Cornell Estates Retirement And Assisted Living Residence

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

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose new move-in evaluation was reviewed. Findings include, but are not limited to: Resident 2 was admitted into the facility in 12/2025 with diagnoses including chronic low back pain, anxiety, major neurocognitive disorder, and osteoporosis. The resident’s record was reviewed and revealed the new move-in evaluation failed to address the following required elements: * Customary routines, including eating; * Interests and hobbies; * Spiritual and cultural preferences and traditions; * Physical health status, including visits to the health practitioner(s), emergency room, hospital, or nursing facility in the past year; * Mental health, including presence of depression, thought disorders or mood problems, history of treatment, and effective non-drug interventions; * Decision making ability; * Activities of daily living, including personal hygiene, dental status, and assistive devices used; * Pain, including pharmaceutical and non-pharmaceutical interventions and how a person expresses pain or discomfort; * Fall risk or history; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident’s behavior including, but not limited to: noise, lighting, and room temperature. The need to ensure move-in evaluations included all required elements was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 1:15 pm. They acknowledged the findings.

1.The residents cited were immediately reviewed to complete and document their move-in evaluations. Missing elements were added and verified by the LPN. Care plans were updated accordingly. 2. A standardized Move-In Evaluation Checklist has been developed and incorporated into the admission process. The LPN or RCC will complete and sign off on the checklist within 24 hours of admission. Staff received re-training on admission evaluation requirements. 3.The Administrator or LPN will audit 100% of new admissions weekly for 4 weeks, then monthly moving forward, to ensure evaluations are complete and accurate. 4.The Administrator and the Health Services Director (LPN) are responsible for completion and ongoing monitoring.

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

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

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 2 of 2 sampled resident (#s 1 and 3) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2025 with diagnoses which included diabetic mellitus with polyneuropathy and chronic pain. The resident's 02/01/26 through 02/17/26 MAR and signed physician orders, dated 02/09/26, were reviewed. The following was identified: The resident had an order for oxycodone 10 mg tablet every four hours as needed for chronic pain, max dose six tablets. a. The 02/01/26 through 02/17/26 MAR revealed the resident was administered the PRN narcotic on 58 occasions. * The Controlled Substance log contained 73 entries for 02/2026. Fifteen of the entries on the controlled substance log were not reflected on the MAR. * The number of tablets remaining noted in the Controlled Substance log matched the number of tablets remaining in the corresponding medication packet. b. On the 02/01/26 through 02/17/26 MAR, the area where MTs documented the effectiveness of PRNs administered showed the oxycodone was administered on 61 occasions. * The Controlled Substance log contained 73 entries for 02/2026. Twelve entries were not reflective on the PRN oxycodone date and time stamp on the electronic MAR. Inconsistencies between the MAR and Controlled Substance Disposition log were reviewed with Staff 3 (Health Services Director) and Staff 4 (Regional RN) on 02/18/26 at 2:20 pm. They reviewed the documentation and acknowledged the discrepancies. During an interview on 02/18/26 at 2:50 pm, Staff 2 (RN) acknowledged the discrepancies. He stated the software system for the electronic MAR had an issue when there was a medication administration overnight, which may account for some of the errors. The need to ensure a system was in place for tracking controlled substances was discussed with Staff 1 (ED), Staff 3, and Staff 4 on 02/19/26 at 1:00 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2025 with diagnoses including lumbar radiculopathy (compression of a nerve), spinal stenosis (narrowing) of the lumbosacral (low back) region, and pain of left lower extremity. The resident's 02/01/26 through 02/17/26 MAR, signed physician orders, dated 02/09/26, and corresponding Controlled Substance Disposition logs were reviewed. The following was identified: The resident had an order for oxycodone five mg tablet, two tablets twice daily every four hours as needed for chronic pain and that the resident could “self direct” for PRN medications. The 02/01/26 through 02/17/26 MAR revealed the resident was administered the PRN narcotic on six occasions. a. The corresponding medication packet contained oxycodone 10 mg tablets with instructions to take one tablet by mouth every hour as needed for pain. Additionally, there was a small, sealed envelope attached to the packet labeled 02/12/26, on which the resident’s first name and “PRN Oxy” was written. There was also an entry in the corresponding Controlled Substance log that was not dated but stated “added 1 back to count.” The number of tablets remaining noted in the Controlled Substance log matched the number of tablets remaining in the corresponding medication packet, including the tablet in the envelope. During an interview on 02/17/26 at 1:47 pm, Staff 23 (Lead Medication Coordinator) stated the packet contained a PRN oxycodone tablet that was signed for and sent out with Resident 4 and family in case s/he experienced pain while out of the facility. Staff 23 stated the process was to put the medication back in an envelope and attach to the medication packet. During an interview on 02/18/26 at 11:30 am, Staff 2 (RN) stated the facility procedure is to immediately destroy any medication returned back to the facility, and the medication would be destroyed with a nurse and a witness. He acknowledged the discrepancy between the signed physician order and the instructions on the medication packet from the pharmacy and stated he would obtain correct order instructions. b. On 02/12/26, the PRN narcotic was signed out on the corresponding Controlled Substance log twice, and one instance lacked a time stamp. However, the MAR reflected only one administration. c. On 02/13/26, the PRN narcotic was signed out on the MAR twice for lunch and evening, but there was no data entered on 02/13/26 in the corresponding Controlled Substance log. d. On 02/14/26, the PRN narcotic was signed out on the corresponding Controlled Substance log once, but there was no data entered on the MAR. During an interview on 02/18/26 at 11:35 am, Staff 2 acknowledged the discrepancies. He stated the software system for the electronic MAR had an issue when there was a medication administration given overnight, the entry was placed on the previous day, which may account for some of the discrepancies. The need to ensure a system was in place for tracking controlled substances was discussed with Staff 1 (ED), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 12:50 pm. The findings were acknowledged.

1. What actions will be taken to correct the rule violation for each example/resident? 1.All controlled substance logs cited were immediately reconciled and corrected. Any discrepancies were investigated and resolved, and involved staff received immediate re-training. 2. Shift-to-shift controlled substance counts with dual staff signatures have been implemented. The controlled substance tracking form was updated to include detailed verification fields. All medication staff received refresher training on reconciliation procedures. 3. Weekly audits of controlled substance logs will be conducted moving forward. Results will be reviewed by the Administrator and/or Health Services Director monthly. 4. The HSD and Resident Care Coordinator will ensure corrective actions are completed and monitored. RCC or lead med tech will conduct weekly audits April 8th 2026

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

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

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a physician or other legal prescriber and for which the facility was responsible to administer for 3 of 5 sampled residents (#s 2, 4, and 5). Findings include, but are not limited to: 1. Resident 4 was admitted into the facility in 02/2024 with diagnoses including hypertension, degenerative joint disease, and anxiety. The resident’s 02/01/26 through 02/17/26 MAR and current physician’s orders were reviewed. The following medications lacked a reason for use: * Buspirone 30 mg, one tablet twice daily; * Docusate sodium 100 mg, one capsule twice daily; * Lorazepam 0.5 mg, one tablet three times daily; * Tramadol 50 mg, one tablet four times daily; * Vitamin D3 50 mcg, one tablet daily; * Reguloid SF orange powder, 15 grams daily; * Divalproex ER 500 mg 24 hour, one tablet daily; * Pantoprazole 40 mg, one tablet daily; * Fluticasone/salmeterol 500-50 mcg, one puff twice daily; and * Magnesium citrate 1.745 gram/30 ml, 296 mL for one dose. During an interview on 02/18/26 at 11:45 am, Staff 2 (RN) confirmed the above medications lacked a reason for use. The need for MARs to be accurate and include a reason for use was discussed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN), on 02/19/26 at 12:50 pm. The findings were acknowledged. 2. Resident 2 was admitted into the facility in 12/2025 with diagnoses including osteoporosis. The resident’s 02/01/26 through 02/17/26 MAR and current physician’s orders were reviewed, and the following medications lacked a reason for use: * Alendronate 70mg tablet, one tablet every seven days; * Cal/Mag/Zinc/Vitamin D, one tablet daily; * Centrum adult tablets, one tablet daily; * Vitamin B-6 100mg, one tablet daily; * Losartan 100 mg, one tablet daily; and * Acetaminophen 500 mg, two tablets every six hours as needed. On 02/19/26 at 11:33 am, the above was reviewed with Staff 3 (Health Services Director) and Staff 4 (Regional RN), who confirmed the MAR lacked a reason for use for the above medications. The need to ensure MARs were accurate and included a reason for use for each medication was reviewed with Staff 1 (Executive Director), Staff 3, and Staff 4 on 02/19/26 at 1:15 pm. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 06/2023 with diagnoses including atrial fibrillation and memory impairment. The resident’s 02/01/26 through 02/17/26 MAR and current physician’s orders were reviewed. The following medication lacked a reason for use: * Mirtazapine 30mg tablet, Take 1.5 tablet (45mg) daily. On 2/18/26 at 1:00 pm Staff 4 (Regional RN) confirmed the above medication lacked a reason for use. The need to ensure the MAR was accurate and included a reason for use for each medication, was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 on 02/19/26 at 2:00 pm. They acknowledged the findings. No further documentation was provided.

1.The medication administration records for residents cited were immediately reviewed and corrected. The medication techs involved received targeted re-education on the seven rights of medication administration. 2. A weekly audit of least 20% of all MARs has been implemented by the LPN to ensure accurate documentation. 3. Weekly MAR audits will be conducted weekly for 60 days, then monthly afterwards. 4.The LPN and Administrator are responsible for monitoring and ensuring compliance.

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

OAR 411-054-0055 (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.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer medications had an evaluation completed upon move-in, and at least quarterly thereafter, to assure their ability to safely self-administer medications for 2 of 2 sampled residents (#s 3 and 4) reviewed for self-administration of medication. Findings include, but are not limited to: 1. Resident 3 was admitted into the facility in 04/2025 with diagnoses including lumbar radiculopathy (compression of a nerve) and spinal stenosis (a narrowing) of the lumbosacral (low back) region. During review of current physician orders, dated 02/09/26, and the 02/01/26 through 02/17/26 MAR, it was identified that Resident 3 self-administered diclofenac sodium 1% gel for low back pain four times daily. In an interview on 02/17/26 at 11:30 am, Resident 3 stated s/he kept the medication in a personal bag for self-administration but was unable to locate it upon surveyor request. There was no documented evidence a self-administration evaluation had been completed for Resident 3. On 02/17/26 at 2:03 pm, Staff 3 (Health Services Director) confirmed there was no evaluation of the resident's ability to self-administer his/her medication. The need to ensure residents who self-administered their medications were evaluated upon move-in and at least quarterly thereafter was discussed with Staff 1 (Executive Director), Staff 3, and Staff 4 (Regional RN), on 02/19/26 at 12:45 pm. The findings were acknowledged. 2. Resident 4 was admitted to the facility in 02/2024 with diagnoses including stenosis (narrowing) of the external ear canal and constipation. During review of current physician orders, dated 02/09/26, and of the 02/01/26 through 02/17/26 MAR, it was identified that Resident 4 self-administered the following medications: * Soothe Extra Protection drops for dry eyes as needed daily; * Bisacodyl suppository daily as needed for constipation; and * Sodium chloride nasal spray daily as needed for nasal dryness, and estradiol cream daily. During an interview on 02/18/26 at 10:15 am, Resident 4 stated s/he kept the medications in the bathroom or at the bedside, and all medications were observed by surveyor. There was no documented evidence a self-administration evaluation had been completed for Resident 4. On 02/18/26 at 11:50 am, Staff 2 (RN) confirmed there was no evaluation of the resident's ability to self-administer his/her medications. The need to ensure residents who self-administered their medications were evaluated upon move-in and at least quarterly thereafter was discussed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 12:50 pm. The findings were acknowledged.

1.All residents currently self-administering medications were reassessed for appropriateness. Missing documentation was completed, and secure storage was verified. 2. Quarterly reassessments will be scheduled for all residents approved for self-administration. Written approval by the LPN will be required prior to initiation. Secure storage verification has been added to routine checks. 3. Quarterly audits of all self-administering residents will be conducted. 4. The RCC conducts assessments and reassessments. The Administrator will monitor documentation compliance.

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.

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

Based on interview and record review, it was determined the facility failed to review the ABST evaluation no less than quarterly at the same time the resident’s service plan was updated for 2 of 5 sampled residents (#s 4 and 5) and multiple unsampled residents. Findings include, but are not limited to: The facility’s ABST data was reviewed on 02/17/26 through 02/19/26 and revealed the following: 1. Resident 4 was admitted to the facility in 02/2024. Review of Resident 4’s ABST and clinical records identified the facility failed to update and review the ABST no less than quarterly at the same time the resident’s service plan was updated. Resident 4’s service plan was updated on 01/20/26, however, the last ABST update was on 03/07/25. The need to ensure resident ABST evaluations were reviewed at least quarterly was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN), on 02/19/26 at 2:00 pm. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 06/2023. Review of Resident 5’s ABST and clinical records identified the facility failed to update and review the ABST no less than quarterly at the same time the resident’s service plan was updated. Resident 5’s service plan was updated on 02/07/26; however, the last ABST update was on 11/20/25. The need to ensure resident ABST evaluations were reviewed and updated at least quarterly was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 2:00 pm. They acknowledged the findings. 3. Facility census during survey was 53. Facility ABST evaluations updates were reviewed on 02/19/26. It was determined that 30 unsampled residents’ ABST evaluations had not been updated within the past quarter. and one unsampled resident who had been out facility since 12/2025 was still active on the ABST. On 02/19/26 at 11:45 am, Staff 3 (Health Services Director) and Staff 4 (Regional RN) confirmed the ABST lacked updates at least quarterly for Resident 4, Resident 5, and multiple unsampled residents. They also confirmed the unsampled resident who was still active on the ABST was discharged to the hospital in 12/2025. The need to ensure resident ABST evaluations were reviewed and updated at least quarterly was discussed with Staff 1 (Executive Director), Staff 3, and Staff 4 on 02/19/26 at 2:00 pm. They acknowledged the findings.

1. Resident 4 and Resident 5’s ABST evaluations were reviewed and updated to reflect their current service needs and to align with their most recent service plans. The discharged resident who remained active on the ABST was removed from the ABST census. A 100% audit of all 55 residents was conducted. All residents identified as overdue for quarterly ABST review had their ABST evaluations updated. The ABST census was reconciled to ensure accuracy of active residents. 2.The ABST will be reviewed and updated concurrently with each resident’s quarterly service plan review. The RCC is responsible for completing the ABST update at the time of the service plan review. Upon discharge, residents will be removed from the ABST census the same day as discharge documentation. 3. The RCC will conduct a 100% audit of ABST evaluations monthly. 4. The RCC is responsible for completion of quarterly ABST updates and monthly audits.The Executive Director is responsible for oversight and review of audit findings. Any additional support will be provide by the HSD.

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.

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

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly-hired staff (#5) completed required pre-service dementia training. Findings include, but are not limited to: Staff training records were reviewed with Staff 10 (Business Office Manager) on 02/19/26. The following was identified: There was no documented evidence Staff 5 (CG), hired 10/17/25, had completed one or more of the following pre-service dementia care training topics: * Dementia disease process, including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia, including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need for staff to complete all required pre-service dementia training was discussed with Staff 1 (ED), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 1:00 pm. They acknowledged the findings.

1. All staff lacking required pre-service training completed the required training immediately. Documentation was updated in personnel files. 2. A New Hire Orientation Checklist has been implemented. Staff may not provide resident care independently until all required pre-service training is completed and documented. 3.100% of new hires will be audited for compliance for 90 days. Thereafter, quarterly personnel file audits will be conducted. 4. The Administrator oversees compliance. Department supervisors verify training completion prior to independent work.

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

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

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 5, 11, and 26) demonstrated satisfactory performance in any duty they were assigned within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed with Staff 10 (Business Office Manager) on 02/19/26. The following was identified: There was no documented evidence Staff 5 (CG), Staff 11 (CG), and Staff 26 (MT), hired on 10/17/25, 11/26/25, and 10/30/25, respectively, demonstrated competency within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation, and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; * Other duties as applicable (medications and treatments); and * First Aid/Abdominal thrust training. The need to ensure there was documentation that newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 1:00 pm. They acknowledged the findings.

1. All employees exceeding the 30-day competency requirement were immediately evaluated. Documentation was completed and filed. 2.A 30-day competency tracking system has been implemented using a hire-date-based calendar reminder. 3. Monthly audits of employees within their first 60 days of employment will be conducted. 4.RCC will complete competency evaluations. The Administrator will monitor the tracking system.

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.

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

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month and in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: On 02/19/26 at 10:43 am, fire drill records for the previous six months were reviewed with Staff 9 (Building Services Director) and revealed fire drills were conducted in the independent living area of the building, but had not been conducted in the assisted living. The need to conduct unannounced fire drills every other month and in accordance with the OFC was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 1:15 pm. They acknowledged the findings.

1. A fire drill was conducted in the Assisted Living area immediately after the deficiency was identified. The last six months of drill records were reviewed. Leadership (Executive Director, Health Services Director, and Building Services Director) reviewed the requirement for unannounced fire drills every other month in accordance with the Oregon Fire Code. 2. A standardized fire drill documentation form has been implemented to clearly identify the location (Assisted Living), with all information required under Oregon Fire Code. The Executive Director will verify monthly that drills are completed as scheduled. 3.The Executive Director will review fire drill logs monthly with the building services director moving forward, drills are conducted in Assisted Living, drills are unannounced, drills occur every other month, documentation is complete accurately. 4. • The Building Services Director is responsible for scheduling and conducting fire drills. The Executive Director is responsible for oversight and monthly monitoring.

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.

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.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and re-instruct residents, 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. Findings include, but are not limited to: On 02/19/26 at 10:43 am, the facility fire and life safety records for the previous six months were reviewed with Staff 9 (Building Services Director) and revealed the facility lacked documented evidence residents were instructed within 24 hours of admission and re-instructed, at least annually, on general safety procedures, evacuation methods, and responsibilities. The need to ensure residents received instruction in general safety procedures, evacuation methods, and responsibilities during fire drills within 24 hours of admission, and were re-instructed at least annually, was reviewed with Staff 1 (Executive Director), Staff 3 (Health Services Director), and Staff 4 (Regional RN) on 02/19/26 at 1:15 pm. They acknowledged the findings.

1. Residents lacking documentation of fire safety education received training immediately. Signed acknowledgments were placed in our 2026 fire life & safety binder. 2. Fire and life safety education has been added to the Move-In Checklist and must be completed within 24 hours of admission. An annual resident fire safety re-education schedule has been implemented and added to the community training calendar. 3. The Executive Director will audit: 100% of new admissions for 60 days to ensure instruction occurs within 24 hours. A quarterly random sample of five resident files to verify annual re-instruction documentation. 4. The Building Services Director (or designee) is responsible for providing resident instruction. The Executive Director is responsible for oversight and monitoring compliance.

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.

Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: The facility was unable to provide physician orders for Resident 1's Valacyclovir 1mg (antibiotic). An incident report for Resident 1, dated 07/24/24, indicated one dose of Valacyclovir 1mg was remaining in a medication card for Resident 1, despite the order having ended. Resident 1's MAR, dated 07/01/24 through 07/31/24, indicated his/her Valacyclovir had been administered as prescribed. During an interview on 10/14/24, Staff 2 (LPN) stated "there was one pill left over" once the medication regimen should have been completed, and there was "no way to tell which med tech [made the error]." It was determined the facility failed to administer medication as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24. Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week. Facility had begun to review resident's prescribed antibiotics during clinical meetings. Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: Physician orders, dated 02/02/24, indicated Resident 2 was to receive Clonazepam 0.25mg (anxiety) every morning, as well as Clonazepam 0.5mg at night. Resident 2's MAR, dated 04/01/24 through 04/30/24, indicated Clonazepam 0.5mg had been administered to Resident 22 on the mornings of 04/01/24 through 04/09/24. An incident report, dated 04/14/24, indicated a med tech had marked the medication as given but had not administered the medication to the resident. It further indicated the medication had not been signed out in the facility's narcotics logbook and was accounted for. During an interview on 10/14/24, Staff 2 (LPN) stated s/he remembered the med tech had marked the medication as given and forgot to "pop" the medication from the narcotics drawer. It was determined the facility failed to administer medication as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24. Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week. Med tech responsible no longer employed by the facility. Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: A physician order for Resident 2, dated 02/02/24, indicated s/he was to be administered Propranolol 10mg (anxiety) twice a day, and to hold the medication if systolic blood pressure was below 110 or if the resident's heart rate was lower than 60 beats per minute (bpm). Incident reports, dated 03/10/24 and 03/12/24, indicated Resident 2 had received Propranolol outside of parameters. Resident 2's MAR, dated 03/01/24 through 03/30/24, indicated s/he had received Propranolol on 03/10/24 when his/her blood pressure had been recorded at 57bpm, as well as on 03/12/24 when his/her blood pressure had been recorded at 55bpm. Physician orders for Resident 2, dated 02/02/24, indicated s/he was to receive Clonazepam 0.5mg once a day. An incident report, dated 02/18/24, indicated a med tech had been unable to find Resident 2's Clonazepam. Resident 2's MAR, dated 02/01/24 through 02/29/24, indicated s/he had not received his/her Clonazepam on 02/18/24. It was determined the facility failed to administer medication as prescribed. Staff 2 (LPN) stated the incidents had occurred. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24. Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week. Based on observation, interview, and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 4). Findings include, but are not limited to: Physician orders for Resident 4, dated 02/04/24, indicated s/he was to be administered Clonazepam 0.125mg (anxiety) twice a day. An incident report, dated 03/04/24, indicated Resident 4's Clonazepam had been marked off as administered on his/her MAR but had not been administered and had been found in the facility ' s medication cart. Staff 2 (LPN) stated the incident had occurred and the med tech responsible had been terminated. It was determined the facility failed to administer medication as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24. Verbal plan of correction: Facility self-reported incident. Med tech responsible had been terminated. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week. Based on observation, interview, and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: An incident report, dated 03/03/24, indicated Resident 5's order had been changed from Losartan 50mg twice a day to Losartan 100mg once a day on 03/01/24, and the facility had not processed the order. Resident 5's MAR, dated 03/01/24 through 03/30/24, indicated s/he had received Losartan 50mg twice a day on 03/03/24. Staff 2 stated med techs were supposed to provide first checks and process orders. It was determined the facility failed to administer medication as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24. Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week. Based on observation, interview, and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: An incident report, dated 02/04/24, indicated a med tech had filled out the facility's narcotic logbook and not administered the medication, Hydrocodone 5mg (pain management), to Resident 3. Staff 2 (LPN) stated the med tech had been new and had been coached on dispensing the medication prior to filling out the paperwork. It was determined the facility failed to administer medication as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24. Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week. Med tech responsible no longer employed at facility. Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: Physician orders for Resident 3, dated 02/04/24, indicated s/he was to receive Clonazepam 0.5mg (anxiety) once a day. An incident report, dated 02/18/24, indicated a med tech had not known the location of Resident 3's Clonazepam 0.5mg and therefore had not administered it to Resident 3. Resident 3's MAR, dated 02/01/24 through 02/29/24, indicated s/he had not received his/her Clonazepam 0.5mg. Staff 2 (LPN) stated the med tech "didn't know Clonazepam was a narcotic" and didn't look in the narcotics drawer of the med cart. It was determined the facility failed to administer medication as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24. Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week. Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 2 of 3 sampled residents (#s 6 and 8). Findings include, but are not limited to: An incident report, dated 02/15/24, indicated on 02/13/24  " Med tech popped one of [Resident 6 ' s] oxycodone 5mg thinking it was [Resident 8 ' s] oxycodone 5mg and gave it to [Resident 8] "  and  " correct med given, but given from [Resident 6 ' s] card instead of from [Resident 8 ' s]. " A quarterly physician order review for for Resident 6, dated 03/22/24, indicated s/he was to receive oxycodone 5mg (pain management) three times daily. Physician orders for Resident 8, dated 12/22/23, indicated s/he was to receive oxycodone 5mg six times a day. During an interview, Staff 2 (LPN) stated the error had occurred. It was determined the facility failed to administer medication as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24. Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week. Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 3). Findings include, but are not limited to: An incident report, 02/05/24, indicated on 02/04/24 "[Resident 3] missed her AM dose of oxycodone 5mg." Staff 2 (LPN) confirmed the error had occurred. It was determined the facility failed to administer medication as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24. Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week.

Based on observation, interview, and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled resident (# 3). Findings include, but are not limited to: An incident report, dated 03/03/24, indicated Resident 3 had not received his/her Oxycodone 5mg on 03/03/24. Resident 3's MAR, dated 03/01/24 through 03/30/24, indicated s/he had not received his/her oxycodone on 03/03/24. Staff 2 (LPN) stated the pharmacy hadn't sent the medication when ordered, and when they were contacted sent it over immediately. It was determined the facility failed to administer medication as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 10/14/24. Verbal plan of correction: Facility self-reported incident. RCC performing quarterly med tech trainings, RCC observes a medication pass with one med tech a week.

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 re-licensure survey, conducted 09/25/23 through 09/28/23, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to the deficiencies identified in the report.

C150:  The administrator is starting a monthly quality assurance meeting each month. During this meeting all department heads will meet with the administrator to review each of the following areas. Nurses: will be responsible for weights, exceptions, skins, infection control log, PRN parameters, Diabetic/Nursing assessments, Delegations, assistive device assessments, smoking assessments, RCC's: Responsible for the monthly med room audits, med cart audits, service plans, new move in criteria Activities: Will be responsible to bring any new areas of interest for the residents to be added to the service plan Maintenance: Will be conducting monthly walk throughs with administrator of the assisted living side and the kitchen. Documenting what needs to be fixed and documenting to ensure that it is followed up on. The walk throughs will begin the first week of the month and then will meet during the quality assurance meeting to review.

Based on observation and interview 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 second revisit survey, conducted on 05/17/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations. Refer to C 240 and C 455.

*Physical plant issues in the Kitchen of Cornell Estates have been ongoing from pipe leaks, aged equipment failure and aged deterioration.  Some issues have been a result of repairing something else. The actions to correct each issue are ongoing and monitored via a CAP EX spreadsheet by the Administrator and Regional Director The sytems can be monitored preventatively by detailed oversight of aged equipment and physical plant in the kitchen. The Kitchen Director and Administrator will monitor this weekly. The Regional Director will review these areas weekly with the Administrator.

Based on observation and interview it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. This is a repeat citation. Findings include, but are not limited to: During the third revisit survey, conducted on 09/05/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations. Refer to C 240 and C 455.

1. A kitchen maintenance checklist has been developed and will be utilized daily and weekly to oversee kitchen maintenance and infection control. The Dining Services Director will complete the daily checklist and submit it to the Administrator each day. If repairs are needed, the Maintenance Director will be notified through our work order system, and the Administrator will review the status of repairs daily to ensure progress. Additionally, the Administrator will conduct weekly inspections and observations of food service. Both the Administrator and Dining Services Director are enrolled in a Safe Serv class, which they will complete by 09/20/24. 2. This system will enhance oversight, allowing maintenance issues to be addressed more promptly. 3. The kitchen area will be assessed on a daily and weekly basis. 4. The Dining Services Director and Administrator will be responsible for ensuring that necessary corrections are made and that the kitchen is consistently monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure proper food preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility kitchen was toured on 09/26/23 at 9:52 am. a. The following areas were in need of cleaning or repair: * The caulk adjoining the stainless-steel ware washing area and the wall had a build up of black matter and the caulk was deteriorating which caused water to saturate the wall beneath the ware wash counter; * The floor underneath the three compartment sink had a buildup of dirt, food debris and rubbish; * There was a hole in the wall with exposed pipes underneath the sprayer sink in the dishwashing area; * There was a water leak from unknown source in the dishwashing area that was leaking water through the wall and floor to the other side of the kitchen near the food service table (located at the entrance of the kitchen); * Wall baseboard coving was pulling away from the floor and wall near the hand washing sink, near the steam table, food prep area, and wall surrounding the dish washing area; * Laminate veneer on the left corner of the food service table was missing with exposed wood, which created an uncleanable surface; * Walk in freezer door gasket was failing which cased condensation and ice buildup on the freezer door; * The dry food storage area had a build up of food debris underneath shelves, and sticky brown matter on the floor; * Flying insects were observed in the dry food storage area and janitorial closet; and * The kitchen exit door that entered into the assisted living dining room had a door hinge that was disconnected from the door frame. b. Observations of the food preparation and food service identified the following: * Poultry and poultry-based food product temperatures were prepared under the required 165 degrees F.; * Cold food items (milk and fresh cut fruit) plated for food service had temperatures above 41 degrees F.; and * Alcohol wipes were not used to sanitize the food thermometer after each use. c. Observations of sanitation including pots, pans, plates, food service equipment, utensils and knives identified the following: * The ware wash machine was a low temp (120 degrees F.) machine that was equipped with a sanitizer solution. The solution was empty and had not been replaced by the dishwasher. This created a situation in which the food service equipment was not effectively sanitized when using a low temperature ware wash machine. d. Review of employee infection control practices identified the following: * Staff 12 (Cook) failed to ensure his hair and beard were restrained; and * Staff 16 (Prep cook) failed to have a valid Oregon Food Handler card. e. Resident's who chose to dine in their apartments were served their food in styrofoam containers, including styrofoam drinking containers and plastic-ware utensils verses those resident's who dined in the assisted living dining room. The kitchen was toured, and the above areas were discussed with Staff 1 (Administrator), Staff 5 (Dining Services Director), and Staff 6 (Regional Director of Operations) on 09/26/23 at 1:41 pm. They acknowledged the findings. Staff 6 instructed Staff 1 and Staff 5 to immediately contact the facility maintenance, a plumber and the facility's contracted pest control.

Environmental: Administrator and Maintenance director will do a walk through of the assisted living side building at the beginning of each month. Maintence and Administrator will collaborate on there findings. Review there findings with regional to ensure that the environment is up to CBC standards. The administrator will document these meetings by keeping a "quality assurance binder" to review with the regional director to ensure compliance with CBC regulations. C240: Trim and caulking will be replaced along the wall. Wall has been examined and repair to ensure that there is no water damage underneath to prevent further damage. Floors beneath the sink have been deep cleaned. The kitchen manager reviewed with all kitchen staff about the importance of checking daily for build up of dirt, food debris and rubbish. Deep cleaning of the area beneath the sink have been added to the kitchen staff duties as of 10/1/23. New expectations have been reviewed with kitchen staff as of 10/1/23 The maintenance director will be patching and fixing the hole that shows the exposed pipes and sprayer beneath garbage disposal. Repair date is November 2023 Commercial Plumber vendor has been called to get garbage disposal fixed. Vendor order parts on 10/6/23, the parts will arrive 10/20/23. The installation of the new parts will happen in the week of 10/23/23 Wall baseboards will be replace4d and installed by the maintenance director. Wall baseboards have been ordered and estimated delivery is 11/1/23. Side corner near the salad bar has been replaced and covered with a stainless-steel corner as on the opposite side. This has been completed 10/2/23 Walker in freezer gasket will be replaced. The maintenance director will be replaced. Gasket has been ordered and will be installed by 11/1/23 Dry Food storage has been deep cleaned as of 10/1/23. Cleaning logs have been updated as of 10/1/23 so staff are aware of the additional responsibility. The Dining Director has reviewed with staff the expectations making sure its cleaned nightly. Pest Control exogenixs have been moved to a monthly service for the kitchen to reduce the knats/Flys. "Safer" brand Fly traps were bought 10/12/23 and installed around the kitchen and dry storage area on 10/18/23. Traps will be replaced monthly and has already been added to the cleaning logs as of 10/18/23. Kitchen manager has reviewed this with his staff and understand the expectations moving forward. The assisted living kitchen door hinge has been repaired as of 10/2/23. C240: Part B Routine temp logs are currently in use for each meal. Kitchen manager will be having for an in-service for all kitchen staff about for holding temperatures for food. Kitchen manager will also be moving food into double boilers to maintain temperature The kitchen manager has reviewed with kitchen staff about food times. Reviewing when products such as milk or fresh cut fruit need to be put out at the appropriate time not too early and not too late. Alcohol wipes have been ordered 10/2/23. Currently being used as of 10/18/23. Wipes will be kept near the steam line in visible sight for kitchen staff to know when and where to use them. C240 Part C Kitchen Manager called Alto- Shaam Vendor to get the appropriate testing strips. Dishwasher was retrained on testing as it is stated on the dishwasher machine itself. The dishwasher understood what was expected of him moving forward. The kitchen manager replaced all empty chemicals. Dishwasher was reviewed to check the chemicals before washing and then was showed where to get the chemicals when low or empty. Dishwasher acknowledged what was expected of him moving forward. C240 Part D: The kitchen manager bought beard and hair restraints for cooks and prep cooks. Kitchen manager reviewed the rules and regulations with kitchen staff about proper hair and beard restraints. Kitchen staff acknowledge the rules and regulations for them when it comes to hair restraint. Staff member 16 food handlers card has been renewed as of 10/1/23. Full audit of food handlers cards happened as of 10/5/23. All current staff have up to date Oregon food handlers cards. C240: Part E Kitchen manager has ordered all meal tray service amenities. This includes more trays, plates, silverware, glasses, plates, food covers, pitchers. These will be used for all meal delivery moving forward. An in-service training will be held for the kitchen staff and health services staff on what is expected moving forward for all meal tray deliveries. To prevent this from happening again administrator and Dining Director will be doing monthly walk through of the kitchen to review the kitchen in depth. Findings will be documented and a plan of action will occur to make sure issues are fixed according. All plans and walk through will be placed in the quality assurance binder as discussed in C150. Monthly in-service training for kitchen staff to review rules and regulations. Dining services will host these monthly meetings and Administrator will oversee. Documentation with sign in sheet and agenda will be placed in monthly meeting binder.

Based on observation and interview, it was determined the facility failed to ensure proper food preparation and food service, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: The facility kitchen was toured on 02/14/24 at 9:40 am. a. The following areas were in need of cleaning or repair: * Walk-in freezer door gasket was secured with tape; and * A large can opener had build-up of black residue on the blade and surrounding housing. b. Observations of the dry storage, food preparation and food service identified the following: * Alcohol wipes were not used or available to sanitize the food thermometer after each use; * A package of pancake mix in the dry storage area was unsealed and had a scoop stored in the mixture; and * Multiple bags of dry foods in the dry storage area were unsealed or uncovered; and * Observations of three kitchen staff who were preparing food failed to have hair restrained. c. The ware washer was not installed at the time of the re-visit survey and there was repair work in process for the surrounding walls. The kitchen was toured and the above areas were discussed with Staff 1 (Administrator) on 02/14/24 at 2:30 pm. Staff 1 reported the repairs to the kitchen walls and ware washing station were expected to be completed soon and acknowledged the findings.

C455 Please referr to C240 for the plan of correctionC 240} a. The following areas were in need of cleaning or repair: POC Walk in freezer door gasket has been fixed as of 3/1/24 A new can opener has been bought to replace the old one. Once it has arrived that will be installed and replaced. In the mean time we have added the can opener to the cleaning log list to ensure that is being properly cleaned and disenfected. b. Observations of the dry storage, food preparation and food service identified the following POC kitchen staff were retrained and show the proper way to disenfect. We have ensured that staff know who and where to ask if they run out of the alcohol sanitizer wipes Proper lids have been bought and secured to be used to esnure that dry storage lids are sealing properly. Kitchen staff been reminded and are being audtied daily for to ensure that beard restraints are being used while preping or cooking food. c. The ware washer was not installed at the time of the re-visit survey and there was repair work in process for the surrounding walls. POC Wash ware system has been installed as of 2/19/24. Every month during my maintenance walk through of the community the administrator will make sure to do a walkthrough of the kitchen with my maintenance director to monitor the seal, wash ware systems and the overall the physical wellbeing of the kitchen to ensure that we are catching any thing that needs

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: The facility kitchen was toured on 05/17/24 at 9:40 am. a. The following areas were in need of repair: * Walk-in freezer door gasket was secured with tape; * Walk-in refrigerator door was damaged and in need of repair; * There was one-to-three inches of ice buildup in various areas of the walk-in freezer, including ice on food product, pipes and floor; * The ware washer area floor had multiple areas of cracked tile and/or missing tile grout; * There was a two inch diameter hole in the floor next to the grease trap (Located in the dish washing area); * The tile and grout surrounding the grease trap was damaged and deteriorating; * There was a hole in the wall surrounding the pipes in the dish washing area which allowed for the entry of pests; * The garbage disposal was not operable; * The janitor's closet had two areas approximately 14 inches long that were missing coved baseboards; * The floor and wall surrounding the dish washing area (facing the prep table and tray line) had missing coved baseboards; * There was missing floor tile between the tray line and the chef refrigerator and at the end of the tray line; * There was missing baseboards on the front of the tray line, which had exposed wood rendering the surface uncleanable; and * The entry door and threshold to the kitchen had been removed. The need to ensure the kitchen was maintained in good repair and in accordance with Food Sanitation Rules was discussed with Staff 6 (Regional Director of Operations), Staff 24 (Dining Services Director) and Staff 25 (Interim Designee) on 05/17/24. They acknowledged the findings.

Work with vendors are ongoing in the kitchen. 1) Walk in door was being replaced when the surveyor was onsight - custom built due to age of walk-in 2) The freezer walk-in door will be replaced by 6/21/2024 - customer built due to age of walk in freezer 3) The garbage disposal will be replaced by 7/15/2024 by an outside vendor 4) Dish pit area drywall is complete 5) Dish pit area tiles to be complete 7/15/2024 6) Floor tiles will be replaced by 7/15/2024 7) Cove base on flooring in mop area and in kitchen is complete 8) Gap between wall and tile will be complete by 7/15/2024 9) door to kitchen will be in by 7/15/2024 Outside vendor time and supply chain times have contributed to delays in work completed.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: The facility kitchen was toured on 09/05/24 at 10:45 am with Staff 24 (Dining Services Director) and Staff 25 (Administrator). a. The following areas were in need of repair: * Ice accumulation was observed in two locations of the walk-in freezer and were up to six inches in length and three-four inches in width. The ice was hanging from the pipes that were connected to the freezer condenser and blower mechanism; * The tile and/or grout surrounding the grease trap was damaged and deteriorating; * The metal cover of the grease trap was rusted and deteriorating creating a whole in the back right corner and the perimeter of the grease trap cover was not flush to the floor creating an approximate 1/4 inch gap around the perimeter of the grease trap and the surrounding floor;   * The garbage disposal was not operable; * The wall and coved baseboards facing the prep table and tray line were pulling away from the wall and surrounding floor creating a gap between the wall and baseboard which continued to allow dirt, debris and potential insects to harbor; * The floor thresholds to the two entry doors of the kitchen had been removed, creating a gap between the dining room flooring and the kitchen flooring; and * Upon entering the walk-in refrigerator, near the floor on the right side (roughly ankle height) was a piece of rusted metal refrigeration wall that was pulled away from the surrounding wall and protruding out on a sharp angle. The need to ensure the kitchen was maintained in good repair and in accordance with Food Sanitation Rules was discussed with Staff 24 and Staff 25 on 09/05/24. They acknowledged the findings.

1. Vender was onsite on 09/10 to fix the ice accumulation in the walk-in. New connections were installed under the freezer condenser and pipe coverings were placed. Vendor will also be onsite on 09/19 to asses how the repair is holding and provide recommendations at that time. 2. The tile and grout have been replaced around the grease trap. 3. On 09/06 a new grease trap lid was ordered. FedEx tracking number 778524909124. Lid is expected to be delivered on 09/17. 4. The electrical box missing for the garbage disposal operation arrived on 09/12. The electrician is scheduled to arrive onsite on 09/17 to install the box which will make the disposal operable. 5. The coved baseboards have been cleaned and reapplied to the wall. 6. On 09/09 the thresholds were placed. 7. On 09/10 the metal sheet in the walking was fastened and is no longer sticking out. During this visit further discovery of sheet metal replacement was noted. Vendor will be back onsite on 09/19 to place new metal to newly discovered area. The Dining Director and Administrator will be monitoring the progress of these repairs. If selected vendors do not complete the job as agreed upon, Administrator will seek a different vendor.

Based on interview and record review, it was determined the facility failed to ensure an initial move-in evaluation included all required elements, for 1 of 1 sampled resident (# 5) who recently moved in. Findings include, but are not limited to: Resident 5 moved into the assisted living community in 09/2023 with diagnoses including pancreatitis and type 2 diabetes mellitus. Resident 5's move-in evaluation, dated 09/22/23, lacked information regarding the following required elements: * Interests, hobbies, social and leisure activities; * Personality: including how the person copes with change or challenging situations; and * Recent losses. The move-in evaluation was reviewed with Staff 1 (Administrator), Staff 2 (RCC), Staff 4 (LPN), Staff 6 (Regional Director of Operations), and Staff 11 (Director of Health Services, RN) on 09/27/23 at 2:30 pm. They acknowledged the findings.

C252: The administrator has contacted Yardi specialist for EHR system. Weekly calls have been set up with Yardi specialist with administrator, LPN, RN, Resident care coordinators to address the needs of states regulation for service plans. Weekly calls started 10/10/23 and will continue each week. During these Yardi calls we discuss what is needed such as the service plans. Yardi specialist has corrected the issue to include the interests, hobbies, social and leisure activities. How a resident cope with a challenging situation and recent losses. The administrator did review to make sure it included all key components. This is reflective on the assessments and service plans as of 10/15/23. The administrator will oversee these weekly meetings will be until all areas of Yardi EHR that need their fixed are address. When completed these meetings will turn to monthly. If any other issues arise, we now have the Yardi specialist name, email and number so the community can address the issues quicker.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective and provided clear direction regarding the delivery of services for 4 of 5 sampled residents (#s 1, 2, 3 and 4). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including cerebrovascular accident. The service plan dated 09/15/2023, temporary service plans and progress notes dated 07/31/23 through 09/25/23 were reviewed. Interviews with care staff were conducted and observations were made. The resident's service plan was not reflective and failed to provide clear instruction to staff in the following area: * Siderail use and safety. On 09/28/23, the need to ensure service plans provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN). They acknowledged the findings. 2. Resident 3 was admitted to the facility in 06/2021 with diagnoses including diabetes. The service plan dated 08/03/2023, temporary service plans and progress notes dated 07/23/23 through 09/25/23 were reviewed. Interviews with care staff  and Resident 3 were conducted and observations were made. The resident's service plan was not reflective and failed to provide clear instruction to staff in the following area: * Pressure ulcer; and * Discontinuation of walker use. On 09/28/23, the need to ensure service plans provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN). They acknowledged the findings. 3. Resident 4 moved into the facility in 06/2021 with diagnoses including diabetic neuropathy. Resident 4's service plan, updated 08/16/23, was reviewed during the survey and was not reflective of the resident's current status or failed to provide specific instruction to staff in the following areas: * Use of modified/weighted utensils. The need to ensure service plans were reflective of the resident's needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings. 4. Resident 1 was admitted to the facility in 07/2020 with diagnoses including Parkinson's disease, depression and major depressive disorder. The service plan dated 09/20/2023, temporary service plans and progress notes dated 08/01/23 through 09/24/23 were reviewed. Interviews with care staff and Resident 1 were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas: * Communication; * Mental health issues including: presence of depression; and * Siderail use. The need to ensure service plans were reflective of the residents' care needs and provided clear caregiving instruction was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), Staff 6 (Regional Director of Operations), Staff 11 (Director of Health Services, RN) on 09/28/23.  They acknowledged the findings.

C260: On 10/2/23 were reviewed by administrator, LPN, RN and the resident care coordinator to address the following area of concerns reported such as communication, diagnosis's, assistive devices. RN has made a list of all resident assistive devices and restraints that are currently in use by residents. RN has completed their assessments and added them to the service plans. RCC faxed PCPs for an updated list of diagnosis to review and update for any missing diagnosis in residents service plans. RCC's has reviewed service plans and updated any communication needs in the resident's service plan. The administrator will be reviewing these with the health services team during the quality assurance meeting as described in C150 above.

Based on interview and record review, it was determined the facility failed to determine and document what action or interventions were needed for a resident, communicate the interventions to staff on each shift, and ensure short-term changes of condition were monitored with weekly progress noted through resolution for 2 of 5 sampled residents (#s 4 and 6) reviewed for changes of condition.  Findings include, but are not limited to: 1. Resident 4 moved into the facility in 06/2021 with diagnoses including type II diabetes and diabetic neuropathy. Resident 4's 07/27/23 through 09/11/23 facility progress notes and 09/01/23 through 09/25/23 MAR showed the following changes of condition: * 09/01/23 - 09/03/23: On a new anti-biotic medication. The facility initiated short-term monitoring. However, there was no documented evidence the change was monitored at least weekly through resolution. The need to ensure short term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings. No further information was provided. 2. Resident 6 moved into the facility in 10/2020 with diagnoses including type II diabetes. Interviews with staff and Resident 6's 07/31/23 through 09/25/23 facility progress notes showed the following changes of condition: * 08/28/23: Received "a shot of left eye"; and * 09/08/23: Experienced a low blood sugar episode. The facility initiated short-term monitoring of the eye injection. However, there was no documented evidence the change was monitored at least weekly through resolution. There was no documented evidence the resident's condition was evaluated to determine what actions or interventions were needed for the resident's low blood sugar episode and communicated to staff on each shift. There was no evidence the resident's change of condition was monitored through resolution. The need to ensure short term changes of condition were monitored with weekly progress noted until resolution was reviewed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings. No further information was provided.

C270: RN will be hosting an in-service training on change of condition monitoring for all health service staff. This training will include what change of condition is, how to identify a change of condition in a resident, proper charting for a change of condition.   RN will be informed by the LPN when a resident is having a change of condition via phone, text ,email, facetime etc. White board has been set up for RN that set up for communication for on which residents are on change of condition for them to review. The administrator will oversee and make sure RN is on track with her change of condition. This will also be monitored in our clinical meetings and quality assurance meetings.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 6) who was being assisted with insulin injections or CBG readings by unlicensed facility staff. Resident 6 experienced avoidable medical complications related to the lack of training and supervision to ensure safety and accuracy of insulin administration of unlicensed staff. Findings include, but are not limited to: Resident 6 moved into the facility in 10/2020 with diagnoses including type II diabetes. During the acuity interview on 09/25/23, Resident 6 was identified to be administered insulin injections by non-licensed staff. a. The resident's delegation records and clinical records were reviewed and identified the following: * Staff 18 (MT) documented on the MAR she administered Resident 6's insulin injection on multiple occasions; and * There was no documented evidence Staff 18 was delegated to administer Resident 6's insulin. b. Interviews with Staff and the resident's 09/01/23 through 09/25/23 MARs were reviewed and identified the following: * The MAR directed staff to administer insulin to the resident twice a day; * The MAR noted the following instruction "do not administer [the insulin] if blood sugar is below 100."; * The MAR showed the resident's CBG was 74 on 09/08/23 at 7:00 am and staff signed on the MAR that they administered insulin to the resident when the CBG was 74; * During an interview on 09/25/23, Staff 18 confirmed she administered the insulin to the resident when the resident's CBG was "around 70's". She further stated a caregiving staff reported to her that the resident was having "low blood sugar" episode approximately 15 minutes after she had administered the insulin to the resident. Staff 18 reported she checked the resident's blood sugar level and it was "around 40's."; and * The facility investigation noted Staff 18 was "unaware of" the instruction to hold insulin when CBG was below 100. The facility's failure to complete Staff 18's delegation and supervision of special tasks of nursing care put the resident at risk for an insulin administration error and avoidable medical complications. During the survey on 09/27/23, Staff 11 (Health Services Director, RN) reported she completed the delegation of the insulin administration task to Staff 18 on 09/26/23. c. Interviews with staff, review of delegation records and the 09/01/23 through 09/25/23 MAR identified the following: * Staff 9 (MT), Staff 13 (MT) and Staff 19 (MT/CG) initialed the MAR for insulin administration; * Staff 9 and Staff 13, lacked determination of frequency resident should be reassessed, including rationale and determination of frequency the unlicensed staff should be supervised and re-evaluated, including rationale; and * Staff 19 had no documented evidence of the delegation task for Resident 6 had been completed as of 09/25/23. On 09/28/23 at 11:30 am, the need to ensure all staff who administered insulin injections or performed delegated, taught tasks were appropriately delegated and supervised in accordance with OSBN Administrative Rules with Staff 1 (Administrator) and Staff 11 was reviewed. They acknowledged the findings.

C282: RN has reviewed all diabetic residents at the facility currently. RN has added specific parameters to each resident. Administrator will have RN to audit eMAR weekly to ensure only delegated MTs are performing CBGs and giving prescribed Insulins or other subq injections per orders and to monitor that Parameters remain up to date as well.

Based on observation, interview, and record review, it was determined the facility failed to ensure adequate professional oversight for a safe medication system. The lack of adequate professional oversight for the safe medication system including insulin administration and delegated tasks put Resident 6 at risk. Findings include, but are not limited to: 1. Resident 6 moved into the facility in 10/2020. During the acuity interview on 09/25/23, Resident 6 was identified to be administered insulin injections by non-licensed staff. a. The resident's 08/14/23 physician's orders, delegation records and 09/01/23 through 09/25/23 MARs were reviewed. Resident 6 had a physician order to administer Humalog 70/30 (an intermediate-acting insulin combined with the more rapid onset of action) 60 units injection subcutaneously at 7:00 am and 20 units at 3:30 pm and to check CBG four times daily. The MAR showed an instruction "do not administer [the insulin] if blood sugar is below 100." Further review of the MAR showed the resident's CBG was 74 on 09/08/23 at 7:00 am and staff initialed on the MAR that they administered insulin to the resident on 09/08/23 at 7:00 am when CBG was below 100. During an interview on 09/25/23, Staff 18 (MT) confirmed she administered insulin to the resident when the resident's CBG was "around 70's." She further stated a caregiving staff reported to her that the resident was having "low blood sugar" episode approximately 15 minutes after she had administered the insulin to the resident. Staff 18 reported she checked the resident's blood sugar level and it was "around 40's." b. Review of the delegation records revealed there was no documented evidence Staff 18 was delegated to administer Resident 6's insulin. The facility investigation noted Staff 18 was "unaware of" the instruction to hold insulin when CBG was below 100. The facility's failure to provide professional oversight of the medication administration system including following a special instruction on the MAR and the lack of documented evidence that the delegation and supervision of special tasks of nursing care had been completed, put the resident at risk for an insulin administration error and avoidable medical complications. On 09/28/23 at 11:30 am, the above findings were shared with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC) and Staff 11 (Director of Health Services, RN). They acknowledged the findings. Refer to C282 2. Resident 7 moved into the assisted living community in 02/2023 with diagnoses including anxiety, Bi-polar mood disorder, posttraumatic stress disorder (PTSD), and schizoaffective disorder. During the acuity interview on 09/25/23, Resident 7 was identified to be administered an as needed psychotropic medication. The resident's 09/01/23 through 09/25/23 MAR, physician orders, and 08/28/23 through 09/25/23 progress notes were reviewed during the survey. Resident 7 was prescribed prochlorperazine (for PTSD), one tablet every day, as needed. On 09/10/23, unlicensed staff (MT) administered the as needed medication twice, for a total of two tablets. During an interview on 09/26/23 at 3:10 pm, Staff 4 (LPN), reported the physician orders were entered into the electronic MAR (EMAR) by the pharmacy. The pharmacy entered the order incorrectly which failed to alert the MT that the medication had already been given and was too soon to administer another dose. The facility staff failed to review the order that was entered into the EMAR by the pharmacy which resulted in the medication administration error. The need to ensure the facility had effective oversight of the medication system was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Coordinator), Staff 4 (LPN), Staff 6 (Regional Director of Operations), and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings. 3. During the re-licensure survey, conducted 09/25/23 through 09/28/23, administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C 282: Systems: RN Delegation; * C 302: Systems: Tracking Controlled Substances; * C 310: Systems: Medication Administration; * C 325: Systems: Self Administration of Medications; and * C 330:  Systems: Psychotropic Medication.

C300: RN, LN, Administrator and RCC did a review of the resident's MARs that was completed on 10/5/23. Administrator and RCC flagged any routine or PRN for bowels, pain, psychotropic medications, CBG and insulin that had no clear Parmenter's on the resident's MAR. RN and LPN have added the parameters for each residents needs for bowel medications, pain, and psychotropic, CBG and insulin orders To ensure overview admin will supervise clinical meetings so the RCC and Nurse will review each new orders for each resident to make sure it has the correct parameters. During the quality assurance meeting each month admin will do an MAR audit check with the nurses and RCC's to maintain that administrator/Nursing oversight. All documentation will be in our quality assurance binder.

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 1 sampled resident (# 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 4 moved into the facility in 06/2021 and had diagnoses including chronic neck and back pain. Resident 4 had an order for hydrocodone-acetaminophen 5/325 mg, one tablet every six hours as needed for pain. Resident 4's Controlled Substance Disposition Logs and MARs, reviewed from 09/01/23 through 09/25/23, revealed 29 occasions when staff signed on the drug disposition log that the hydrocodone-acetaminophen was given. However, the MAR lacked documentation that the resident received the medication. Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Administrator), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN) during the survey. They reviewed the documentation and acknowledged the discrepancies.

C302: Effective 10/2/23 Narcotic books are required for review at each clinical meeting. During these reviews administrator, resident care coordinator and nurse are to review each narcotic page to ensure that med techs are signing out properly and dispensing the medication. Med techs are getting an in-service training about narcotics and signing out medications properly on there next health services meeting on 10/25/23. Administrator is requesting Narcotic audits done monthly as stated in C150 for review. These audits will be done by the resident care coordinators and the Nurses.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included resident specific parameters, and instructions for PRN medications for 4 of 5 sampled residents (#s 2, 3, 4 and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including cerebrovascular accident. The resident's current physician's orders and the MAR dated 09/01/23 through 09/25/23 were reviewed and revealed the following: The following medications did not include clear parameters for unlicensed staff to follow: * PRN Vicodin (for pain); and * PRN Morphine (for pain). The need to ensure MARs included clear parameters was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of health Services, RN). They acknowledged the findings. 2. Resident 3 was admitted to the facility in 06/2021 with diagnoses including diabetes. The resident's current physician's orders directed staff to obtain pulse and BP prior to administration of Coreg (for high blood pressure). The MAR dated 09/01/23 through 09/25/23 was reviewed and revealed the following multiple blanks for the following: * Pulse; and * Blood pressure. During an interview with Staff 4 (LPN), she stated the resident had been refusing daily vitals and staff had not always been documenting the refusals on the MAR. The need to ensure MARs were accurate was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 and Staff 11 (Director of Health Services, RN). They acknowledged the findings. 3. Resident 4 moved into the facility in 06/2021 with diagnoses including irritable bowel syndrome. Resident 4's 09/01/23 through 09/25/23 MAR was reviewed and the following was identified: * PRN polyethylene powder and PRN Senna 8.6 mg were both prescribed to treat constipation and lacked clear parameters for the sequence of administration . The need to ensure MARs included clear parameters for multiple PRN medications prescribed to treat the same condition was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services , RN) on 09/28/23. They acknowledged the findings. 4. Resident 6 moved into the facility in 10/2020 with diagnoses including type II diabetes. Resident 6's 09/01/23 through 09/25/23 MAR was reviewed and the following was identified: * A PRN glucose medication for low blood sugar lacked clear parameters for administration; and * A PRN milk of magnesium for constipation lacked clear parameters for administration. The need to ensure MARs included clear parameters for PRN medications use was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings.

C310: RN and LPN have reviewed all mars to add clear parameters for med techs to review. Med tech Inservice training will be reviewing on what to look for when looking at the order in the MAR. During the health services clinical meetings nurses will be reviewing each new order to make sure it includes a clear set of parameters for med tech to follow. Administrator will be overseeing the clinical meetings and doing reviews of the new orders for residents to ensure accuracy of MARS. Please refer to C150 for corrective oversight.

Based on observation, interview, and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer a specific medication for 1 of 1 sampled resident (#4) who self-administered an insulin injection. Findings include, but are not limited to: Resident 4 moved into the facility in 06/2021 with diagnoses including type II diabetes. On 09/27/23 at 9:40 am, diabetic supplies and a sharp container was observed in the resident's room. Resident 4 confirmed s/he self administered his/her insulin injection. During the survey, an evaluation of the resident's ability to safely administer the insulin was requested. Reviewed the facility's "Medication Self Administration Assessment Results" which showed "DNA" on the administer subcutaneous injections. There was no other information on the form related to the resident's ability to safely self-administer subcutaneous insulin injections. On 09/27/23 at 10:20 am, evaluating Resident 4's ability to safely self-administer medications was review with Staff 1 (Administrator), Staff 4 and Staff 11 (Director of Health Services, RN). They acknowledged the findings.

C325: A full self-med assessment audit was done by our resident care coordinator. That has been sent to our RN and LPN for review. RCC's has faxed PCP for an updated self-med administration order for residents. Each month RN, LPN and Administrator will review the self-med assessments together to ensure that they are up to date.

Based on interview and record review, it was determined the facility failed to ensure written, resident-specific parameters and non-pharmacological interventions were attempted and documented to have ineffective results, prior to administering a PRN psychotropic medication for 1 of 1 sampled resident (#7), whose records were reviewed. Findings include, but are not limited to: Resident 7 moved into the assisted living community in 02/2023 with diagnoses including anxiety, bipolar mood disorder, posttraumatic stress disorder (PTSD), and schizoaffective disorder. The resident's 09/01/23 through 09/25/23 MAR and 08/28/23 through 09/25/23 progress notes were reviewed during the survey. Resident 7 was prescribed prochlorperazine (for PTSD), one tablet every day, as needed. Between 09/07/23 and 09/12/23, Resident 7 was administered six doses of the PRN prochlorperazine. There was no documented evidence unlicensed staff (MTs) documented non-pharmacological interventions were attempted with ineffective results prior to administering the PRN medication. During an interview on 09/26/23 at 3:10 pm, Staff 4 (LPN) confirmed there were no resident specific parameters or non-pharmacological interventions on the MAR and staff were not documenting non pharmacological interventions were attempted prior to administering the medication. The need to ensure the MAR included resident specific parameters and staff documented non-pharmacological interventions were attempted prior to administering a PRN psychotropic was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 4, Staff 6 (Regional Director of Operations), and Staff 11 (Health Services Director, RN) on 09/27/23 at 2:30 pm. They acknowledged the findings.

C330: Residents that are on Psychotropic medications have had interventions added by RN and LPN. In service training to med techs about proper documentation of interventions for psychotropic medications During clinical meetings each day RN,LPN and RCC will review to ensure that interventions were done first before giving the psychotropic medication. This will be reviewed everyday in clinical however there will still be a monthly audit done by Administrator and Nurses to ensure interventions are added to the order and that med techs are following interventions.

2. Resident 3 was admitted to the facility in 06/2021 with diagnoses including diabetes. On 09/26/23, during an interview with the resident in his/her apartment, half-bilateral side rails were observed on the bed in the up position, and securely fastened to the bed. Review of Resident 3's record revealed there was no documented evidence an assessment of the side rails had been completed by an RN, PT or OT nor were the devices with restraining qualities included on the resident's service plan including the use and precautions. The lack of assessment and service planning for devices with restraining qualities was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of health Services, RN). They acknowledged the findings. 2. Resident 4 moved into the facility in 06/2021 with diagnoses including congestive heart failure. During an interview on 09/27/23, Resident 4's hospital bed was observed to have bilateral half-length siderails on the bed. The siderails were in the up position and securely fastened to the bed. In an interview with Staff 4 (LPN) on 09/27/23, siderail assessment documentation was requested. On 09/28/23 at 9:32 am, Staff 1 (Administrator) reported no siderail assessment had been completed for Resident 4. The resident's 08/16/23 service plan showed there were no instructions to caregivers on the correct use of the siderails and precautions related to use of the device. The need to ensure supportive devices with potentially restraining qualities were assessed and service planned prior to use was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, failed to instruct caregivers on the correct use and precautions related to the use of the device, and failed to include the use of the supportive device in the service plan and evaluated on a quarterly basis for 3 of 3 sampled residents (#s 1, 3, and 4) who used a supportive device with restraining qualities. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 07/2020 with diagnoses including Parkinson's disease. During an interview on 09/25/23, Resident 1's hospital bed was observed to have a quarter-length siderail on the right side of the bed. The siderail was in the up position and securely fastened to the bed. Review of Resident 1's service plan dated, 09/20/23, revealed there was no documentation of the use of supportive devices with restraining qualities included in the resident service plan. In an interview with Staff 4 (LPN) on 09/25/23, siderail assessment documentation was requested. Staff 4 was unaware that siderails were present and stated that a siderail assessment had not been completed for Resident 1. The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and documentation of the use of supportive devices with restraining qualities was included in the resident service plan was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), Staff 6 (Regional Director), Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings.

C340: LPN has done an audit list of all the assistive devices for residents that are currently using them. RN has reviewed and performed the assessments for the residents. Resident Care Coordinator will be adding the assistive device into the service plan to make sure it is reflective of the service plan. During clinical nurses will review if there is a resident needing an assistive device assessment and to ensure that they are up to date. Administrator will review during monthly quality assurance meeting as outlined in C150

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 8, 14 and 17) completed the required minimum 12 hours of in-service training annually which included six hours of dementia care training. Findings include, but are not limited to: Staff training records were reviewed on 09/26/23. There was no documented evidence Staff 8 (CG), Staff 14 (CG) and Staff 17 (MT) hired 07/14/06, 10/07/21 and 07/16/20 respectively, had completed the required minimum 12 hours of in-service training annually, based on hire dates, related to the provision of care which also included six hours of dementia care training. The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN) and Staff 11 (Director of Health Services, RN). They acknowledged the findings.

C374: Resident care coordinator assigned all annual trainings to the health services staff. 6-hour dementia course has been assigned to the health services staff meet that requirement. Cornell Estates has partnered with realis training program platform. While using this platform we are able to monitor and send alerts when annual training is due and the administrator can assign staff trainings for annual, 30 day, initial, etc. Administrator and Resident care coordinator are able to monitor this monthly to ensure annual trainings are kept up to date for health services staff.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented all required components in accordance with Oregon Fire Code every other month, and Life Safety instruction was provided to staff on alternating months. Findings include, but are not limited to: Review of Fire and Life safety records for 03/2023 through 09/2023 and an interview with Staff 1 (Administrator) on 09/26/23 at 9:15 am revealed the facility lacked documentation of the following: * Fire and life safety instruction to staff on alternate months; and * Fire drills conducted and recorded every other month according to the Oregon Fire Code. On 09/26/23, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training, and fire drills included required components according to the Oregon Fire Code was reviewed with Staff 1, Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), Staff 6 (Regional Director of Operations) and Staff 11 (Director of Health Services, RN). They acknowledged the findings.

C420: Administrator has reviewed fire life and safety protocols with maintenance director. A fire drill was conducted on 10/10/23 with the maintenance director. The drill was properly documented as per CBC guidelines. Administrator will ensure fire drills are done every other month and fire safety training is completed for staff. Administrator will review fire drill documentation and staff training with the maintenance director to ensure proper CBC guidelines are met. A

Based on observation and interview, it was determined the facility failed to ensure exterior surfaces were maintained in good repair. Findings include, but are not limited to: Observations of facility pathways outside courtyards and seating areas on 09/27/23 identified the following: * Multiple drop-offs of four to five inches were noted along pathway edges around the perimeter of outside courtyards and seating areas. The need to ensure pathways around the facility were in good repair with no potential tripping hazards was discussed with Staff 1 (Administrator) on 09/27/23. He acknowledged the findings.

C610: Administrator has called cedar landscaping company on 10/6/23. Administrator reviewed environmental findings with the landscaping company on 10/9/23. Landscaping company corrected the drop off points as of 10/13/23. Administrator will be doing a monthly walk through with the maintenance director to ensure drop-offs are being monitored and corrected by the landscaping company in a more efficient manner.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to: During a tour of the facility on 09/25/23 and 09/26/23, the following was observed: * Multiple benches in the common areas had stains on seating area and had chips and gouges on legs; * Carpet throughout the common areas and hallways had black spots, stains and blackened areas; * Handrails throughout the facility had gouges; * Multiple doors including Room 161, 189, 253, 281 and 290 had scuffs and scratches; * Ventilation covers and filters, near the first floor nursing station, were covered with layers of dust; * Room 154, the cabinet and kitchenette sink areas were gouged and not cleanable surfaces; and * The laundry room linoleum floor was ripped, torn, chipped and had accumulated dust in the corner and behind washers and dryers. The environment was toured on 09/27/23 at 10:45 am with Staff 1 (Administrator). He acknowledged the above areas needed to be cleaned and repaired.

C613: All benches that had stains, chips, gouges on legs were replaced effective 10/10/23. Handrails have been reviewed with maintenance director. Maintenance will be sanding and staining any handrails that have bumps, grooves or knicks. All assisted living doors will be replaced, painted and adding LVP to the lower half of the door to prevent any bumps, scrapes or knicks. Process is started for the first week of November 2023. Room 154 Kitchenette and cabinet has been reviewed by the maintenance director and is going to replace the laminate counters, sand/stain the sides to remove any gouges or nicks. Laundry room linoleum floor has been seen by a flooring vendor. Installation for new flooring will be in November 2023. Walls will be patched up and painted. Housekeepers have added to their deep cleaning log schedule to ensure no dust in the laundry room.

Based on observation and interview, it was determined the facility failed to ensure residents had keys to a lockable storage space (e.g., drawer, cabinet, or closet) for the safekeeping of their small valuable items and funds. Findings include, but are not limited to: On 09/26/23 at 1:00 pm, eight non-sampled residents attended a group interview. All residents interviewed confirmed that although they had a lockable storage space in their apartments, they did not have a key to the space. The need to ensure residents had a key to their lockable storage space was discussed with Staff 1 (Administrator), Staff 2 (RCC), Staff 3 (RCC), Staff 4 (LPN), Staff 6 (Regional Director of Operations) and Staff 11 (Director of Health Services, RN) on 09/28/23. They acknowledged the findings.

C615: Maintenance director and Administrator did a walk through for the assisted living side. All 60 cabinet locks have been ordered on 10/6/23 and delivered 10/18/23. Maintenance director will start installation 10/23/23 and have keys for all assisted living lockable storage compartments. During move in's RCC's will monitor to make sure that all residents get there key to there lockable storage unit.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: The building was toured on 09/27/23 with Staff 1 (Administrator). Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building. On 09/27/23, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1. He acknowledged the findings.

C655: Administrator bought door alarms through there call system provider "arial". Door Alarms have been delivered on 10/13/23 and installed by the maintenance director on 10/16/23. They door alarms connect to the call system and sends an alert to the walkies letting the Health services staff know when a resident leaves the facility. Monthly walk throughs with maintenance director and administrator to test the door alarms to ensure they are working properly. If an issue arises backups were bought to replace.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to: Refer to C 240.

C 240} a. The following areas were in need of cleaning or repair: POC Walk in freezer door gasket has been fixed as of 3/1/24 A new can opener has been bought to replace the old one. Once it has arrived that will be installed and replaced. In the mean time we have added the can opener to the cleaning log list to ensure that is being properly cleaned and disenfected. b. Observations of the dry storage, food preparation and food service identified the following POC kitchen staff were retrained and show the proper way to disenfect. We have ensured that staff know who and where to ask if they run out of the alcohol sanitizer wipes Proper lids have been bought and secured to be used to esnure that dry storage lids are sealing properly. Kitchen staff been reminded and are being audtied daily for to ensure that beard restraints are being used while preping or cooking food. c. The ware washer was not installed at the time of the re-visit survey and there was repair work in process for the surrounding walls. POC Wash ware system has been installed as 02/19/24..C 240} a. The following areas were in need of cleaning or repair: POC Walk in freezer door gasket has been fixed as of 3/1/24 A new can opener has been bought to replace the old one. Once it has arrived that will be installed and replaced. In the mean time we have added the can opener to the cleaning log list to ensure that is being properly cleaned and disenfected. b. Observations of the dry storage, food preparation and food service identified the following POC kitchen staff were retrained and show the proper way to disenfect. We have ensured that staff know who and where to ask if they run out of the alcohol sanitizer wipes Proper lids have been bought and secured to be used to esnure that dry storage lids are sealing properly. Kitchen staff been reminded and are being audtied daily for to ensure that beard restraints are being used while preping or cooking food. c. The ware washer was not installed at the time of the re-visit survey and there was repair work in process for the surrounding walls. POC Wash ware system has been installed as of 2/19/24.

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

These are ongoing repairs that have continued and most of the issues are not related to the first survey, but new leaks that caused additional damage to some of the same areas in the kitchen.

Based on observation and interview, it was determined the facility failed to ensure their third revisit survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 150 and C 240.

Refer to actions outlined in C150 and C240.

The findings of the re-licensure survey conducted 09/25/23 through 09/28/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 09/28/23, conducted 02/14/23 through 02/15/24, 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 09/28/23, conducted on 05/17/24, 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 09/28/23, conducted on 09/05/24, 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the fourth re-visit to the kitchen inspection of 09/28/23, conducted 10/15/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the on-site investigation, conducted 08/10/23/2023 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: 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 12/06/2022.  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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: 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 12/06/2022.  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 living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services were rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 9/14/21 through 9/16/21, administrative oversight to ensure adequate resident care and services rendered in the facility were found to be ineffective based on the severity and number of citations. Refer to deficiencies in report.

OAR 411-054-0025 (1) Facility Administration: Operation Refer to C 231, C 240, C 252, C260, C270, C282, C290

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure the quality of care and services that were rendered in the facility. This is a repeat citation. Findings include, but are not limited to: During the re-visit survey, conducted 02/10/22 through 02/15/22, administrative oversight to ensure adequate resident care and services rendered in the facility were found to be ineffective based on the number of citations. Refer to deficiencies in report.

Refer to C 231, C 240, C 252, C 260, C 270, C 282, C 300, C 303, C 305, C 310, C 372, C 422 and C 455

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. This is a repeat citation.  Findings include, but are not limited to: During the second re-visit survey, conducted 08/29/22 through 09/06/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat and new citations. Refer to deficiencies in report.

ADMINISTRATIVE OVERSIGHT refer to plan of corrections for c240, c260, c270,c280, c282, c300,c303, c305, c310, c372, c455

3. Resident 4 was admitted to the facility in March 2021. On 5/4/21 staff documented on the facility progress note the resident "has been with the same underwear for 5 days..." The 8/26/21 service plan indicated the resident was incontinent in both bowel and bladder management and used adult briefs at all times. The service plan also noted the facility would provide stand-by assistance for toileting. On 9/15/21, an incident report was requested. On 9/15/21 at 3:00 pm, Staff 2 (Resident Care Manager) stated there was no incident report and confirmed there was no facility investigation completed to rule out neglect of care related to wearing the same clothing. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator) and Staff 2 during the survey. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in October 2020. Resident 3's service plan, dated 5/27/21, directed staff to do two hour safety checks.  A progress note indicated Resident 3 had a fall on 9/1/21 and was sent to the hospital. There was no documented evidence noting why the resident was sent out. The After Visit Summary, dated 9/1/21 had a new diagnosis of a pelvic fracture.  An incident report was requested on 9/14/21. On 9/15/21 at 2:11 pm Staff 2 (Resident Care Manager) and Staff 3 (RN) confirmed there was no facility investigation completed to rule out abuse and neglect. An interview with Staff 2 on 9/15/21 at approximately 2:30 pm revealed the resident had been increasingly confused and the facility had been trying to obtain a physician's order to get a urine analysis. The facility suspected the resident may have had a urinary tract infection. During an interview with Resident 3 on 9/15/21 at 2:40 pm, the resident stated s/he broke his/her tailbone but didn't recall what happened. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 during the survey. The staff acknowledged the findings.

Based on interview and record review it was determined the facility failed to ensure incidents and reports of suspected abuse were thoroughly investigated to rule about abuse for 3 of 5 sampled residents (#s 2, 3 and 4) whose records were reviewed. Findings include but are not limited to: 1. Resident 2 was admitted to the facility in July 2018 and was identified in the acuity interview to be at risk for falls. The resident's service plan 5/11/21 included the following fall interventions: * When the resident was awake be sure that s/he was wearing shoes; and * One hour checks to be completed around the clock. The resident's progress notes listed the following incidents: * 6/21/21 the resident was found on the floor and later complained of pain to his/her head and; * 8/3/21 the resident was found on the floor and later complained of soreness to his/her lower back. The 6/21/21 and 8/3/21 Investigation Forms for the incidents included the following questions: * Was proper footwear worn; and * When did [facility staff] last check on the resident. Both questions were answered as N/A [non applicable] for both incidents. In an interview with Staff 3 (RN) on 9/15/21, she confirmed the incidents were not thoroughly investigated including determining if staff were following the fall interventions noted for Resident 2. The facility lacked documented evidence the incidents were thoroughly investigated to rule out neglect of care as a contributor to the residents injuries. The need to ensure incidents were thoroughly investigated to rule out abuse was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

OAR 411-054-0028 (1-3) Abuse Reporting and Investigation 1. All staff to complete Oregon Care Partners training for Abuse prevention and investigation prior to October 29, 2021 2. Staff will be trained on abuse reporting and Clinical meetings will be implemented to review all incident reports and documentation for changes indicative of abuse or neglect. 3. meeting at least weekly to review all incidents and documentation of resident condition. 4. Administrator tor designee to monitor

Based on interview and record review it was determined the facility failed to ensure incidents were thoroughly investigated to rule out abuse or suspected abuse for 1 of 3 sampled residents (#9) who was reviewed for injuries of unknown cause and injury falls. This a repeat citation. Findings include, but are not limited to: Resident 9 was admitted to the facility in January 2021. During the acuity interview on 02/10/22 the resident was identified as having falls with injuries. Resident 9's service plan dated and 12/08/21 and interim service plans noted the resident required one person assist with transfers, use of a gait belt and assistance with toileting. Progress notes dated 01/14/22 through 02/10/22 listed the following injury of unknown cause and injury falls: * 01/21/22 - return from emergency room due to a fall; * 01/21/22 - staff documented the resident had a swollen right buttock; * 01/22/22 - staff walking by room heard the resident say "help me please". Resident was laying face down on the floor. Resident was sent to the hospital for hitting his/her head during the fall; and * 02/04/22 - injury fall while in the bathroom which resulted in back pain. There was no documented evidence the facility completed an investigation to rule out abuse or neglect for the injury of unknown cause and three injury falls. On 02/11/22 at 2:00 pm Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN) confirmed there was no facility investigation completed to rule out abuse and neglect for the injury of unknown cause and the injury falls. Surveyor requested the facility self report the incidents to the local SPD office. Verification of self reporting was received prior to survey exiting the building. The need to ensure incidents were thoroughly investigated to rule out abuse was discussed with Staff 1, Staff 2 and Staff 15 on 02/11/22. They acknowledged the findings.

1. Resident #9 incidents reported to APS and investigation completed for all incidents. All current and newly hired staff to complete oregon care partners training for abuse prevention and investigation. 2. Training tracking system implemented. 3. Clinical meetings to occur at least twice weekly to review resident incidents and documentation of resident condition. 4. Administrator or designee to monitor.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: During a tour of the kitchen on 9/14/21 at 12:28 pm, it was determined the following areas were in need of cleaning or repair: * Left side of the convection oven had food spills on its surface; * Bottom of both ovens, underneath the doors were sticky with black and brown substances; * Drawer of the prep table, underneath the pan storage had debris along the bottom surface and a sticky substance along the perimeter of the drawer; * Bottom shelf of the prep table beside the two sink counter had debris and a sticky substance on its surface; * Black oscillating fan had a thick build up of dust covering the guard; * Shelf above the silverware storage had spillage on it; * Food steamer had a damaged power button and debris and spillage around its perimeter; * Cabinets underneath the service table had spillage on the surfaces and debris on the shelves and; * Wooden prep table had a black substance covering its surface and was not easily cleanable. The areas needing cleaning and repair were discussed with Staff 1 (Administrator) and Staff 4 (Executive Chef) on 9/16/21. They acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule 1. Kitchen will be commercially cleaned by an outside agency. A cleaning roster will be implemented. A walkthrough of the kitchen will be completed weekly for a month after outside agency cleans, and then monthly going forward. 2. This is a new system being implemented to avoid re-occurrence. 3. weekly for a month, then monthly afterward. 4. Administrator or designee to complete walk-throughs of kitchen at timing intervals mentioned above. Administrator or designee to review completed cleaning rosters.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: During a tour of the kitchen on 02/10/22 at 10:30 am with Staff 4 (Executive Chef), it was determined the following areas were in need of repair: * Food steamer had a damaged power button and was in need of being replaced; and * White cabinets underneath the service table had broken doors and multiple areas of white laminate surface removed with exposed wood underneath. The areas needing repair were discussed with Staff 1 (Administrator) and Staff 4 on 02/10/22. They acknowledged the findings.

1. Kitchen has been approved for renovations 2. Kitchen equipment and food service space will be replaced to avoid re-occurrence. 3. Will evaluate monthly after renovations. 4. Administrator or designee to complete. See attached approved plans to renovate kitchen

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The kitchen was observed in an unsanitary condition which posed a situation that could threaten the health, safety, or welfare of residents. This is a repeat citation. Findings include, but are not limited to:   Observation of the kitchen on 08/29/22 at 2:00 pm identified the following areas of concern:   1. Main kitchen area:   * Flies and gnats were observed throughout the kitchen; * Floors throughout the kitchen, including walk-in cooler and freezer, food prep areas, behind and underneath ovens and appliances, had an extensive build-up of black matter, grease, and food debris; * Pipes, walls, gauges, disposal, drain, and flooring behind/underneath the dish machine and three compartment sinks were covered in black matter, grease, and corrosion; * Pipes beneath cupboards and behind ice machine were covered with a layer of dirt, dust, and lint; * Walls and ceilings throughout the kitchen had multiple spills, smears, and food splatters; * Garbage cans throughout the kitchen area were uncovered, food debris and spills stuck to the outside of containers; * Doors, door frames, ceiling, and walls had food splatters, spills, and stains; * Exterior of ovens were covered in grease, food spills, orange and black sticky build up; * Interior of ovens had a buildup of burnt food debris, grease, and spills; * Oven hoods had a buildup of grease and grime; * Floor drains had a buildup of rotting gray matter; * Interior and exterior of walk-in cooler and freezer, including shelving, had food debris, spills, splatters, chipped paint, and areas of rusting; * Kitchen janitor closet walls and flooring showed water damage and mold. The mop sink had a dense buildup of black matter and debris. A cluster of gnats was noted flying in the closet, and the door was covered in dead gnats; * An additional closet connected to the kitchen area needed to be deep cleaned, sanitized, and properly organized; * Undated and unlabeled food items were noted in the reach-in and walk-in cooler and freezer; * Rolling carts throughout the kitchen had loose food debris, dried liquid spills, and stuck food matter; * Food boxes were stored on the walk-in and dry storage floors; * Multiple kitchen staff were observed not sanitizing hands upon entering the kitchen, nor washed hands between tasks, and were not consistently wearing face masks properly; and * Multiple kitchen staff lacked documented evidence of Oregon Food Handlers certification. 2. Dry food storage area:   * Extensive build-up of black matter/dirt/food debris was observed on the floor and behind/underneath shelving units; * Cardboard box of rotting potatoes stored on shelving unit was infested with gnats; * Clusters of flies were seen swarming around the back of the dry storage area and coming through the seams of the plywood ceiling;   * Ceiling of the dry storage area was made of unfinished plywood rendering an un-cleanable surface; and * Door leading to the dry storage area was unfinished wood creating an un-cleanable surface.   3. Areas in need of repair:   * Interior and exterior particle board cupboards underneath steam table had exposed wood, making it an un-cleanable surface, and a cupboard door was off the hinges; * A piece of wood was attached to a wall near the food steamer and commercial oven, which created a potential fire hazard; * Control knobs missing from both ovens; * Oven next to the food steamer was not working; * Garbage disposal was not functioning; * Continuous water leaking from three compartment sink faucet; * The caulking along the back splash of the dishwashing area, kitchen sinks, counters, and baseboards was corroded, blackened or missing; * Multiple floor tiles were chipped throughout kitchen areas; * Hand washing sink soap dispenser and paper towel dispenser was empty; * Janitor closet had a missing door handle, and splintered exposed wood was around the trim ring; * Doors and door frames throughout the kitchen were gouged, scraped, and splintered; * Kitchen back door had black smears, chipped paint, stains, scuffs, and the screen covering the door was torn, allowing potential entry of insects and pests; * Patches of disintegrated drywall were between the floor and wall behind the dish machine; * Walk-in cooler door gasket was torn and damaged; * Interior side of the walk-in cooler door was significantly dented and had a one-inch diameter hole; and * Self-serve ice and ice cream machines in the dining room were not working and were out of order. At approximately 3:00 pm, the findings and areas of concern were reviewed and toured with Staff 1 (Administrator). At 3:16 pm, the survey team contacted the Community Based Care Manager and shared concerns about the unsanitary condition of the kitchen and dry food storage area. A decision was made to close the kitchen until the unsanitary condition was rectified.   At that time, the facility was informed that the kitchen would be closed down. Staff 1 was instructed by the survey team to submit a (NIC) needs immediate correction plan to address the unsanitary conditions and areas needing repair in the kitchen.   The facility submitted an initial NIC plan on 08/29/22 at 6:15 pm. The plan for how the facility would provide food to the residents for the next 24 hours was accepted; however, additional information was requested for the plan and was agreed to be reviewed the following day.   On 08/30/22, at approximately 12:09 pm, the facility provided additional information on how they were going to proceed to correct the unsanitary conditions of the kitchen. The plan indicated commercial cleaners were scheduled to come out to the facility at 7:00 am on 08/31/22. In the meantime, the kitchen remained closed.   On 08/31/22 at 10:00 am, the surveyor and Staff 1 re-inspected the kitchen. The unsanitary conditions found in the kitchen and dry storage had not been corrected; therefore, the kitchen remained closed. Due to the kitchen closure, the facility contracted with a mobile kitchen truck and the truck was scheduled to arrive on 09/01/22.   The facility was instructed to have a professional pest control company inspect the kitchen. The pest control report dated 09/01/22 was received on 09/02/22. The facility requested a re-inspection of the kitchen on 09/06/22. On 09/06/22, at approximately 1:00 pm, the surveyor and Staff 32 (Regional Director) re-inspected the kitchen and dry food storage room and found the unsanitary conditions had been corrected. The facility planned to re-open the kitchen on 09/12/22 after the repairs were done. The facility plan was approved. The need to ensure the kitchen was maintained in a sanitary manner and in good repair, in accordance with the Food Sanitation Rules, OAR 333-150-000, was discussed with Staff 32 on 09/06/22. He acknowledged the findings.

Resident Services Meals 1) Facility will schedule routine cleaning for hood, drains, appliances, floors and walls. New racks for the walk in dry storage and walk in cooler have been ordered. 2) Cleaning schedule will be implemented by facility for staff to complete daily, weekly and monthly. 3) Cleaning regimen and schedule to be reviewed monthly. Kitchen manager to review on a weekly bases. 4) Administrator or Designee, Kitchen Manager *Additional Notation as requested by survey team: A. Main kitchen area: * Flies and gnats as noted on our walk-through, are not present. Rotten potatoes have been removed and no further issue has been noticed. * Floors throughout the kitchen have been cleaned by outside provider and will be continuously cleaned by kitchen staff. * Pipes, walls, gauges, disposal, drain, and flooring behind/underneath the dish machine and three compartment sink area have been thoroughly cleaned, the leak was repaired immediately however, this is on our construction crew list for a rebuild of the wall under the sinks. * Pipes beneath cupboards and behind ice machine were covered with a layer of dirt, dust, and lint; this area was clean on our walkthrough together, FRP has since been installed. * Walls and ceilings throughout the kitchen had multiple spills, smears, and food splatters; * All garbage receptacles are covered and cleaned and will remain covered with ongoing training/checklists. * Doors, door frames, ceiling, and walls had food splatters, spills, and stains. These areas have been cleaned and will be placed on routine schedule to clean for kitchen staff to follow. * Exterior of ovens were covered in grease, food spills, orange and black sticky build up. These area were cleaned several times and will continue via checklists for the team. * Interior of ovens had a buildup of burnt food debris, grease, and spills. These areas were cleaned several times and will continue to clean via checklists for the team.  Admin to review weekly * Oven hoods have been cleaned by outside agency and will be maintained by kitchen staff. * Floor drains have been thoroughly cleaned and emptied of any gray rotting matter. * New shelves installed in walk in cooler. * Kitchen janitor closet was thoroughly cleaned as noted in our walk-through, however, we have plans to replace flooring, repair tile, install a new mop basin, replace door and prep and paint walls * Mechanical room will have drywall repaired and storage items removed. The drywall repair is added to our construction crew list. * Undated and unlabeled food items were noted in the reach-in and walk-in cooler and freezer; This is no longer the case, all items are dated and labled. * Rolling carts throughout the kitchen had loose food debris, dried liquid spills, and stuck food matter; * Food boxes were stored on the walk-in and dry storage floors * Multiple kitchen staff were observed not sanitizing hands upon entering the kitchen, nor washed hands between tasks, and were not consistently wearing face masks properly; and   As noted on your return visit, a training was immediately conducted for the team.  This will be an ongoing training and review by Admin weekly. * Currently all kitchen staff members have their food handlers certifications with the exception of the two dishwashers.  Those dishwashers will have theirs within a week.  Ongoing, this will be a part of the onboarding process. B. Dry food storage area: * Extensive build-up of black matter/dirt/food debris was observed on the floor and behind/underneath shelving units. Shelving units have been replaced and flooring removed and replaced. * Cardboard box of rotting potatoes stored on shelving unit was infested with gnats; This has been removed. *Flies and Gnats in dry storage - as noted in our walk-through, this area was completely sealed up and painted as well as the entire storage area, see pictures sent via email.  In addition, new flooring was installed. *Ceiling of dry storage was painted and sealed. * Door leading to the dry storage area has been painted and is now a cleanable surface. C. Areas in need of repair: * Cabinets under steam table have been outfitted with cleanable surface to cover cubbies and is no longer used as a storage area. * Pipe has been attached to the wall near the food steamer and commercial oven, * We will be ordering one new oven unit and removing one, once the new unit is here. * We are ordering a new oven unit, this is about 60 days out. * Garbage disposal repaired and is functioning properly. * Continuous water leaking from three compartment sink faucet; * The caulking along the back splash of the dishwashing area, kitchen sinks, counters, and baseboards has been replaced or repaired. * Multiple floor tiles of issue will be repaired/replaced by our construction team. * Hand washing sink soap dispenser and paper towel dispensers are filled and will be going forward with checklists for the team. * Janitor closet had a missing door handle, and splintered exposed wood was around the trim ring;   Referred to above as a new door will be installed. * Doors and door frames throughout the kitchen will be evaluated and repaired or replaced as needed for gouging or splintering. * Kitchen back door has been sanded, painted and FRP has been installed on the inside ½ of the door. This door will continue to be cleaned. * Patches of disintegrated drywall will be addressed with the construction team. * Walk-in cooler new gaskets will be installed by the vendor. * Interior side of the walk-in cooler door was significantly dented and had a one-inch diameter hole; We agreed during the walk-through that this was aesthetics only and had no affect on the cooling of the walk-in.   * Self-serve ice and ice cream machines in the dining room were not working and were out of order.  The ice machine has been removed completely and the ice cream machine is functional.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 5) and failed to ensure quarterly evaluations were accurate and used as the foundation to develop service plans for 3 of 4 sampled residents (#s 1, 3 and 4) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in March 2020. Resident 4's 90-days nursing assessment, dated 6/3/21, failed to be reflective of the resident's condition in the following areas: * Current left rib fracture; * HHRN outside provider services for wound care; and * Use of special shoe for the left foot. The need to ensure evaluations were reflective of the resident's condition was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) during the survey. No additional information was provided. 2. Resident 1 was admitted to the facility in July 2020. Resident 1's 9/13/21 quarterly evaluation was not reflective of the resident's current condition in the following areas: * Independence with care; * Prosthetic use with HHPT guidance; * HHRN providing wound care; and * Type of insulin the resident self administered. The need to ensure evaluations were accurate and reflective of the resident's condition was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings. 3. Resident 3 was admitted to the facility in October 2020. Resident 3's quarterly evaluation was dated 7/26/21. The resident's service plan was dated 7/20/21. The facility failed to ensure Resident 3's evaluation was used as the foundation to create the service plan as it was done after the service plan was created. The need to ensure evaluations are the foundation used to develop the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings. 4. Resident 5 was admitted to the facility in August 2021. The move in evaluation was reviewed and was identified to be missing the following required elements: * Spiritual, cultural preferences and traditions; * Memory, orientation and confusion and decision making abilities; * Dental status; * Nutritional habits including fluid preferences; * History of dehydration or unexplained weight loss or gain; and * Recent losses. On 9/16/21 the need to address all required elements on the move in evaluation was discussed with the Staff 1 (Administrator) and Staff 2 (Resident Care Manager) who acknowledged the findings.

OAR 411-054-0034 (2-4) Resident Move-in and Eval: Res Evaluation 1. Evaluations for residents 1, 3, 4 and 5 will be audited for all required elements and to assure information is reflective of current resident conditions. 2. RCC will be educated on evaluation areas of concern and evaluations for residents 1, 3, 4, and 5 will be updated to reflect current needs and eval to be used as foundation for plan of care. 3. Evaluations for all residents will be reviewed quarterly to assure accuracy, and used as foundation for plan of care. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 7) whose evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 7 was admitted to the facility in January 2022. The move-in evaluation was reviewed and was identified to be missing the following required elements: * History of dehydration or unexplained weight loss or gain; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature. On 02/11/22 the need to address all required elements on the move-in evaluation was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN). They acknowledged the findings.

1. Move-in evaluation for resident #7 has been reviewed and missing elements of need have been implemented. Evaluations will be audited for all required elements and implemented as necessary. 2. Care Coordinator and health services management will be trained on implementing move-in requirement into current care planning software. 3. Evaluations will be reviewed as they are completed for one month and then quarterly. 4. Administrator or designee to monitor.

3. Resident 4 was admitted to the facility in March 2020. Resident 4's service plan, updated 8/26/21, and subsequent temporary service plans were reviewed during the survey and were not reflective of the resident's current status or failed to provide specific instruction to staff in the following areas: * Pain management due to new onset of chest pain and neck pain; * Fall preventions; * Signs and symptoms of how they exhibit behaviors; * Outside provider services including who to report and when to report; * Use of a special shoe on the left foot; * Use of a side rail while in bed; * Oxygen use including who changes tubing and filter; and * Resident specific signs and symptoms of having low or high blood sugar. The need to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. 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' needs, provided clear direction to staff regarding the delivery of services, handwritten updates were dated and initialed and were updated quarterly for 4 of 5 sampled residents (#s 1, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in July 2020. Resident 1's service plan was reviewed and was not reflective or lacked clear caregiving instruction in the following areas: * Daily blood pressure checks and which arm to take blood pressures on; * Prosthetic teaching; * Anxiety and if the resident could request a PRN, what the signs and symptoms are and any non-drug interventions to offer; * Dialysis relating to care needs before and after, location, transportation, and food provided by the facility; * Mental health and preference of the door and window being open; * Breakfast routines; and * Resident specific signs and symptoms of having low or high blood sugar. The resident's service plan that was available to staff was dated 5/27/2021. The facility had not updated the document quarterly. There were two handwritten updates. One lacked a date and initials of the staff member who made the changes. The need to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, handwritten updates were dated and initialed and were updated quarterly was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings. 2. Resident 3 was admitted to the facility in October 2020. Resident 3's service plan, dated 7/20/21, was reviewed and was not reflective or lacked clear caregiving instruction in the following areas: * Fall interventions; * Breakfast habits and preferences; * Signs and symptoms of how they exhibit anxiety; * Non-drug interventions relating to anxiety; * After care instructions for a pelvic fracture; and * Unclear directions relating to dressing, transfers and toileting. The need to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings. 4. Resident 5 was admitted to the facility in August 2021 with a diagnosis of hypertension. The resident was identified in the acuity interview as being administered Warfarin (blood thinner). The resident's 8/30/21 service plan was reviewed and was not reflective and did not include clear instruction for staff in the following areas: * Routine lab draws and; * Warfarin administration including common side effects and risks. The need to ensure service plans were reflective of resident's current health status and provided clear instruction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manger) on 9/16/21. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General 1. Service plans will be audited and reviewed for accuracy and corrected as needed for residents 1, 3, 4 and 5. Evaluations will be completed to reflect the current resident condition and then used for foundation of service plan. 2. Service plans will be audited and reviewed going forward for accuracy. 3. This will be reviewed prior to date of alleged compliance as well as quarterly going forward. 4. The administrator or designee will be responsible for monitoring and auditing service plans.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff for 1 of 3 sampled residents (# 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 6 was admitted to the facility in 2015 with end stage renal disease. The residents service plan, dated 02/03/22, was reviewed and was not reflective or lacked clear care giving instruction in the following areas: * Location of fistula and which arm to take blood pressures on; * Use and placement of a sling for use by the resident on dialysis treatment days; * Mobility, left-sided weakness and need for two person-assist during transfers; * Resident's current plan for desired weight loss; * Directions regarding CBG readings and insulin administration; and * Recent fall and current fall interventions specific to the resident. During observations and interviews on 02/11/22, Resident 6 was up in a wheelchair, had a fistula in his/her right upper arm and stated s/he goes to dialysis three times a week and returns to the facility at about 9:00 pm, some of his/her medications are not to be taken on days s/he goes to dialysis and the resident is able to self-direct certain aspects of his/her care. Resident 6 stated some staff "are good about knowing how to take care of me and others are not. I have to tell them each step of what needs to be done." The need to ensure service plans were reflective of residents' needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 02/15/22. They acknowledged the findings.

1. Resident #6 service plan has been updated to reflect current plan of care and communication has been established between providers to ensure changes to plan of care are implemented in timely manner. All Service plans will be audited and reviewed for accuracy and corrected. Evaluations will be completed to reflect the current resident condition and needs. 2. Service plans will be audited and reviewed going forward for accuracy. 3. This will be reviewed quarterly. 4. The administrator or designee will be responsible for monitoring and auditing service plans.

2. Resident 11 was admitted to the facility in 09/2021 with diagnoses including congestive heart failure and hypertension. During the acuity interview on 08/29/22, Resident 11 was was identified with a history of falls, and a recent fall resulting in a head injury. Observations and interviews with the resident and staff from 08/29/22 to 08/31/22, review of clinical record and most recent service plan, dated 07/27/22, indicated the service plan failed to reflect the resident's current care needs and lacked specific instruction to staff in the following areas: * Recent falls and interventions; * Significant change of condition related to a fall on 08/26/22, sustained a head injury; * Cognition, including memory, orientation, confusion and decision making ability; * Current skin condition; and * Pain areas, indicators of pain, pharmaceutical and non pharmaceutical interventions. The need to ensure service plans were reflective of residents' current needs and provided specific instruction to staff was discussed with Staff 1 (Administrator) on 08/31/22. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff for 2 of 2 sampled residents (#s 11 and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 12 was admitted to the facility in 09/2021 with Type 2 Diabetes. The residents service plan, dated 07/11/22 and Interim Service Plans (ISP's) were reviewed during the survey. During observations and interviews on 08/30/22, Resident 12 had a hospital bed with bilateral 1/4 length side-rails in the up position. The resident was seated in a wheelchair and was alert, oriented and able to report on his/her care needs. The service plan was not reflective or lacked clear care giving instruction in the following areas: * Mobility, including escorts to and from the dining room (resident was independent); * Need for one-to-two person-assist during transfers; * Use of bilateral side rails, risk and instructions for use; * Need for one person dressing assistance; * Increased weakness and pain; * Self administering CBG readings and insulin (staff assisted); and * Current fall interventions specific to the resident. The need to ensure service plans were reflective of residents' needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

SERVICE PLAN GENERAL 1) Resident 11's service plan was reviewed and updated to reflect current plan of care. 2) All Service plans will be audited and reviewed for accuracy and corrected. Evaluations will be completed to reflect the current resident condition and needs. 3) This service plan will be reviewed quarterly. 4) The administrator or designee will be responsible for monitoring and auditing service plans.

4. Resident 4 was admitted to the facility in March 2020. The resident's clinical records dated 6/28/21 through 9/9/21 indicated the following: a. On 6/28/21 staff documented in a facility progress note that the resident "had an injury fall ... [in the] bathroom..." Resident was sent to an emergency department and returned to the facility on the same day. The resident had experienced a fall. The facility failed to evaluate the fall risk to determine and document what action or intervention was needed for the resident.   b. On 7/2/21 staff documented the resident was sent to the hospital due to complaint of chest pain and returned to the facility on the same day with a new diagnosis of a left rib fracture. On 9/16/21 at 9:45 am, Staff 2 (Resident Care Manager) stated the diagnosis of the left rib fracture was sustained by the 6/28/21 fall. There was no documented evidence the resident was evaluated to determine what action or intervention was needed regarding the left rib fracture and no evidence the resident's change of condition was monitored through resolution.   c. During the acuity interview on 9/14/21, Resident 4 was identified to have an open wound on his/her left foot and received HHRN for wound care. On 7/27/21, staff documented "bottom of left foot with 100 % granulation. Small amount of serosanguineous drainage. Measure 2.3 x 2.2 x 0.3 cm ..." There was no documented evidence of weekly skin monitoring between 7/27 and 8/28/21. The need to ensure the facility monitored residents' changes of condition weekly through resolution, including determining new actions or interventions was discussed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings. 3. Resident 3 was admitted to the facility in October 2020. Progress notes dated 6/16/21 through 9/8/21 were reviewed.  Resident 3 had a fall on 9/1/21, was sent to the emergency room and returned the same day.  The "After Visit Summary" dated 9/1/21 and received by the facility on 9/9/21, noted the resident had a pelvic fracture. There was no documented evidence the facility evaluated the resident's change of condition and determined if actions/interventions were needed. The need to ensure the facility monitored residents' changes of condition through resolution, including implementing new interventions and monitoring those interventions for effectiveness, was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 3 (RN) during the survey. 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 monitoring until the condition resolved, and documented evidence of 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 for 4 of 4 sampled residents (#s 2, 3, 4 and 5) who experienced changes of condition. Resident 2 experienced significant and ongoing weight loss. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in July 2018 with diagnoses including obesity and major depressive disorder. The resident's 12/1/20-9/15/21 progress notes, 4/28/21 physician's orders, incident reports, Interim Service Plans (ISP's), weight records spanning from 8/2019 through 9/15/2021 and 9/1/21 through 9/13/21 MARs were reviewed. Resident 2's weight record revealed the following: * 12/14/20 - 159 pounds; * 1/8/21 - 152 pounds; * 4/3/21 - 148.6 pounds; * 5/8/21 - 146.2 pounds; * 6/10/21 - 132.4 pounds; and * 9/15/21 - 114 pounds. From 1/2021 to 4/2021, Resident 2 lost 3.4 pounds. The resident received a 4/28/21 physician's order for the facility to increase the administration for one bottle of Ensure (nutritional supplement) from once daily to twice daily. The facility lacked documented evidence they monitored the increase of the nutritional supplement to determine if it was effective in addressing the resident's weight loss. Between 5/2021 to 6/2021 the resident lost an additional 13.8 pounds or 9.43% of his/her body weight in one month. This represented a severe loss. Between 6/2021 to 9/15/21 the resident lost an additional 18.4 pounds or 13.89% of his/her body weight in a three month period. The resident continued to experience a severe weight loss. Observations made during lunch on 9/16/21 found the resident ate 25% of the meal before asking staff for an escort out of the dining area. There was no documented evidence in the residents records the weight loss had been evaluated, actions or interventions had been determined to address the weight loss and communicated to staff, the facility was monitoring for subsequent weight loss, or had referred to the RN for a significant change of condition assessment. During an interview on 9/15/21 with Staff 3 (RN), she stated the facility's system did not alert her to the resident's severe weight loss. The facility's failure to have an effective monitoring system in place to monitor Resident 2's weight loss contributed to the resident's severe ongoing weight loss. 2. Resident 5 was admitted to the facility in August 2021. The resident's 8/16/21 through 9/13/21 progress notes were reviewed and revealed the following: * The resident experienced a non-injury fall on 8/26/21 and; * On 9/1/21 staff charted an observation of large bruising underneath the resident's arm and lower waist area. The resident informed staff s/he had fallen down the staircase and hit his/her head. The facility lacked documented evidence it determined and documented what action or interventions were needed for the resident's falls, skin condition, or injury to his/her head, communicated the actions or interventions to staff on each shift, or monitored each at least weekly through resolution. During a 9/16/21 interview with Staff 2 (Resident Care Coordinator), she confirmed the resident's falls, skin condition and head injury were not evaluated or monitored by the facility.       The facility's failure to effectively monitor, evaluate, determine what actions or interventions were necessary for resident's with short term changes of condition, communicate the interventions to staff on each shift, refer significant changes of condition to the RN for assessment and monitor interventions for effectiveness was discussed with Staff 2 (RN) on 9/15/21 and Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring 1. RN to complete the OHCA course "role of the RN" 2. RN will be educated on proper change of condition and monitoring and required elements for these concerns. Clinical meetings will review all residents for any possible changes of condition. 3. Clinical meetings held at least weekly, check ins for resident condition to be completed at least 3 times per week. 4. Administrator or designee to monitor.

3. Resident 9 was admitted to the facility in January 2021. Resident 9's progress notes dated 01/14/22 through 02/10/22 revealed the resident experienced the following change of condition: * On 02/04/22 - fall with injury which resulted in back pain. There was no documented evidence the facility determined and documented what resident specific action or interventions were needed to address the resident's fall and failed to monitor the residents pain with weekly progress noted until resolved. The need to ensure the facility had a system to determine if new interventions were needed and monitor interventions for effectiveness was reviewed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN) on 02/14/22. They acknowledged the findings. 2. Resident 10 was admitted to facility in October 2020. Resident 2's progress notes, dated 01/13/22 through 02/10/22, revealed the resident experienced the following new changes of condition: * On 01/31/22 -  fall with injury; * On 02/04/22 -  fall with injury; and * On 02/10/22 -  a non-injury fall. There was no documented evidence the facility determined and documented what resident specific actions or interventions were needed to address the resident's falls and help prevent future falls . The need to ensure the facility had a system to determine if new interventions were needed and monitor interventions for effectiveness was reviewed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN) on 02/14/22. They acknowledged the findings.

Based on 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 and weekly monitoring until the condition resolved, for 3 of 3 sampled residents (#s 6, 9 and 10) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 2015 and had a stroke in 2021. The resident's 01/14/22 through 02/11/22 progress notes and temporary service plans were reviewed and revealed the following short term changes of condition: * The resident experienced a fall on 01/20/22 and sustained an abrasion to the arm; and * The resident was receiving wound care for chronic skin breakdown to the buttock area. The clinical record lacked documented evidence of: * what action or interventions were needed following the resident's fall to prevent further falls; * documentation of monitoring of the skin wounds at least weekly through resolution. During a 02/15/22 interview, Staff 15 (RN) stated Resident 6 was receiving home health services for skin wounds and the home health notes were reviewed weekly by the facility RN, however the facility RN was not observing the wounds weekly. The resident's fall interventions and skin conditions were not monitored at least weekly by the facility.     The need to evaluate, determine what actions or interventions were necessary for resident's with short term changes of condition and monitor the interventions for effectiveness was discussed with Staff 1 (Administrator) and Staff 15 on 02/15/22. They acknowledged the findings.

1. Resident #s 6, 9 and 10 records have been reviewed and change in condition documentation and interventions have been implemented. RN and health services management team has been trained on areas of need for required elements and procedure for change of condition. 2. Clinical meetings twice weekly to review resident services and identify changes in condition. 3. will review quality assurance once monthly to assure changes are identified and procedure is implemented. 4. Administrator or designee to monitor.

2. Resident 11 was admitted to the facility in 09/2021 with diagnoses including congestive heart failure, hypertension, atrial fibrillation, and vitamin D deficiency. During the acuity interview on 08/29/22, Resident 11 was identified as a fall risk and had a recent fall that resulted in a head injury. The resident's current service plan,  interim service plans, incident reports, charting notes and RN assessments were reviewed during the survey. Resident 11's 07/27/22 service plan indicated that resident had a history of falls and a fall prevention program was in place and staff were to follow the fall prevention program. Interviews with staff during the survey revealed there were no resident specific fall interventions in place or fall program instructions for the staff to follow. On 08/26/22, staff heard the resident calling for help from her/his apartment and found the resident on the floor with an open wound in the back of his/her head.  The resident was sent to the emergency room and returned to the facility the following day with ten staples in the back of his/her head. There was no documented evidence the facility evaluated the resident, determined what resident specific actions or interventions were needed following the fall, communicated the actions and interventions to staff on all shifts and updated the service plan as needed. The need to ensure resident specific actions or intervention were developed after a fall, and they included resident specific instructions for staff was discussed with Staff 1(Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

Based on 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 and weekly monitoring until the condition resolved, for 2 of 2 sampled residents (#s 11 and 12) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 12 was admitted to facility in 09/2021 with Type 2 D iabetes. Progress notes dated 07/13/22 through 08/29/22, service plan dated 07/11/11 and Interim Service Plans (ISP's) were reviewed during the survey. Resident 12's current service plan noted the following fall interventions: * Transfer pole in bathroom; * Grab bars in shower; * Very frequent checks; and * Shower chair. The following changes of condition were identified: * On 07/16/22 - Injury fall with skin tear to chin and lip; * On 08/05/22 - Injury fall with abrasion to the right side of back; * On 08/23/22 - Injury fall with scratches to the forearm and hand; * On 08/27/22 - Non-injury fall; * On 08/29/22 - Injury fall with skin tear to right forearm; and * On 08/29/22 - Hypoglycemic event. There was no documented evidence the facility determined and documented what resident specific actions or interventions were needed to address the resident's falls or reviewed the service planned interventions for effectiveness. Additionally, there was no documented evidence the facility monitored the residents condition through resolution when his/her CBG's were outside of baseline. The need to ensure the facility had a system in place to monitor interventions for effectiveness, determine if new interventions were needed and monitored changes of condition through resolution was reviewed with Staff 1 (Administrator), Staff 10 (Resident Care Coordinator) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

CHANGE OF CONDITION AND MONITORING 1) Evaluations have been completed for residents 11 and 12 to address current needs and reflect resident specific instructions and interventions. 2) Nurse will review all chart notes at least twice weekly and implement changes and interventions as needed. 3) Quality Assurance meeting held monthly. 4) Administrator or designee

3. Resident 4 was admitted to the facility in March 2020. Clinical records were reviewed and revealed Resident 4 sustained a fall on 6/28/21 which resulted in fractured left rib which represented a significant change of condition that required an RN assessment. An RN assessment was requested on 9/14/21 during the survey. On 9/15/21 at 3:00 pm, Staff 2 (Resident Care Manager) confirmed there was no RN assessment for the change of condition. The need to document an RN assessment for significant changes of condition was discussed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings. 2. Resident 3 was admitted to the facility in October 2020. Clinical records were reviewed and revealed Resident 3 sustained a fall on 9/1/21 which resulted in a fractured pelvis. An RN assessment was requested on 9/14/21. On 9/15/21 at 2:11 pm, Staff 3 (RN) confirmed there was no RN assessment for the significant change of condition and was not aware one needed to be completed. The need to document an RN assessment for significant changes of condition was discussed with Staff 1 (Administrator) and Staff 3 during the survey. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN assessed all residents with a significant change of condition, and documented findings, resident status, and interventions made as a result of the assessment, and communicated the actions or interventions to staff for 3 of 3 sampled residents (#s 2, 3 and 4) who experienced a significant condition. Resident 2 experienced severe weight loss.  Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in July 2018 with diagnoses including obesity and depression. From 1/2021 to 4/2021, Resident 2 lost 3.4 pounds or 13.89% of his/her body weight in 3 months. This represented a significant change of weight loss that required an RN assessment.  Between 5/2021 and 9/15/21 the resident continued to lose weight. The facility lacked documented evidence the RN assessed Resident 2 for the significant change of condition. The requirement for the facility to ensure an RN assessed residents experiencing  significant changes of condition, documented findings, resident status, and interventions made as a result of the assessment, and communicated the actions or interventions to staff was discussed with Staff 3 on 9/15/21, Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings. Refer to C270, example 1.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services 1. Residents 2, 3 and 4 have been assessed for significant changes of condition and required elements are in place. RN to attend the Role of RN class. 2. Clinical meetings held at least weekly will review pertnient information to indicate possible changes of condition, nurse will evaluate as needed. 3. This will be reviewed no less than weekly. 4. The administrator to review and monitor.

2. Resident 11 was admitted to the facility in 09/2021 with diagnoses including congestive heart failure. Progress notes dated 07/11/22 through 08/29/22, incident reports, current service plan, interim service plans and RN assessments were reviewed during the survey. The following deficiency was identified: On 08/26/22, the resident had a fall with injury and sustained an open wound to the back his/her head. The resident returned to facility with with ten staples in the back of his/her head. The resident's head injury represented a significant change of condition. The RN documented a significant change of condition assessment on 08/27/22; however, the assessment failed to include findings, resident status and interventions made as a result of the assessment. The resident's service plan was not updated.   The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment and the resident's service plan was updated was discussed with Staff 1 (Administrator) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN assessed all residents with a significant change of condition, and documented findings, resident status, and interventions made as a result of the assessment, and communicated the actions or interventions to staff for 2 of 2 sampled residents (#s 11 and 12) who experienced a significant change in condition. Findings include, but are not limited to: 1. Resident 12 was admitted to the facility in 9/2021 with diagnoses including Type 2 Diabetes and history of broken femur. During the entrance conference it was reported the resident had a change in condition and now needed one-to-two person transfers and generally needed additional assistance from caregivers. Between 07/13/22 through 08/29/22, the resident had five falls, experienced increased pain, weakness, inability to transfer independently,  provide his/her own incontinent care and now required the use of a wheelchair. This represented a significant change of condition that required an RN assessment. There was no documented evidence the facility RN completed a timely assessment that documented the resident's current condition, status, findings and interventions made as a result of the assessment. Additionally, there was no documented evidence the service plan was updated after the resident had a significant change of condition. The need to ensure the facility RN completed an assessment for a significant change in condition was discussed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant). They acknowledged the findings.

RESIDENT HEALTH SERVICES 1. Resident 11 and 12 charts have been reviewed and residents re-evaluated for current needs and proper resident-specific interventions in place. 2. Nurse to review all chart notes at least twice weekly and ensure implementation and interventions occur. 3. This will be reviewed monthly. 4. Administrator or designee.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: During the acuity interview on 9/14/21, Resident 4 was identified to be administered insulin injections by non-licensed staff. Interviews with staff, delegation records and the 9/1/21 -  9/14/21 MAR revealed the following: * Staff 10 (MT) and Staff 11 (MT) lacked documented evidence an individual observation/return demonstration of competence of the staff to determine if the staff remains capable and willing to safely perform the task. * Staff 11 documented on the MAR she administered Resident 4's insulin injection on 9/5/21, 9/7/21, 9/8/21, 9/9/21, 9/11/21 and 9/13/21. The last evaluation for  Staff 11's skills and ability was completed on 11/26/20 and scheduled for re-evaluation on 5/26/21. There was no documented evidence of re-evaluation of the delegation task for Resident 4 had been completed as of 9/16/21. * Staff 12 (MT) documented on the MAR he administered Resident 4's insulin injection on 9/1/21, 9/2/21, 9/5/21, 9/6/21, 9/8/21, 9/9/21, 9/10/21, 9/12/21, 9/13/21  and 9/14/21. The last evaluation for Staff 12's skills and ability was completed on 7/12/21 and scheduled for re-evaluation on 9/12/21. There was no documented evidence of re-evaluation of the delegation task for Resident 4 had been completed as of 9/16/21. The requirements for delegation were reviewed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) during the survey. They acknowledged the findings.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching 1. RN to attend OHCA Role of RN class. 2. RN will be educated on delegation and teaching requirements and will audit delegation files to assure complaince. 3. This will be audited by date of alleged compliance and every 6 months. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 6) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to: During the acuity interview on 02/10/22, Resident 6 was identified to be administered insulin injections by non-licensed staff. Interviews with staff, delegation records and the 01/01/22 -  02/11/22 MAR revealed the following: 1. Staff 20 (MT) administered insulin to Resident 6 on 01/20, 01/24, 01/28 and 02/10/22. The records lacked documented evidence of Staff 20 being delegated to administer insulin to Resident 6. In a phone interview on 02/11/22, Staff 3 (RN) confirmed that Staff 20 had not been delegated to provide insulin for Resident 6. 2. Delegation documentation showed the following: a. Staff 12 (MT) had an initial delegation on 11/23/21. The next delegation was scheduled for 180 days later on 5/23/22. This exceeded the 60 day required re-evaluation period following the initial delegation; b. Staff 22 (MT) had an initial delegation on 10/02/21. The next delegation was scheduled for 180 days later on 4/02/22. This exceeded the 60 day required re-evaluation period following the initial delegation; and c. Staff 23 (MT) had an initial delegation on 01/19/22. The next delegation was scheduled for 180 days later. This exceeded the 60 day required re-evaluation period following the initial delegation. During an interview on 02/11/22, Staff 1 (Administrator) and Staff 15 (RN) stated the documentation of the intial delegation may have been inaccurate and that Staff 12, 22 and 23 had been previously delegated. No other documentation was provided. 3. Delegation documentation was reviewed on 02/11/22 and showed the following inaccuracies: a. Staff 12 (MT) had been re-evaluated by the RN on 05/23/22. The re-evaluation was signed by the RN and the "justification for reassessment" had been completed; b. Staff 8 (MT) had been re-evaluated by the RN on 05/29/22. The re-evaluation was signed by the RN and the "justification for reassessment" had been completed; c. Staff 24 (MT) had been re-evaluated by the RN on 03/30/22. The re-evaluation was signed by the RN and the "justification for reassessment" had been completed; and d. Staff 22 (MT) had been re-evaluated by the RN on 04/02/22. The re-evaluation was signed by the RN and the "justification for reassessment" had been completed. During an interview on 02/11/22 with Staff 1 and Staff 15 it was discussed that the delegations cannot be dated in advance. The requirements for delegation and the need to ensure accurate documentation was provided were reviewed with Staff 1 and Staff 15 during the survey. They acknowledged the findings.

1. Delegation records have been reviewed for resident #6 and all staff has been delegated for this resident. Delegation forms have been revised to include all required elements of delegation training. 2. Delegations will all be completed using new forms. 3. Delegations will be reviewed as part of quality assurance meetings. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 12) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to: During the acuity interview on 08/29/22, Resident 12 was administered insulin injections by non-licensed staff. Interviews with staff, review of delegation records and the 08/01/22 - 08/29/22 MAR revealed the following: 1. On seven occasions, Staff 25 (MT) recorded CBG's and administered insulin to Resident 12. The records lacked documented evidence of Staff 25 being delegated to administer insulin to Resident 12. 2. On 13 occasions, Staff 28 (MT) recorded CBG's and administered insulin to Resident 12. The records lacked documented evidence Staff 28 was delegated to administer insulin to Resident 12. 3. Delegation documentation showed the following: a. Staff 8 (MT/Assistant RCC) had an initial delegation on 04/03/22. At the time of survey on 08/29/22, Staff 8 had not been reevaluated. This exceeded the 60 day required re-evaluation period following the initial delegation; b. Staff 20 (MT) had an initial delegation on 04/01/22. At the time of survey on 08/29/22, Staff 8 had not been reevaluated. This exceeded the 60 day required re-evaluation period following the initial delegation; and c. Staff 12 (MT) had an initial delegation on 05/14/22. At the time of survey on 08/29/22, Staff 12 had not been reevaluated. This exceeded the 60 day required re-evaluation period following the initial delegation. The requirements for delegation and the need to ensure accurate documentation was reviewed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant) during the survey. They acknowledged the findings.

RN DELEGATIONS AND TEACHING 1. Delegation records have been reviewed for resident #12 and all staff has been delegated for this resident. 2. Delegating RN trained in performing and documenting delegation. Delegating nurse will be attending role of the RN class. 3. Delegations will be reviewed by nurse consultant at each visit. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 17) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to: During the acuity interview on 04/04/23, Resident 17 was identified to be administered insulin injections by non-licensed staff. Interviews with staff, review of delegation records and the 03/01/23 - 04/04/23 MAR revealed the following: * Staff 25 (MA) documented on the MAR she administered Resident 17's subcutaneous injection. The evaluation for Staff 25's skills and ability was completed on 10/23/22 and scheduled for re-evaluation in 120 days or no later than 02/20/23. The re-evaluation of the delegation task was completed on 03/15/23, 23 days after it was scheduled; and * Staff 28 (MA) documented on the MAR she administered Resident 17's subcutaneous injection. The evaluation for Staff 28's skills and ability was completed on 10/21/22 and scheduled for re-evaluation in 120 days or no later than 02/18/23. The re-evaluation of the delegation task was completed on 03/29/23, 45 days after it was scheduled. The requirements for delegation were reviewed with Staff 27 (LPN Consultant), Staff 34 (Administrator) and Staff 35 (RN) during the survey. They acknowledged the findings.

C282: Cornell Estates Plan of Correction  What actions will be taken to correct the rule violation? Facility new RN will be taking delegation course on 4/12/23 and will be taking Role of the RN through OHCA on 5/9/2023 - 5/11/2023. Delegation training on 4/12/23 has been completed already. How will the system be corrected so this violation will not happen again? Monthly evalutions of the delegation binder and tracking form will be reviewed RN was supplied a Delegation tracker for RN to utilize How Often with the area needing correction be evaluated? Administrator and will review tracker and delegation packet monthly to ensure delegation match RN plan for delegations Who will be responsible to see the corrections are completed/monitored? Administrator & Resident Care coordinator

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 1 sampled resident (# 3) who had pelvic fracture home care instructions. Findings include, but are not limited to: Resident 3 was admitted to the facility October 2020. The resident's progress notes dated 6/16 through 9/8/21, service plan, ISP (interim service plans) and the quarterly evaluation were reviewed. Documentation revealed Resident 3 had a fall on 9/1/21 and was sent out to the hospital. The "After Visit Summary" dated 9/1/21 noted the resident sustained a pelvic fracture. There were aftercare instructions included in the summary the hospital printed. On 9/15/21, both Staff 2 (Resident Care Manager) and 3 (RN) confirmed the hospital's recommendations were not passed on to the staff for the provision of care for Resident 3's pelvic fracture. The need to ensure the coordination of care with outside providers in order to ensure the continuity of care, including hospital home care instructions, were communicated to caregiving staff was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 during the survey. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc 1. Res 3 condition has been evaluated. Evaluation and subsequent service plan are reflective of resident's condition. 2. Clinical meetings implemented to review resident needs and outside provider recommendations. 3. Outside provider recommendations to be reviewed daily and implemented in interim service plan or change of service plan as needed. 4. Administrator or designee to monitor.

Based on observation, interview and record review, it was determined the facility failed to ensure adequate professional oversight for a safe medication system. Findings include, but are not limited to: Refer to C303, C305, C310 and C325.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments 1. Clinical meetings to be held at least weekly and medications will be reviewed. 3 step check system will be implemented for all new orders. 2. The current system will be enhanced to include 3 steps for checking new orders for accuracy in the MAR. 3. This will be reviewed at least weekly 4. Administrator or designee will hold clinical meetings and monitor this system.

Based on interview and record review, it was determined the facility failed to ensure it had a safe medication system approved by a pharmacist consultant, registered nurse, or physician and failed to ensure adequate professional oversight of the medication system. This is a repeat citation. Findings include, but are not limited to: 1. During the re-visit survey, the 01/01/22 through 02/10/22 MARs were reviewed for multiple residents (#'s 6, 9 and 10). The MARs lacked specific medication administration times for multiple medications, including some medications with time sensitive parameters. Interviews with Staff 1 (Administrator), Staff 15 (RN) and Staff 2 (Resident Care Manager) on 02/10/22 and 02/11/22 revealed the following: * Physician orders were reviewed by unlicensed staff and the facility lacked a system for the RN or other licensed staff to consistently review physician orders; * The facility lacked a system for routine audits of the MAR; and * The facility was unable to identify whether an RN, pharmacist or physician was providing oversight of the current medication system. 2. During the re-visit survey, conducted 02/10/22 through 02/15/22, administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C 303: Systems: Medication and Treatment Order; * C 305: Systems: Resident Right to Refuse; * C 310: Systems: Medication Administration; and * C 330: Systems: Psychotropic Medications. 3. Resident 9 was admitted to the facility in January 2021 with a diagnosis of hypotension. A physician's order for Midodrine (for low blood pressure), dated 1/4/22, instructed staff to administer the medication from 8:00 am-10:00 am, 10:00 am-12:00 pm, and 2:00 pm, and included parameters to "administer doses in three to four hour intervals." Medication administration times for Midrodrine were requested, however the facility was unable to provide documented evidence of actual administration times. On 02/11/22, Staff 1 (Administrator) and Staff 15 (RN) stated the MT's were having issues with internet connectivity and they were not able to fully sign out the medications until after they completed the entire medication pass for all residents. Once the MT returned to the nurses' desk to connect to the internet they were allowed to save the medication pass time. Staff 1 stated this could be hours later and may reflect that the 8:00 am medication pass was given at the same time as the 10:00 am medication pass. On 02/15/22, Staff 1 stated the facility "added hotspots to each floor to address the internet connectivity issue." The need to ensure the facility had a safe medication system that documented specific medication administration times was discussed with Staff 1 and Staff 15 on 02/15/22. They acknowledged the findings.

1. MARs were reviewed of residents #s 6, 9 and 10. for specific administration times and time sensitive parameters put in place. Consultant RN will review medication services and advise other necessary changes to systems as needed. 2. Systems to be implemented as advised by consultant RN. A staff member will be trained and designated as med tech trainer to ensure all med techs are trained according to systems and regulation. 3. this will be reviewed monthly in quality assurance meetings. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. This is a repeat citation.  Findings include, but are not limited to: During the second revisit survey, conducted 08/29/22 through 08/31/22, administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: * C 282: Systems: RN Delegation; * C 303: Systems: Medication and Treatment Orders; * C 305: Systems: Resident Right to Refuse; and * C 310: Systems: Medication Administration. The unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

SYSTEMS MEDICATIONS & TREATMENTS Refer to C282, C303, C305, C310

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 4 of 5 sampled residents (#s 1, 2, 3 and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in July 2020. The resident's September 1 through 14, 2021 MAR, TAR and current physician orders were reviewed. a. The following medications had current physician's orders but showed as discontinued on the MAR: * Lanthanun (for kidney disease); * Novolog (for diabetes); * Trazadone (for insomnia); * Clotrimazole (fungal treatment); * Wound care, twice weekly, to right heel; * Bisacodyl (for constipation); and * Daily skin checks to right foot and left stump. b. There were two orders, both dated 9/9/21, one from the physician and the other from the pharmacy relating to the medication, hydrocod/APAP (for pain). The pharmacy showed an active order, however the hand-written order from the physician directed the facility to discontinue the medication. The resident received one hydrocod/APAP tablet on 9/11/21. It was not clear if the resident received a discontinued medication. On 9/15/21 at approximately 12:30 pm, Staff 2 (Resident Care Manager) and Staff 3 (RN) confirmed the prescriber had not been contacted to clarify the order. c. Resident 1 had a physician's order for Levothyroxine (for hypothyroidism) to be administered on Tuesday, Thursday, Saturday and Sunday at 11:00 am. The MAR reflected the medication could be administered between 10:00 am and 12:00 pm.  However, the medication was identified as time sensitive, and must be administered at least 30 to 60 minutes prior to eating. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 during the survey. They acknowledged the findings. 2. Resident 3 was admitted to the facility in October 2020. The resident's September 1 through 14, 2021 MAR, TAR and current physician orders were reviewed. Resident 3 sustained a pelvic fracture on 9/1/21. S/he requested a PRN for pain on 9/4/21. The resident had two PRN pain medications ordered prior to the fracture, acetaminophen and Tramadol. Per a progress note dated 9/4/21, when staff looked to see what the resident could have for pain, she noticed the only medication available was the PRN acetaminophen. When the staff member attempted to administer the PRN acetaminophen, the resident refused, stating, "Tylenol isn't strong enough, it doesn't work, get them out of here." The same progress note dated 9/4/21 stated the PRN Tramadol was not available to staff to administer to the resident at that time, indicating the physician's order could not be carried out as prescribed. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 during the survey. They acknowledged the findings. 3. Resident 2 was admitted to the facility in July 2018. Residents 2's 4/28/21 physician's orders and 9/1/21 through 9/13/21 MARs were reviewed and revealed the following: Resident 2 had a physician's order for daily blood pressure checks and parameters for staff to inform the physician of readings over 140/90. * On 9/2/21 the residents blood pressure was documented as 144/51; and * On 9/11/21 the residents blood pressure was documented as 143/71. The facility lacked documented evidence the physician was notified when the resident's blood pressure was outside of parameters. During a 9/15/21 interview with Staff 2 (Resident Care Manager), Staff 2 confirmed the physician had not been notified when the residents blood pressure was outside of parameters. The need to ensure physician's or other legally recognized prescriber's orders were followed was discussed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings. 4. Resident 5 was admitted to the facility in August 2021. The resident's 8/30/21 physician's orders and 9/1/21 through 9/13/21 MAR were reviewed and revealed the following: Resident 5 had a physician's order for daily weights and instructions for the facility to administer furosemide (diuretic) one 20 mg tab daily if the resident had weight gain of more than three pounds daily. The MAR lacked documentation of the residents weights on the following dates: 9/1/21, 9/2/21, 9/5/21, 9/6/21, 9/8/21, 9/9/21, 9/10/21 and 9/13/21. During a 9/15/21 interview with Staff 2 (RN), she confirmed the weights had not been obtained. The need to ensure physician's or other legally recognized prescriber's orders were followed was discussed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders 1. Clinical meetings to be held at least weekly and treatment will be reviewed. 3 step check system will be implemented for all new orders. 2. The current system will be enhanced to include 3 steps for checking new orders for accuracy in the MAR. 3. This will be reviewed at least weekly. 4. Administrator or designee will hold clinical meetings and monitor this system.

3. Current physician's orders, the 02/01/21 - 02/10/21 MAR, and the progress notes for Resident 10 were reviewed and identified the following:   Resident 10 had a physician's order, dated 02/05/22, to hold Eliquis and aspirin until 02/06/22 due to fall with bleeding to the back of his/her head. A 02/07/22 progress note documented the medications had not been held. In an interview with Staff 2 (Resident Care Manager) on 02/11/22 at 12:00 pm, she verified the medications had not been held and the pharmacy had not received the "hold" order. Staff 2 stated s/he believed the pharmacy had to provide a "hold" order for the prescription in order for staff to "hold" it. The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 and Staff 15 (RN) on 02/11/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 3 of 3 sampled residents (#'s 6, 9, and 10) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in January 2021, with diagnoses including chronic kidney disease, peripheral vascular disease and hypotension. The resident was admitted to the hospital from 01/22/22 through 02/04/22. Resident 9's signed physician orders, dated 02/04/22, and 02/01/22 through 02/10/22 MAR reviewed during the survey revealed the following: The following medications were not added to the 02/2022 MAR when the resident returned to the facility on 02/04/22 and were not administered to the resident from 02/04/22-02/06/22 without documentation of why the medications had not been administered or having a signed physician order to discontinue: * Ferrous Sulfate (iron supplement), two missed doses; * Fludrocortisone (used to promote sodium retention by the kidney), two missed doses; and * Midodrine (for low blood pressure), seven missed doses. On 02/11/22, the need to ensure medications were administered per physician orders was discussed with Staff 1 (Administrator), Staff 15 (RN) and Staff 2 (Resident Care Manager). They acknowledged the findings. 2.  Resident 6 was admitted to the facility in 2015 with diagnoses including end stage renal disease and hypertension. Review of Resident 6's 01/01/22 through 02/10/22 MARs and current medication orders revealed: * A 12/29/21 physician's order for Metoprolol 50 mg was to be administered twice daily for blood pressure control. The order instructed staff to hold the morning dose on dialysis days; and * The January and February MARs showed between 01/14/22 and 02/10/22, the resident did not receive the evening dose of Metoprolol on 11 occassions. The MAR was marked as "out of facility". During an interview on 02/11/22 at 10:30 am, Resident 6 stated he/she routinely returns to the facility from dialysis at about 9:00 PM. Resident 6 stated staff do not offer the medication when s/he returns from dialysis and stated "I should probably be taking that". This was discussed with Staff 15 (RN) on 02/15/22 and the facility will follow up with the physician and modify the administration time as needed. The need to ensure physician's orders were followed and medications were administered according to the resident's schedule were reviewed with Staff 1 (Administrator) and Staff 15. They acknowledged the findings.

1. Residents #'s 6, 9, and 10 physician orders reviewed for MAR accuracy. Consultant RN will review medication services and advise necessary changes to systems. 2. Systems to be implemented as advised by consultant RN. A staff member will be trained and designated as med tech trainer to ensure all med techs are trained according to systems and regulation. 3. this will be reviewed monthly in quality assurance meetings. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 2 sampled residents (#12) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 12 was admitted to the facility in 09/2021 with diagnoses including Type 2 Diabetes. There was no documented evidence Resident 12's signed physician orders were available in the resident's chart. The need to ensure signed physician orders were accessible in the residents chart was discussed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

SYSTEMS TREATMENT ORDERS 1. Current 90 day physician orders were in facility possession at time of survey, these have since been filed in the chart. 2. Systems to be implemented as advised by consultant nurse. *complete 3 way chart audit before sending orders out. *nurse to review and sign when orders are returned to complete physican order *place returned orders in residents charts after triple check is completed with nurse signuture and faxed to pharmacy. 3. Quarterly physician orders have been scheduled to obtain and RCC trained on how to obtain. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 3 of 3 sampled residents (#s 1, 2 and 3) who had documented refusals. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in July 2020. September 1 through 14, 2021 MAR and TAR was reviewed and revealed the resident had 47 refusals of medications and treatments between 9/1/21 and 9/11/21. An interview with Staff 2 (Resident Care Manager) on 9/15/21 at approximately 3:00 pm confirmed the physician had not been notified of the refusals to consent to the orders. The need to ensure the facility notify the physician when a resident refuses to consent to orders was discussed with Staff 1 (Administrator) and Staff 2 during the survey. They acknowledged the findings. 2. Resident 3 was admitted to the facility in October 2020. September 1 through 14, 2021 MAR and TAR was reviewed and revealed the resident refused Diclofenac gel on 9/12/21. On 9/15/21 at 2:11 pm, Staff 2 (Resident Care Manager) confirmed the physician had not been notified of the refusal. The need to ensure the facility notify the physician when a resident refuses to consent to orders was discussed with Staff 1 (Administrator) and Staff 2 during the survey. They acknowledged the findings. 3.  Resident 2 was admitted to the facility in 2018 with diagnoses including asthma, osteoporosis and major depressive disorder. Resident 2's 9/1/21 through 9/13/19 MARs were reviewed during the survey. Staff documented the resident refused the following medications: * Divalproex (depression); * Oyst-Cal+ D (supplement); * Montelukast (asthma); and * Rivastigmine (dementia).   There was no documented evidence the facility notified the physician when the resident refused to consent to the orders. In a 9/15/21 interview with Staff 2 (Resident Care Manager), she confirmed the refusals were not reported to the physician. On 9/16/21 the refusals were reviewed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse 1. Residents 1, 2 and 3 MAR have been reviewed for refusals and prescribers have been informed of these refusals. 2. All resident refusals will be audited and prescriber to be contacted for residents with frequent refusals to indicate their preference of notification frequency. 3. Refusals will be monitored at clinical meeting. 4, Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 3 sampled residents (#s 6 and 8) who had documented refusals. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in February 2019. Review of the 02/01/22 through 02/10/22 MAR/TAR revealed the following: Resident 8 refused prescribed Nystatin Powder on 02/07/22 and 02/08/22. On 02/11/22, Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN) confirmed the physician had not been notified of the refusals to consent to the order. The need to ensure the facility notified the physician when a resident refuses to consent to orders was discussed with Staff 1, Staff  2 and Staff 15 on 02/11/22. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 2015. Review of the 01/01/22 through 02/10/22 MAR/TAR revealed the following: Resident 6 had multiple refusals of the following medications: * Sevelamer Carbonate (for phosporous regulation); * Veltassa (for potassium regulation); and * Acetaminophen (for chronic pain). The clinical record lacked documented evidence the prescriber had been informed of the resident's refusals. The need to ensure the facility notified the physician when a resident refuses to consent to orders was discussed with Staff 2 (Resident Care Manager) on 02/15/22. No additional information was provided.

1. Consultant RN will review systems, MAR to be reviewed for refusals and proper notification will be made to prescribers as necessary. 2. All resident prescribers will be asked to advise their preference of notification frequency for refusals. 3. Refusals will be monitored monthly at quality assurance meeting. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 2 sampled residents (#12) who had documented refusals. This is a repeat citation. Findings include, but are not limited to: 1. Resident 12 was admitted to the facility in 9/2021. A review of the 08/01/22 through 08/29/22 MAR/TAR and Resident 12's weight records revealed the following  medications and treatments were refused: * Weekly weights on four occasions; * Polyethylene Glycol Powder on eight occasions; * Novolin insulin on one occasion; and * Senna on two occasions. The facility failed to ensure the physician was notified when Resident 12 refused consent to the above orders and failed to ensure subsequent refusals to consent to an order were reported as requested by the prescriber. The need to ensure the facility notified the physician when a resident refuses to consent to orders was discussed with Staff 1 (Administrator), Staff  10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

RESIDENT RIGHT TO REFUSE 1. Facility provided notification to Resident 12's pcp of refused medication. 2. Refused medications will be communicated as advised by prescriber.  Med Tech training has been completed to go instruct what "when to notify providers" means and how to complete request by providers. 3. Refusals will be monitored weekly at clinical meeting. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, provided resident-specific parameters and staff instruction for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in March 2020 with diagnoses including Type II diabetes. Resident 4's 9/1/21 through 9/14/21 MARs were reviewed and identified the following: The MAR directed staff to document the resident's blood sugar level prior to administering insulin injections three times daily, but the MAR revealed staff documented dose of insulin, not the resident's blood sugar level. On 9/16/21, the need to ensure accurate documentation of the MAR was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager). They acknowledged the findings. 4. Resident 1 was admitted to the facility in July 2020. The resident's September 1 through 14, 2021 MAR and TAR were reviewed and revealed the following inaccuracies: * Eight medications lacked a reason for use; * There were 23 blanks on the MAR with no information regarding if the medication was administered; and * PRN medications for diarrhea, nausea and constipation lacked clear instruction for unlicensed staff regarding when and how much of the medication to administer. The need to ensure accurate documentation of the MAR was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings. 5. Resident 3 was admitted to the facility in October 2020. The resident's September 1 through 14, 2021 MAR and TAR was reviewed and revealed the following inaccuracies: * Multiple blanks on 9/13/21 with no documentation as if the medication was administered; * Medications lacking reason for use; * PRN Bisacodyl (used for constipation) entered three times with the same direction to staff; and * Lacking documentation if a PRN bowel medication was effective. The need to ensure accurate documentation of the MAR was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings. 2. Resident 2 was admitted to the facility in July 2018. The resident's 9/1/21 through 9/13/21 MARs were reviewed and revealed the following: * Two PRN pain medications without clear instructions to staff which medication to attempt first; * Two PRN bowel medications for constipation without clear instructions to staff on which to administer first; and * An order for a PRN nasal spray for allergies lacked clear instruction of when to administer one spray verses two sprays and lacked information regarding the resident's ability to self-direct the medication. The need to provide resident specific parameters and instructions for PRN medications was reviewed with Staff 1 (Administrator) and Staff  2 (Resident Care Manager) on 9/16/21. They acknowledged the findings. 3. Resident 5 was admitted to the facility in August 2021. The resident's 9/1/21 through 9/13/21 MAR was reviewed and revealed multiple medications lacked a reason for use. The need to include reasons for use in the medication record for each medication the facility administers was reviewed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration 1. Parameters have been implemented on MAR. 2. All PRN medications to be reviewed and PRN parameters were established as needed. 3. PRN medication parameters will be reviewed with all new orders at clinical meetings daily. 4. Administrator or designee to monitor

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, provided resident-specific parameters and staff instruction for 3 of 4 sampled residents (#s 6, 9 and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in January 2021 with diagnoses including chronic kidney disease, peripheral vascular disease and hypotension. a. Resident 9's 02/01/22 through 02/10/22 MAR identified the following medications lacked reasons for use: * Ferrous Sulfate (iron supplement); * Fludrocortisone (used to promote sodium retention by the kidney); * Midodrine (for low blood pressure); and * PRN Tylenol (for pain). b. Resident 9's signed physician orders dated 01/04/22 and January 2022 MAR, reviewed during the survey revealed the following: The January 2022 MAR lacked specific medication administration times for the following medications: * Allopurinol (for gout), daily 8:00 am-10:00 am; * Atrovastatin (for high cholesterol), daily 8:00 am-10:00 am; * Ferrous Gluc tablet (for iron supplement), daily 8:00 am-10:00 am; and * Midodrine (for low blood pressure), 8:00 am-10:00 am, 10:00 am-12:00 pm, and 2:00 pm. On 02/11/22, the findings were reviewed with Staff 1 (Administrator) and Staff 15 (RN). They acknowledged the findings. 3. Resident 10's 01/01/22 through 02/10/22 MAR was reviewed and revealed the following: * Resident 10's MAR revealed multiple blanks for eight routinely scheduled medications; and * There were no clear PRN parameters or instruction to staff regarding multiple PRN prescriptions for nausea and/or vomiting, or upset stomach.   In an interview with Staff 15 (RN) at 12:00 pm on 02/11/22, she acknowledged the blanks on the MAR and lack of PRN parameters. The need to ensure an accurate MAR must be kept of all medications, including date and time given and clear instruction to staff, was reviewed with Staff 1 (Administrator) and Staff 15 on 02/11/22. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 2015 with diagnoses including end stage renal disease and hypertension. Resident 6's 01/01/22 through 02/10/22 MARs identified the following: a. Multiple time sensitive medications, including Clopidogrel (for blood thickness), Fluoxetine (for depression) and Lantus Solostar (for diabetes), had a range of times listed on the MAR for administration. The MAR did not instruct Med Tech's on specific times to administer the medications. b. Multiple routine medications, including Acetaminophen (for chronic pain), Lantus (for diabetes) and Metoprolol (for blood pressure), had blanks on the MAR. Staff 1 (Administrator) stated there were internet connectivity issues in the facility that were contributing to the missed documentation. c. A 12/29/21 physician's order for Veltassa was to be administered once daily on Saturdays and Sundays for potassium control; and * The January and February MARs showed between 01/14/22 and 02/10/22, the resident refused the medication four times and received the medication four times. During an interview on 02/11/22 at 10:30 am, Resident 6 stated his/her understanding was that s/he was supposed to take Veltassa on "non-dialysis" days. Since the resident was currently going to dialysis on Saturdays, s/he would refuse the medication on Saturdays. This was discussed with Staff 15 (RN) on 02/15/22 and the facility will follow up with the physician to get the order changed. d. The 12/29/21 physician's order for Veltassa included parameters to "separate dose by 3 hours before and 3 hours after any other medications taken by mouth". The parameters had not been included on the MAR. On 02/15/22, the need to ensure acurate MARs, including provisions for clear instructions for unlicensed staff, was reviewed with Staff 1 (Administrator) and Staff 15. They acknowledged the findings.

1. Consultant RN to review and provide recommendation for medication systems. Parameters have been implemented on MAR. 2. All PRN medications to be reviewed and PRN parameters were established as needed. 3. PRN medication parameters will be reviewed with all new orders at clinical meetings daily. 4. Administrator or designee to monitor

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, provided resident-specific parameters and staff instruction for 1 of 2 sampled residents (#12) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 12 was admitted to the facility in 09/2021 with diagnoses including Type 2 Diabetes. a. Resident 12's 08/01/22 through 08/31/22 MAR identified the following medications lacked parameters for when to hold the medications and medication specific instructions for who to report to: * Novolin flexpen, 30 units once daily in the am; and * Novolin flex pen, 15 units once daily in the pm. b. On 08/09/22 Penicillin, Atorvastatin and Senna lacked initials for administration or a reason why the medication was not administered. c. On 08/10/22 CBG value was not recorded on the MAR. The need to ensure the facility had a system in place to ensure accurate MAR/TARs were kept was discussed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 ( LPN Consultant) on 08/31/22. They acknowledged the findings.

MEDICATION ADMINISTRATION 1) RN has added parameters for resident 12 insulin. 2) RN or PCP will advise parameters for all insulin administration and instruction. 3) This will be monitored as needed with new insulin orders. 4) Clinical Team (RN, RCC, Administrator)

Based on observation, interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer a specific medication and failed to obtain a physician's order to self-administer a specific medication for 1 of 1 sampled resident (#1) who self-administered medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in July 2020. On 9/15/21 at 11:32 am, Resident 1 confirmed s/he self administered the following medications: * Basaglar Kwikpen (insulin for diabetes); * Novolog (insulin for diabetes); and * Flovent (inhaler for asthma). On 9/14/21 physician's orders and an evaluation of the resident's ability to safely administer the three medications were requested. During an interview with Staff 3 (RN) on 9/15/21 at 2:11 pm, she reported Resident 1 only self administered his/her insulin, even though there was a signed physician's order stating the resident could self administer his/her Flovent inhaler in the resident's record. There was no documented evidence the facility evaluated Resident 1's ability to safely self-administer the Flovent. There was no documented evidence the physician signed an order for the resident to self administer the Basaglar Kwikpen injection. The need to complete evaluations of a resident's ability to self administer medications and to obtain signed physician orders were discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) during the survey. They acknowledged the findings.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds 1. Resident 1 has been evaluated for self administration of all medications and treatments of which have been indicated by the provider okay to self administer. 2. RN hours have been increased in the community to meet community need for RN hours. RN to attend role of RN class. 3. This will be evaluated quarterly and as needed.\ 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly-hired direct care staff (# 7) completed all required pre-service orientation. Findings include, but are not limited to: Training records were reviewed with Staff 2 (Resident Care Manager) on 9/15/21. The following was identified: Staff 7 (MT/CG) was hired 8/14/21 and did not complete pre-service orientation training on the following topics: * Resident rights and values of CBC care; * Abuse reporting requirements; and * Standard precautions for infection control. The need to ensure newly-hired direct care staff completed pre-service training prior to working independently was reviewed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts 1. All employee files will be audited and training requirements will be in place by date of alleged complaince. 2. All new hire staff will receive check off list with all training requirements and this will be monitored. RCC will be educqated on training requirements by date of alleged compliance. & Tracking system for annual in-service hours will be established by date of alleged compliance. 3. Audit of employee files will be completed by date of alleged compliance and as needed. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 6, 7, 8 and 9) had documented demonstration of competency in all required areas and First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records on 9/15/21 indicated the following: 1. Staff 6 (MT), hired 8/14/21, lacked documented evidence of competency completed within the first 30 days of hire for: * The role of service plans in providing individualized resident care; * Providing assistance with ADL's; * Changes associated with normal aging; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; * Perform the duties of a medication technician; and * Abdominal Thrust training. 2. Staff 7 (MT/CG), hired 8/14/21, lacked documented evidence of competency completed within the first 30 days of hire in the areas of : * The role of service plans in providing individualized resident care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification of changes in the resident's condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * First Aid and Abdominal Thrust training. 3. Staff 8 (CG), hired 8/5/21, lacked documented evidence of competency completed within the first 30 days of hire in the areas of: * The role of service plans in providing individualized resident care;; * Providing assistance with ADL's; * Changes associated with normal aging; and * General food safety, serving and sanitation. 4. Staff 12 (MT), hired 8/4/21, lacked documented evidence of competency completed within the first 30 days of hire for: * The role of service plans in providing individualized resident care; * Changes associated with normal aging; * Identification of changes in the resident's condition; and * Conditions that require assessment, treatment, observation and reporting. During an interview with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21, the surveyor requested that Staff 6 (MT) not administer medication to residents until competency of ability to safely carry out the duties of a medication technician had been determined. Staff 1 and Staff 2 acknowledged the findings. The need to document demonstrated competency in job duties and complete First Aid and Abdominal thrust training within 30-days of hire was discussed with Staff 1 and Staff 2 on 9/16/21. They acknowledged the findings.

OAR 411-054-0070 (5)(8) Training within 30 days: Direct Care Staff 1. Employee files will be audited to ensure required training components are completed. RCC will be educated on these requirements. 2. Check off lists for each direct care staff will be implemented to identify trainings needed and will be monitored and reviewed as needed to ensure compliance. 3. This will be audited for compliance and reviewed as needed for newly hired direct care staff. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 18 and 20) had documented demonstration of competency in all required areas and First Aid and abdominal thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Review of the facility's training records on 02/10/22 indicated the following: 1. Staff 18 (MT), hired 12/30/21, lacked documented evidence of competency completed within the first 30 days of hire for: * The role of service plans in providing individualized resident care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification of changes in the resident's condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and * Abdominal Thrust training. 2. Staff 20 (MT), hired 12/13/21, lacked documented evidence of competency completed within the first 30 days of hire in the areas of * The role of service plans in providing individualized resident care; * Providing assistance with ADL's; * Changes associated with normal aging; * General food safety, serving and sanitation; and * First Aid and Abdominal Thrust training. During an interview with Staff 2, s/he stated that Staff 18 had completed the competency check list but was unable to locate the documentation. The need to document demonstrated competency in job duties and complete First Aid and Abdominal thrust training within 30-days of hire was discussed with Staff 1 (Administrator) and Staff 2 on 02/11/22. They acknowledged the findings. Staff 2 stated Staff 18 and 20 were scheduled to complete First aid and Abdominal thrust by 02/15/22 or before they returned to their job duties.

1. Employee files will be audited to ensure required training components are completed. RCC will be educated on these requirements. 2. Check off lists for each direct care staff will be implemented to identify trainings needed and will be monitored and reviewed as needed to ensure compliance. 3. This will be audited for compliance and reviewed as needed for newly hired direct care staff. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 29, 30, and 31) had documented demonstration of competency in all required areas within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: A review of the facility's training records on 08/29/22 indicated the following: Staff 29 (CG), hired 07/06/22, Staff 30 (CG), hired 07/18/22, and Staff 31 (CG), hired on 07/14/22, lacked documented evidence of competency demonstrated within the first 30-days of hire in the following training areas: * The role of service plans in providing individualized resident care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification of changes in the resident's condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. During an interview on 08/30/22, Staff 1 (Administrator) reported training had been completed however, the facility was unable to locate the documentation. The need to document demonstrated competency in job duties within 30-days of hire was discussed with Staff 1, Staff 10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

TRAINING 30 DAYS DIRECT CARE STAFF 1) All required pieces of documentation have been received by staff 29, 30 and 31. 2) Training files will be audited to ensure required elements are in place. Training Matrix in place. 3) Upon hire and quarterly. Community will matrix to help with training system. 4) Administrator or designee.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 3 long-term staff (#11) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed with Staff 2 (Resident Care Manager) on 9/15/21. Staff 11 (MT/CG) was hired 11/9/17. Annual training records, provided through online training courses and monthly staff meetings, between 11/9/2019 and 11/9/2020 were reviewed. The records indicated Staff 11 did not complete any in-service training on topics related to the provision of care for persons in a community-based care setting or training related to dementia. The need to ensure direct care staff completed the required annual training was reviewed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings.

OAR 411-054-0070 (6-7) Annual Training and Other Requirements 1. staff 11 training file audited and needed trainings identified (see c370 & c372) staff meetings will be held monthly and include in-service trainings or requirement to complete individual department approved training modules. 2. Attendance in staff meetings will be documented at each meeting. 3. This will be evaluated at least monthly and audited to ensure staff receive training. 4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 3 long-term staff (#16) whose training records were reviewed. This is a repeat citation. Findings include, but are not limited to: Staff training records were reviewed with Staff 2 (Resident Care Manager) on 02/11/22. Staff 16 (CG) was hired 09/14/2020. Annual training records, provided through online training courses and monthly staff meetings, between 09/14/2019 and 09/14/2020 were reviewed. Staff 16 had no annual staff training completed for 2021 or 2022. The records indicated Staff 16 did not complete any in-service training on topics related to the provision of care for persons in a community-based care setting or training related to dementia. The need to ensure direct care staff completed the required annual training was reviewed with Staff 1 (Administrator) and Staff 2 on 02/11/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: During the entrance conference on 9/14/21, the surveyor requested Fire and life safety training records for February 2021 through August 2021. There was no documented evidence of the following areas: * Fire drills conducted every other month consistently; * Evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills; * Date and time of fire drill; * Location of simulated fire origin; * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; * Staff members on duty and participating; and * Evidence of the number of occupants who were evacuated. On 9/15/21 the above areas were reviewed with Staff 1 (Administrator). No further information was received.

OAR 411-054-0090 (1)(a-d) Fire and Life Safety: Drills and Instruction Refer to C422

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to: During the entrance conference on 9/14/21, the surveyor requested Fire and life safety training records for February 2021 through August 2021. The following were identified: * No documentation of alternate escape routes used during fire drills; and * No documentation of fire and life safety training for residents upon admission and at least annually that included 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; and * A written record of fire safety training, including content of the training sessions and the residents attending. The need to ensure all general fire and life safety requirements were discussed with Staff 1 (Administrator) on 9/15/21. No further information was received.

OAR 411-054-0090 (1(e-h))-(2-5) Fire and Life Safety: General 1. Fire drill system has been reviewed and implemented by administrator and maintenance director. 2. Administrator will work with maintenance director to schedule fire drills to take place at least every other month and fire drill training to take place at least every other opposite month. Fire drill form updated to include all required elements of fire drill competency. 3. This will be monitored monthly 4. Administrator to monitor.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. This is a repeat citation. Findings include, but are not limited to: On 02/10/22, Staff 25 (Maintenance Director) reported he was unaware of the process for instructing residents and didn't document the content of fire and life safety, at least annually, for all residents. On 02/14/22, general fire and life safety requirements were reviewed with Staff 1 (Administrator) Staff 1 reported they didn't have a process in place that re-instructed residents, 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. The need for the facility to have a system in place to ensure all residents received and documented general fire and life safety training, at least annually, was discussed with Staff 1 on 02/14/22. He acknowledged the findings.

1. Fire and life safety resident training has been reviewed by administrator and maintenance director. 2. Annual training for residents has been scheduled to train residents on fire and life safety to meet regulation of annual training. 3. This will be monitored twice per year 4. Administrator to monitor.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to: During a tour of the facility on 9/14/21 and 9/15/21, the following was observed: * Carpet throughout the common areas and hallways had black spots, stains, blackened areas and uneven surfaces; * Multiple baseboards throughout the facility had gouges; * Multiple ceiling panels throughout the facility, including hallway between Room 170 and 179,  near library on the second floor and near Room 205, were stained with large brown that looked like it resulted from water leaks; * Multiple doors including Room 162, 163, 152, 189, 191 and Tub room door had scuffs and scratches; and * Ventilation covers and filters, near Room 181, were covered with layers of dust. The environment was toured on 9/15/21 with Staff 1 (Administrator). He acknowledged the above areas needed to be cleaned and repaired.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable 1. Administrator and Regional Director have walked through the community to identify areas of need and are working with outside company to repair noted areas. 2. Administrator will walk through the community after renovation is completed and identify areas of need and  coordinate repairs as needed. 3. This will be evaluated at least monthly. 4. This will be monitored by administrator or designee.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: The facility was toured on 9/14/21 and was observed to have windows with sills lower than 36 inches in the resident's units and common areas on the second floor. The window in Room 292, opened fully and had no mechanism to prevent an accidental incident. On 9/15/21 at 10:20 am, the facility was toured with Staff 1 (Administrator) and he acknowledged windows on the second floor were not designed to prevent accidental falls.

OAR 411-054-0300 (5) Resident Units - Windows on 2nd floor must have policy to prevent accidental falls. 1. For all windows which have sills lower then 36", removable window stoppers will be installed. 2. System will be corrected by implementing policy on windows with sills lower than 36", and adding on to our current room turn process. 3. Windows will be evaluated on an as needed and on-going basis. The need for window stoppers will be evaluated immediately and implemented as needed. This need will also be re-evaluated as part of the room turn process. 4. Administrator and Maintenance director to monitor this need.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to: During the facility tour on 9/14/21, the following were observed: * Wall-mounted heaters were in Residents' bathroom 159, 162, 289 and 292; * The heaters were located where residents could come in incidental contact with them; * When the heaters were turned on, the surface temperatures of the grates measured with the surveyor's thermometers ranged from 131 to 161 degrees F.; and * None of the wall-mounted heaters were in use at the time of survey. On 9/15/21 at 10:20 am, Staff 1 (Administrator) was informed of the increased temperature and acknowledged the need to ensure wall heater covers did not exceed 120 degrees Fahrenheit. The need to ensure that covers, grates, or screens or wall heaters did not exceed 120 degrees Fahrenheit was discussed with Staff 1 on 9/15/21 and 9/16/21. He acknowledged the findings.

OAR 411-054-0300 (8) Heating and Ventilation 1. Wall mounted heaters in all assisted living apartment bathrooms have been disabled to prevent future use. Temperatures of these fixtures will not exceed 120 dgerees. 2. Temperature of bathroom will not be controlled by use of wall mounted heater. 3. This will be evaluated and completed by date of alleged compliance and does not require ongoing evaluation. 4. Administrator or designee to ensure this is completed.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: The building was toured on 9/15/21 with Staff 1 (Administrator). Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building. On 9/15/21, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1.  He acknowledged the findings.

OAR 411-054-0300 (11-13) Call System - Exit doors 1. Exits requiring alarming devices have been identified and alarming devices are now in place on all exit doors 2. Staff will be notified of residents exiting the building by alarming devices on exit doors. 3. The use and activity of alarming devices on exit doors will be evaluated at least quarterly. 4. Administrator or designee to monitor

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 1 of 1 sampled resident (#10) who was prescribed a PRN medication to address behaviors. Findings include, but are not limited to: Resident 10 was admitted to the facility in October 2020. Review of the resident's 01/14/22 through 02/10/22 MARs and progress notes and 10/19/21 hospice orders showed the following: * Lorazepam 2MG/ML, give 0.25ML/0.5MG by mouth every four hours as needed for agitation, anxiety and nausea. The lorazepam was administered once on 01/31/22 and 02/01/22. The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety or agitation. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medication. The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN) on 02/11/22. The staff acknowledged the findings.

1. Consultant RN to review systems and provide recommendations to implement. MARs reviewed, parameters put into place for all residents on psychotropic meds. 2. All psychotropic medications will be reviewed quarterly and resident specific interventions to verify parameters are implemented. 3. This will be reviewed monthly at quality assurance meeting. 4. Administrator or designee to monitor.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 150, C 231, C 240, C 252, C 260, C 270, C 282, C 300, C 303, C 305, C 310, C 372, and C 422

Refer to C 231, C 240, C 252, C 260, C 270, C 282, C 300, C 303, C 305, C 310, C 372, and C 422

Based on interview and record review, it was determined the facility failed to ensure their second re-visit survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 150, C 240, C 260, C 270, C 300, C 303, C 305, C 310, C 372.

NOT FOLLOWING PLAN OF CORRECTION refer to plan of corrections for c240, c260, c270,c280, c282, c300,c303, c305, c310, c372, c455

Based on interview and record review, it was determined the facility failed to ensure their third re-visit survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 282.

C455: Cornell Estates Plan of Correction Not following plan of correction. Please refer to plan of correction for C282

The findings of the re-licensure survey conducted 9/14/21 through 9/16/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 09/16/21, conducted 02/10/22 through 02/15/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 09/16/21, conducted 08/29/22 through 09/06/22, 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 09/16/21, conducted 04/04/23 through 04/06/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the 4th revisit to the re-licensure survey of 09/16/21, conducted 06/23/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.