are not limited to:Staff training records were reviewed on 10/05/21.There was no documented evidence Staff 16 (CG), hired 8/30/21, had completed the following pre-service orientation topics:* Resident rights and values of community based care;* Abuse reporting requirements; and* Standard precautions for infection control.The need to ensure documentation of completed pre-service training was reviewed with Staff 1 (Administrator) and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long term staff (#s 9, 12 and 14) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to:Staff training records were reviewed on 10/05/21 and revealed the lack of documented evidence Staff 9 (CG), Staff 12 (CG) and Staff 14 (MA), hired 06/04/19, 09/30/21, and 06/21/19, respectively, completed one of the following:* A minimum of six hours of training annually related to the provision of care; and* A minimum of six hours of training annually related to dementia care.The need to ensure all required in-service training hours and requirements were completed and documented annually was reviewed with Staff 1 (Administrator) and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records for 07/2021 through 09/2021 were reviewed with Staff 4 (Maintenance) on 10/05/21. Staff 4 reported the facility was not evacuating or relocating residents during fire drills; therefore, the facility's fire drill documentation did not include the following elements:* Escape route used; and* Number of occupants evacuated.The need to ensure the facility documented all required components was discussed with Staff 4 (Maintenance) and Staff 1 (Administrator) on 10/05/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed with Staff 4 (Maintenance) on 10/05/21. The facility lacked documented evidence of the following:* Alternate exit routes were used during fire drills; and* Annual fire and life safety training for residents; including all required training topics.Multiple staff interviewed on 10/05/21 were unaware of the designated point of safety.The need to ensure all fire drills were conducted in accordance to the OFC, was discussed with Staff 1 (Administrator) and Staff 4 on 10/05/21. They acknowledged the findings.