Dorian Place Assisted Living Facility

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

On 07/15/25 and 07/16/25, observations of the facility's kitchen identified the following:

a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following:
* Reach-in refrigerators and freezer shelving, doors, flooring, and ceiling;
* Ice machine, including the vent had a white substance build-up throughout;
* A build-up of brown and gray matter on the light switch in the dry storage;
* Ceiling vents in the dry storage and above the pots and pans;
* Inside of the ovens;
* Flour bins in the dry storage;
* Walls and ceiling throughout the kitchen, most notably at the dish washing station;
* Can opener blade had debris, including metal shavings;
* Stand mixer;
* Interior of microwave;
* Walls and floors of the janitorial closet;
* The top of the ware washing machine;
* Drains throughout the kitchen; and
* Interior and exterior of multiple cabinets and drawers.

b. Food Storage
* There were open brownie, cake mixes, and marshmallow packages opened and not dated;
* Multiple condiments were open and not dated.

c. Food preparation:
* A container of butter that contained milk product was stored next to the stove and not maintained below 41 degrees F; and
* There were no pasteurized eggs available for soft-cooked entrees. During an interview on 07/15/25 at 11:00 am, Staff 2 (Interim Dietary Services Manager) stated eggs were prepared to order, including over easy and over medium.

d. Sanitation and Equipment: there were testing strips available to check sanitizers for the staff, but staff were not using them.

e. Cleaning and Repair
* There was an exposed electrical outlet outside of the pantry;
* The face of the soap dispenser at the hand washing sink was in disrepair; and
* There were multiple small holes in the walls by the coffee pot, oven, and ware washing areas.

f. Infection Control and Cleanliness:
* Clean silverware was not stored in an inverted position
* Kitchen staff failed to consistently perform hand hygiene and change gloves between tasks during plating; and
* Trash cans lacked covers when not in use.

g. The refrigerator temperature ranged between 42 and 44 degrees Fahrenheit during lunch observation on 07/15/25. There was a temperature log for that refrigerator to validate temperatures were being monitored, however, the temperature was not recorded for the last four days. It consistently listed the temperature at 38 degrees F.

During an interview on 07/15/25 at 11:30 am, Staff 2 reported the refrigerator typically ran between 37 and 38 degrees F but did increase during meal service secondary to opening and closing doors. The surveyor returned to the kitchen with Staff 1 (Administrator, Regional Director of Operations) on 07/15/25 at 2:45 pm, and temperature was observed to be 46 degrees F. Staff 1 reported the facility had ordered an internal thermometer to validate the temperature, and it should arrive within an hour. Surveyor directed that non shelf stable food items should not be used prior to validation, and Staff 1 agreed.

On 07/16/26 at 8:40 am, Staff 1 and surveyor checked the internal temperature of the refrigerator, which was 51 degrees F. All non-shelf stable food items were discarded. Staff 1 stated they would be purchasing a refrigerator to use in the interim for non-shelf stable food items.

The kitchen was toured, and the above areas were discussed with Staff 1 on 07/16/25 at 8:40 am. The findings were acknowledged.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

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

This Rule is not met as evidenced by:
Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. This is a repeat citation. Findings include, but are not limited to:

On 10/22/25 from 3:54 pm through 5:27 pm, observations of the facility's kitchen identified the following:

a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following:
* A build-up of brown and gray matter on the light switch in the dry storage;
* Ceiling vents in the dry storage and above the pots and pans;
* Flour and sugar bins;
* Walls and ceiling throughout the kitchen, most notably at the dish washing station;
* Can opener blade had debris, including metal shavings;
* Stand mixer;
* Interior of microwave, most notably the plate;
* Walls and floors of the janitorial closet;
* Drains throughout the kitchen;
* Exterior of multiple cabinets and drawers;
* Exterior of the heating/cooling unit in the dry storage area;
* Two box fans in the kitchen; and
* A tan footstool underneath the coffee area.

b. Cleaning and Repair: there were multiple small holes in the walls by the coffee pot, oven, and ware washing areas.

c. Infection Control and Cleanliness:
* Clean silverware was not stored in an inverted position; and
* Trash can in the dish pit lacked cover when not in use.

The kitchen was toured, and the above areas were discussed with Staff 4 (Administrator) on 10/22/2025 at 5:30 pm. The findings were acknowledged.

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

Refer to C 240.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules for 2 of 2 sampled residents (#s 1 and 2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

Pursuant to OAR chapter 851, division 006, delegation process means the process utilized by an RN to authorize a UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions, and outcomes pursuant to OAR 851-045 including comprehensive assessment and reasoned conclusions that identify client problems and risks, educate the UAP, evaluate their learned knowledge, and provide step-by- step education and evaluation experience with the UAP and the client.

Resident 1 moved into the facility in 04/2020, and Resident 2 moved into the facility in 02/2017. Both residents had diagnoses including insulin dependent diabetes.

Resident 1 and 2’s MARs, dated 11/01/24 through 11/22/24, were reviewed and revealed insulin had been given by Staff 3, 4 and 5 (MTs) on multiple occasions.

Delegation records for Residents 1 and 2 were reviewed on 11/21/24 and 11/22/24 and revealed the following:

a. An initial delegation was completed for Staff 3 on 10/31/24. There was no documentation by Staff 2 (RN) that one or more of the following elements were determined for Resident 1 or Resident 2:
* Resident did not require assessment during the nursing procedure;
* Performance of the nursing procedure did not require independent decision making;
* Procedure was reasonably predictable;
* The consequences of the UAP performing the nursing procedure were not life threatening and posed minimal risk to the resident;
* The environment of care supported the safe performance of the nursing procedure;
* The nursing procedure would be performed by UAP at a frequency that allowed for continued safe performance;
* UAP communicated they were willing and able to perform the procedure for the resident; and
* RN had the appropriate resources necessary to fulfill nursing practice and delegation responsibilities including availability to provide assessment of resident and ongoing competency validation of UAP’s performance.

Additionally, the delegation records were missing the following required documentation:
* Step-by-step evidence-based instructions, including how to perform the nursing procedure and infection control practices to follow;
* Documentation that the RN addressed questions the UAP and resident may have; and
* Health problems that may impact the resident’s condition related to delegated nursing procedure.

b. Periodic inspection and evaluation was completed for Staff 4 on 9/18/24 and Staff 5 on 9/23/24. Delegation lacked documentation that some or all of the following requirements were met for Residents 1 or 2:
* Resident did not require assessment during the nursing procedure;
* Performance of the nursing procedure did not require independent decision making;
* Procedure was reasonably predictable;
* The consequences of the UAP performing the nursing procedure were not life threatening and posed minimal risk to the resident;
* The environment of care supported the safe performance of the nursing procedure;
* The nursing procedure would be performed by UAP at a frequency that allowed for continued safe performance; and
* RN had the appropriate resources necessary to fulfill nursing practice and delegation responsibilities including availability to provide assessment of resident and ongoing competency validation of UAP’s performance.

Additionally, there was no documentation that Staff 2 (RN) verified Staff 4 and 5’s documentation.

The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by an RN in accordance with the OARs adopted by the OSBN in chapter 851, division 047 was reviewed with Staff 1 (Administrator of Wellsprings) and Staff 2 (RN) on 11/22/24 at 4:20 pm. Staff 2 acknowledged the delegation documentation was lacking components of OSBN Division 47 and stated he would update the delegations.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

(1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled medication technicians (#s 3, 4 and 5) demonstrated knowledge and performance in any duty they were assigned prior to providing care services to residents, and 2 of 3 medication technicians (#s 4 and 5) completed First Aid certification and abdominal thrust training. Findings include, but are not limited to:

Staff 3 (MT) was hired 10/21/24, Staff 4 (MT) was hired 06/19/24, and Staff 5 (MT) was hired 06/18/24.

A desk review of employee training records on 11/21/24 and 11/22/24, and a telephone interview with Staff 1 (Administrator of Wellsprings) on 11/22/24 at 12:55 pm revealed the following:

* Staff 3 (MT) was hired 10/21/24. Staff 3 had been working independently in the facility as a MT, which included administering medications to residents. Her MT training documentation had not been completed until 11/20/24;

* Staff 4 (MT) was hired 06/19/24. Staff 4 had been working independently in the facility as a MT, which included administering medications to residents. Her MT training documentation had not been completed until 11/20/24;

* Staff 5 (MT) was hired 06/18/24. Staff 4 had been working independently in the facility as a MT, which included administering medications to residents. Her MT training documentation had not been completed until 11/19/24; and

* Staff 4 and 5 lacked documented evidence of abdominal thrust and First Aid training.

The need for the facility to have a system to ensure staff training was completed and documented within the required time frame was reviewed with Staff 1 on 11/22/24. She acknowledged the findings. She stated all facility MTs would not administer medications until documented training was completed.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff

(5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF.
(a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned.
(b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to:
(A) The role of service plans in providing individualized resident care.
(B) Providing assistance with the activities of daily living.
(C) Changes associated with normal aging.
(D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition.
(E) Conditions that require assessment, treatment, observation and reporting.
(F) General food safety, serving and sanitation.
(G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised.

(9) ADDITIONAL REQUIREMENTS. Staff:
(a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services.
(b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required.
(c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed.

(10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule.
(a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

This Rule is not met as evidenced by:

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



During the CHOW survey conducted 09/17/24 through 09/20/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations.



Refer to deficiencies in the report.

OAR 411-054-0025 (1) Facility Administration: Operation

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

This Rule is not met as evidenced by:

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



During the CHOW survey, conducted 09/17/24 through 09/20/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.



Refer to the deficiencies in the report.

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

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

This Rule is not met as evidenced by:
Based on observation, interview and record review, it was determined the facility failed to develop and conduct an ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction. This is a repeat citation. Findings include, but are not limited to:

During the Revisit 1 survey, conducted 01/13/25 through 01/15/25, the quality improvement oversight for ensuring adequate resident care, services, and satisfaction was found to be ineffective as evidenced by the number of repeated citations.

On 01/15/25, Staff 17 (ED) was interviewed about the facility’s quality improvement program. She reported the facility currently did not have a Quality Assurance (QA) or Quality Improvement (QI) program in place. She mentioned that the facility planned to implement a program called TELS, starting 02/01/25. However, at the time of the survey, no QA or QI program was being utilized or had been implemented.

Refer to the deficiencies in the report

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:
Based on observation, interview and record review, it was determined the facility failed to develop and conduct an ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction. This is a repeat citation. Findings include, but are not limited to:

During the Revisit 1 survey, conducted 01/13/25 through 01/15/25, the quality improvement oversight for ensuring adequate resident care, services, and satisfaction was found to be ineffective as evidenced by the number of repeated citations.

On 01/15/25, Staff 17 (ED) was interviewed about the facility’s quality improvement program. She reported the facility currently did not have a Quality Assurance (QA) or Quality Improvement (QI) program in place. She mentioned that the facility planned to implement a program called TELS, starting 02/01/25. However, at the time of the survey, no QA or QI program was being utilized or had been implemented.

Refer to the deficiencies in the report

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:
Based on observation, interview and record review, it was determined the facility failed to develop and conduct an ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction. This is a repeat citation. Findings include, but are not limited to:

During the Revisit 1 survey, conducted 01/13/25 through 01/15/25, the quality improvement oversight for ensuring adequate resident care, services, and satisfaction was found to be ineffective as evidenced by the number of repeated citations.

On 01/15/25, Staff 17 (ED) was interviewed about the facility’s quality improvement program. She reported the facility currently did not have a Quality Assurance (QA) or Quality Improvement (QI) program in place. She mentioned that the facility planned to implement a program called TELS, starting 02/01/25. However, at the time of the survey, no QA or QI program was being utilized or had been implemented.

Refer to the deficiencies in the report

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to develop and conduct an ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction. This is a repeat citation. Findings include, but are not limited to:

During the Revisit 2 survey, conducted 03/31/25 through 04/01/25, the quality improvement oversight for ensuring adequate resident care, services, and satisfaction was found to be ineffective as evidenced by the number of repeated citations.

The findings were discussed with Staff 17 (ED) and Staff 35 (RN) on 04/01/25 during the exit interview at approximately 4:30 pm. She acknowledged the findings.

Refer to the deficiencies in the report.

Based on interview and record review, it was determined the facility failed to ensure all resident incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office if abuse and/or neglect could not reasonably be ruled out for 2 of 2 sampled residents (#s 1 and 3) who experienced unwitnessed falls with injury. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes mellitus and cerebrovascular accident (stroke).

The service plan dated 11/17/23 noted Resident 1 required one person assist for dressing, bathing, and mobility in wheelchair, and two-person assist for transfers. The service plan also noted Resident 1 had interventions in place for falls.

Review of the resident's 07/31/24 incident report revealed Resident 1 was found lying down on the floor next to the wheelchair. Resident 1 sustained a scrape to his/her left elbow and reopened a scab on his/her left knee.

The investigation did not rule out abuse/neglect as the fall was unwitnessed and Resident 1 was unable to state what took place. The incident was not reported to the local SPD office.

The investigation did not rule out abuse/neglect as the fall was unwitnessed and Resident 1 was unable to state what took place. The incident was not reported to the local SPD office.
On 09/17/24, survey requested the facility report the incident to the local SPD office. At approximately 3:59 PM on 09/17/24, confirmation of the facility reporting the incident to the local SPD office was provided.

On 09/20/24 at 9:00 am, the need to ensure all incidents for which abuse and/or neglect could not be ruled out were reported to the local SPD office was discussed with Staff 1 (Administrator) and Staff 14 (Senior Executive Director). They acknowledged the findings.



2. Resident 3 was admitted to the facility in 08/2024 with diagnoses including hypertension and history of cerebrovascular accident (stroke) with right sided weakness.



Staff were interviewed and the resident's record was reviewed including 08/16/24 through 09/17/24 progress notes. The following was identified:



A progress note dated 08/27/24 stated “Resident had unwitnessed fall sometime in the early morning of 8/27/24. [S/he] got a skin tear on [his/her] arm and a small wound on the back of [his/her] head.” There was no additional information regarding how the injury occurred.



In an interview with Staff 1 (Administrator) on 09/19/24, she stated she was unaware of this incident and no investigation had been completed.



At the request of the survey team, the facility provided confirmation that the incident had been reported to the local SPD office on 09/19/24 at 4:29 pm.



The need to ensure incidents were investigated and immediately reported to the local SPD office, if abuse or neglect could not be ruled out, was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:30 am on 09/20/24. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure an evaluation was completed before a resident moved into the building and included all required elements for 1 of 1 newly admitted resident (#3) and quarterly evaluations were the foundation used to develop residents' quarterly service plans, including documentation relevant to the residents' needs and current condition for 3 of 3 sampled residents (#s 1, 2, and 4) whose evaluations were reviewed. Findings include, but are not limited to:



1.Resident 1 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes mellitus, and cerebrovascular accident (stroke).



A review of the resident's record identified that there were no quarterly evaluations completed between 11/17/23 and 09/17/24.



Staff 1 (Administrator) confirmed in an interview on 09/20/24 that there were no evaluations completed between 11/17/23 and 09/17/24.



The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 (Administrator), and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. They acknowledged the findings.



2. Resident 2 was admitted to the facility in 11/2015 with diagnoses including transient cerebral ischemic attack (TIA) and chronic obstructive pulmonary disease (COPD).



A review of the resident's record identified that there were no quarterly evaluations completed between 10/11/23 and 09/17/24.



Staff 1 (Administrator) confirmed in an interview on 09/20/24 that there were no evaluations completed between 10/11/23 and 09/17/24.



The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 (Administrator), and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. They acknowledged the findings.



3. Resident 3 was admitted to the facility in 08/2024 with diagnoses including hypertension and history of cerebrovascular accident (stroke) with right sided weakness.



During review of the resident’s record the following was identified:



*Resident 3 moved into the facility on 08/16/24; and

*There was no documentation that an evaluation was completed prior to the resident moving in.



In an interview with Staff 1 (Administrator) at 3:00 pm on 09/17/24, she stated the facility was not currently documenting any type of move-in evaluation prior to a resident being admitted to the facility.



The need to complete an evaluation prior to the resident moving into the facility, which included all required elements, was reviewed with Staff 1 and Staff 14 (Senior Executive Director) at 9:30 am on 09/20/24. They acknowledged the findings.



4. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, chronic obstructive pulmonary disease and congestive heart failure.



A review of the resident's record identified that there were no evaluations completed between 11/29/23 and 09/17/24.



Staff 1 (Administrator) confirmed in an interview at 3:30 pm on 09/19/24 that there were no evaluations completed between 11/29/23 and 09/17/24.



The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:30 am on 09/20/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an evaluation was completed before a resident moved into the building and included all required elements for 1 of 1 newly admitted resident (#3) and quarterly evaluations were the foundation used to develop residents' quarterly service plans, including documentation relevant to the residents' needs and current condition for 3 of 3 sampled residents (#s 1, 2, and 4) whose evaluations were reviewed. Findings include, but are not limited to:



1.Resident 1 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes mellitus, and cerebrovascular accident (stroke).



A review of the resident's record identified that there were no quarterly evaluations completed between 11/17/23 and 09/17/24.



Staff 1 (Administrator) confirmed in an interview on 09/20/24 that there were no evaluations completed between 11/17/23 and 09/17/24.



The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 (Administrator), and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. They acknowledged the findings.



2. Resident 2 was admitted to the facility in 11/2015 with diagnoses including transient cerebral ischemic attack (TIA) and chronic obstructive pulmonary disease (COPD).



A review of the resident's record identified that there were no quarterly evaluations completed between 10/11/23 and 09/17/24.



Staff 1 (Administrator) confirmed in an interview on 09/20/24 that there were no evaluations completed between 10/11/23 and 09/17/24.



The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 (Administrator), and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. They acknowledged the findings.



3. Resident 3 was admitted to the facility in 08/2024 with diagnoses including hypertension and history of cerebrovascular accident (stroke) with right sided weakness.



During review of the resident’s record the following was identified:



*Resident 3 moved into the facility on 08/16/24; and

*There was no documentation that an evaluation was completed prior to the resident moving in.



In an interview with Staff 1 (Administrator) at 3:00 pm on 09/17/24, she stated the facility was not currently documenting any type of move-in evaluation prior to a resident being admitted to the facility.



The need to complete an evaluation prior to the resident moving into the facility, which included all required elements, was reviewed with Staff 1 and Staff 14 (Senior Executive Director) at 9:30 am on 09/20/24. They acknowledged the findings.



4. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, chronic obstructive pulmonary disease and congestive heart failure.



A review of the resident's record identified that there were no evaluations completed between 11/29/23 and 09/17/24.



Staff 1 (Administrator) confirmed in an interview at 3:30 pm on 09/19/24 that there were no evaluations completed between 11/29/23 and 09/17/24.



The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:30 am on 09/20/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an evaluation was completed before a resident moved into the building and included all required elements for 1 of 1 newly admitted resident (#3) and quarterly evaluations were the foundation used to develop residents' quarterly service plans, including documentation relevant to the residents' needs and current condition for 3 of 3 sampled residents (#s 1, 2, and 4) whose evaluations were reviewed. Findings include, but are not limited to:



1.Resident 1 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes mellitus, and cerebrovascular accident (stroke).



A review of the resident's record identified that there were no quarterly evaluations completed between 11/17/23 and 09/17/24.



Staff 1 (Administrator) confirmed in an interview on 09/20/24 that there were no evaluations completed between 11/17/23 and 09/17/24.



The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 (Administrator), and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. They acknowledged the findings.



2. Resident 2 was admitted to the facility in 11/2015 with diagnoses including transient cerebral ischemic attack (TIA) and chronic obstructive pulmonary disease (COPD).



A review of the resident's record identified that there were no quarterly evaluations completed between 10/11/23 and 09/17/24.



Staff 1 (Administrator) confirmed in an interview on 09/20/24 that there were no evaluations completed between 10/11/23 and 09/17/24.



The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 (Administrator), and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. They acknowledged the findings.



3. Resident 3 was admitted to the facility in 08/2024 with diagnoses including hypertension and history of cerebrovascular accident (stroke) with right sided weakness.



During review of the resident’s record the following was identified:



*Resident 3 moved into the facility on 08/16/24; and

*There was no documentation that an evaluation was completed prior to the resident moving in.



In an interview with Staff 1 (Administrator) at 3:00 pm on 09/17/24, she stated the facility was not currently documenting any type of move-in evaluation prior to a resident being admitted to the facility.



The need to complete an evaluation prior to the resident moving into the facility, which included all required elements, was reviewed with Staff 1 and Staff 14 (Senior Executive Director) at 9:30 am on 09/20/24. They acknowledged the findings.



4. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, chronic obstructive pulmonary disease and congestive heart failure.



A review of the resident's record identified that there were no evaluations completed between 11/29/23 and 09/17/24.



Staff 1 (Administrator) confirmed in an interview at 3:30 pm on 09/19/24 that there were no evaluations completed between 11/29/23 and 09/17/24.



The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:30 am on 09/20/24. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in and Eval: 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 include the following information: (A) Prior living arrangements; (B) Emergency contacts; (C) Service plan involvement - resident, family, and social supports; (D) Financial and other legal relationships, if applicable, including, but not limited to:(i) Advance directives;(ii) Guardianship;(iii) Conservatorship; and(iv) Power of Attorney. (E) Primary language; (F) Community connections; and (G) 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) 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).(b) 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.(c) 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.(d) Cognition, including:(A) Memory;(B) Orientation;(C) Confusion; and(D) Decision-making abilities.(e) Personality, including how the person copes with change or challenging situations.(f) Communication and sensory abilities including:(A) Hearing;(B) Vision;(C) Speech;(D) Use of assistive devices; and(E) Ability to understand and be understood.(g) 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.(h) Independent activities of daily living including:(A) Ability to manage medications;(B) Ability to use call system;(C) Housework and laundry; and(D) Transportation.(i) Pain pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.(j) Skin condition.(k) Nutrition habits, fluid preferences, and weight if indicated.(l) List of treatments type, frequency, and level of assistance needed.(m) Indicators of nursing needs, including potential for delegated nursing tasks.(n) 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.(o) 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.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were updated quarterly, were reflective of residents' care needs and provided clear direction to staff for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:



1. Resident 3 was admitted to the facility in 08/2024 with diagnoses including hypertension and history of cerebrovascular accident (stroke) with right sided weakness.



The resident's clinical record was reviewed, including service plan dated 09/10/24 and progress notes and temporary service plans dated 08/16/24 through 09/17/24, the resident was observed, and interviews with staff and the resident were conducted.



The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:



*Food preferences including likes and dislikes;

*Activities;

*Frequency of safety checks;

*Fall prevention interventions;

*Smoking frequency and level of assistance required;

*Pain;

*Diagnoses and signs and symptoms to monitor for, including hypertension and history of cerebrovascular accident with residual right-sided weakness;

*Ability to use call system; and

*Assistive devices including grab bars on toilet, bed alarm, hospital bed and power scooter.



The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 14 (Senior Executive Director) at 9:30 am on 09/20/24. The findings were acknowledged, and no further documentation was provided.



2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, chronic obstructive pulmonary disease and congestive heart failure.



In an interview at 3:30 pm on 09/19/24, Staff 1 (Administrator) acknowledged that the resident’s service plan had not been updated quarterly, with the most recent service plan being dated 12/01/23.



The resident's clinical record was reviewed, including service plan dated 12/01/23 and progress notes and temporary service plans dated 06/17/24 through 09/17/24, the resident was observed, and interviews with staff and the resident were conducted.



The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:



*Hospice;

*Bladder management including catheter;

*Bathing;

*Cognition including hallucinations;

*Use of continuous oxygen;

*Oral care;

*History of weight gain; and

*Hospital bed.



The need to ensure resident service plans were updated quarterly, were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:30 am on 09/20/24. The findings were acknowledged, and no further documentation was provided.



3. Resident 1 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes mellitus, and cerebrovascular accident (stroke).



On 09/17/24, Resident 1’s service plan was provided by staff to the surveyor.



Review of the resident's current service plan, dated 11/17/23, revealed it had not been reviewed quarterly.



In an interview on 09/19/24 at 10:00 am, Staff 1 (Administrator) acknowledged the service plan had not been reviewed quarterly.



The need to ensure service plans were reviewed quarterly was reviewed with Staff 1 and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. They acknowledged the findings.





4. Resident 2 was admitted to the facility in 11/2015 with diagnoses including transient cerebral ischemic attack (TIA) and chronic obstructive pulmonary disease (COPD).

On 09/17/24, Resident 2’s service plan was provided by staff to the surveyor.



Review of the resident's current service plan, dated 10/11/23, revealed it had not been reviewed quarterly.



In an interview on 09/19/24 at 10:00 am, Staff 1 (Administrator) acknowledged the service plan had not been reviewed quarterly.



The need to ensure service plans were reviewed quarterly was reviewed with Staff 1 (Administrator) and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services, and was consistently implemented by staff for 5 of 6 sampled residents (#s 7, 8, 9, 11, and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 05/2021 with diagnoses including bipolar disorder.

Observations of the resident, interviews with staff and review of the service plan, dated 12/18/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was consistently implemented by staff in the following areas:

* Transfer assistance, gait belt and transfer pole use;
* Dressing, hygiene, and bathing;
* Toileting assistance and incontinence care;
* Refusals of care and medications;
* Evacuation assistance;
* Behaviors including agitation and aggression during care;
* Grooming including hair and teeth brushing;
* Ability to bare weight and ambulate; and
* Hearing aids.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

2. Resident 12 was admitted to the facility in 05/2023 with diagnoses including pancreatic cancer.

Observations of the resident, interviews with staff, and review of the service plan, dated 12/03/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or consistently implemented by staff in the following areas:

* Dressing, hygiene, oral care, and bathing;

* Toileting assistance and incontinence care;
* Evacuation assistance;
* Hallucinations, agitation, and aggression with staff;
* Non-insulin dependent diabetes;
* Chronic pain and discomfort related to diagnoses;
* Oxygen use and resident non-compliance; and
* Mental health concerns.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

3. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 7's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Fall interventions;
* Behavioral interventions;
* What triggered the resident to have behaviors;
* How the resident exhibited sexual behaviors;
* Two caregivers with all ADLs;
* Who provideed nail care;
* Access to snacks;
* Urinal care;
* Assistance needed for refilling his/her water bottle;
* Wearing shoes in the shower to prevent slipping;
* Daily blood pressures;
* Leisure activities and assistance needed from staff;
* Ability to communicate in English and in Spanish;
* Religious affiliations;
* Person centered evacuation plan; and
* Preference of female caregivers.

The need to ensure service plans provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

4. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 8's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Assistance needed for hearing devices;
* Assistance needed relating to a "lazy eye;”
* Full assistance required for grooming;
* Preferred beverages;
* Choice to only take meals in his/her unit unless family was visiting;
* Right sided weakness;
* Over the counter medications used;
* Direction to staff on who they should notify if the resident started "choking" on his/her food and/or beverages;
* Person centered direction to staff for evacuation;
* Conflicting information related to safety checks;
* Assistance needed with making phone calls;
* Leisure activities and assistance needed from staff;
* Smoking status; and
* Oxygen use.

The need to ensure service plans were reflective of the resident’s needs and provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

5. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes and atrial fibrillation.

During the survey, the resident was observed spending most of the time in bed and required assistance from two staff for bed mobility and personal care, as well as one staff to assist with food intake.

Observation of the resident, interviews with staff, and the 12/13/24 service plan reviewed during the survey showed the service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:

* Use of an air mattress while in bed;
* Required assistance from two staff members for transfer, utilizing a Hoyer lift;
* Conflicting information regarding the resident’s eating status;
* Use of full dentures;
* Dressing status including assistance from two staff members;
* Bed mobility including assistance from two staff members;
* Toileting status;
* Conflicting information regarding mobility;
* Use of oxygen, including care instructions and oxygen setting;
* Use of psychotropic medication, including the signs, symptoms, or specific behaviors;
* Wandering status;
* Emergency evacuation status, including detailed instruction for staff to follow; * Pain status, including the location of pain and non-pharmacological interventions to address the pain; and
* Use of side rails, including clear instructions on what to monitor and who to report if any issues arise.

The need to ensure the service plan reflected the resident’s current care needs and provided clear instructions for staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN) and Witness 1 (RN Consultant) on 01/15/25 at 10:00 am. The staff acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services, and was consistently implemented by staff for 5 of 6 sampled residents (#s 7, 8, 9, 11, and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 05/2021 with diagnoses including bipolar disorder.

Observations of the resident, interviews with staff and review of the service plan, dated 12/18/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was consistently implemented by staff in the following areas:

* Transfer assistance, gait belt and transfer pole use;
* Dressing, hygiene, and bathing;
* Toileting assistance and incontinence care;
* Refusals of care and medications;
* Evacuation assistance;
* Behaviors including agitation and aggression during care;
* Grooming including hair and teeth brushing;
* Ability to bare weight and ambulate; and
* Hearing aids.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

2. Resident 12 was admitted to the facility in 05/2023 with diagnoses including pancreatic cancer.

Observations of the resident, interviews with staff, and review of the service plan, dated 12/03/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or consistently implemented by staff in the following areas:

* Dressing, hygiene, oral care, and bathing;

* Toileting assistance and incontinence care;
* Evacuation assistance;
* Hallucinations, agitation, and aggression with staff;
* Non-insulin dependent diabetes;
* Chronic pain and discomfort related to diagnoses;
* Oxygen use and resident non-compliance; and
* Mental health concerns.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

3. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 7's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Fall interventions;
* Behavioral interventions;
* What triggered the resident to have behaviors;
* How the resident exhibited sexual behaviors;
* Two caregivers with all ADLs;
* Who provideed nail care;
* Access to snacks;
* Urinal care;
* Assistance needed for refilling his/her water bottle;
* Wearing shoes in the shower to prevent slipping;
* Daily blood pressures;
* Leisure activities and assistance needed from staff;
* Ability to communicate in English and in Spanish;
* Religious affiliations;
* Person centered evacuation plan; and
* Preference of female caregivers.

The need to ensure service plans provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

4. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 8's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Assistance needed for hearing devices;
* Assistance needed relating to a "lazy eye;”
* Full assistance required for grooming;
* Preferred beverages;
* Choice to only take meals in his/her unit unless family was visiting;
* Right sided weakness;
* Over the counter medications used;
* Direction to staff on who they should notify if the resident started "choking" on his/her food and/or beverages;
* Person centered direction to staff for evacuation;
* Conflicting information related to safety checks;
* Assistance needed with making phone calls;
* Leisure activities and assistance needed from staff;
* Smoking status; and
* Oxygen use.

The need to ensure service plans were reflective of the resident’s needs and provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

5. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes and atrial fibrillation.

During the survey, the resident was observed spending most of the time in bed and required assistance from two staff for bed mobility and personal care, as well as one staff to assist with food intake.

Observation of the resident, interviews with staff, and the 12/13/24 service plan reviewed during the survey showed the service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:

* Use of an air mattress while in bed;
* Required assistance from two staff members for transfer, utilizing a Hoyer lift;
* Conflicting information regarding the resident’s eating status;
* Use of full dentures;
* Dressing status including assistance from two staff members;
* Bed mobility including assistance from two staff members;
* Toileting status;
* Conflicting information regarding mobility;
* Use of oxygen, including care instructions and oxygen setting;
* Use of psychotropic medication, including the signs, symptoms, or specific behaviors;
* Wandering status;
* Emergency evacuation status, including detailed instruction for staff to follow; * Pain status, including the location of pain and non-pharmacological interventions to address the pain; and
* Use of side rails, including clear instructions on what to monitor and who to report if any issues arise.

The need to ensure the service plan reflected the resident’s current care needs and provided clear instructions for staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN) and Witness 1 (RN Consultant) on 01/15/25 at 10:00 am. The staff acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

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

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

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents’ needs and provided clear direction for staff regarding the delivery of services, for 3 of 3 sampled residents (#s 14, 15 and 16) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 14 was admitted to the facility in 06/2024, with diagnoses including congestive heart failure, hypertension, and osteoarthritis.

Review of Resident 14’s service plan, dated 01/14/25, progress notes, dated 03/01/25 through 03/31/25, interviews with staff, and observations during survey revealed the service plan was not reflective or lacked clear instructions for staff in the following areas:

* Infestation of bed bugs; and
* On 03/24/25, the resident took a fall, and was transported by EMS to the hospital.

The surveyor observed personal protective equipment (PPE) materials hung outside the resident’s door on 03/31/25. These included gloves, gowns, hand sanitizer, and foot “booties”.

In an interview on 03/31/25, Staff 29 (MT/CG) stated the resident had bed bugs in the room, and that was the reason for the PPE equipment.

Resident 14’s service plan lacked any information about the bed bugs, instructions for infection control procedures, or interventions for fall prevention.

On 04/01/25, the need to ensure service plans were reflective of current resident care needs and provided clear instructions to staff was discussed with Staff 17 (ED) and Staff 35 (RN). They acknowledged the findings.

2. Resident 15 moved into the assisted living community in 11/2021 with diagnoses including Type 2 diabetes mellitus with diabetic chronic kidney disease and dementia.

Observations of the resident, interviews with staff, and review of the service plan, dated 02/27/25 with updates made on 02/28/25, 03/11/25, 03/13/25, 03/24/25 showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Skin integrity and interventions;
* Oxygen use and instructions;
* Toileting status: Incontinent and uses briefs verses foley catheter;
* Eating status: Independent verses full assistance; and
* Diet texture: Regular texture cut-up verses puree and mildly thickened liquids.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 17 (ED), Staff 35 (RN) and Witness 2 (RCD sister community). They acknowledged the findings.

3. Resident 16 moved into the assisted living community in 04/2020 with diagnoses including Type 2 diabetes mellitus, unspecified psychosis and major depressive disorder.

Observations of the resident, interviews with staff, and review of the service plan, dated 02/27/25 with updates made on 02/28/25, 03/11/25, 03/13/25, 03/24/25 showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Personality and how one copes with change or challenging situations;
* Behaviors and interventions;
* Cognitive status including memory, orientation, confusion and decision making;
* Skin integrity monitoring instructions due to resistance to accept incontinent care; and
* Increased fall risk and interventions due to bilateral edema and neuropathy, use of psychotropic medications and narcotic pain medications.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 17 (ED), Staff 35 (RN) and Witness 2 (RCD sister community) on 04/01/25 at 11:00 am. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to document what actions or interventions were needed for changes of condition, including resident specific instructions communicated to staff on each shift, weekly progress documented until the condition resolved and/or the facility failed to refer significant changes of condition to the facility RN for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who experienced changes of condition. Findings include, but are not limited to:



1.Resident 1 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes mellitus, and cerebrovascular accident (stroke).



Review of Resident 1's progress notes, temporary service plans (TSP's), 24-Hour Resident Reports dated 05/03/24 through 09/14/24, and incident investigation, and interviews with facility staff were completed during the survey.



a. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:



* 05/03/24 TSP - new medication;

* 07/31/24 Incident report – injury fall with scrape on left elbow and re-opened scab on left knee;

* 08/21/24 24-Hour Resident Report – “Resident had behaviors all day”;

* 08/24/24 24-Hour Resident Report – “kicked chair, ripped some skin off back of heel, put band-aid on it”;

* 08/28/24 24-Hour Resident Report – “shouting help and tore brief half off”; and

* 09/10/24 24-Hour Resident Report – “had diarrhea”.



b. There was no evidence the facility referred the following significant changes of condition to the facility nurse for assessment and determined what actions and interventions were needed for the resident, and provided written instructions to staff:



* 04/11/24 - Admission to hospice; and

* 06/26/24 - Physician order for change of diet to puree texture.



The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift, with monitoring at least weekly through resolution, and significant changes of condition be referred to the facility RN was discussed with Staff 1 (Administrator) and Staff 2 (RN) at 4:00 pm on 09/19/24. They acknowledged the findings.



2. Resident 2 was admitted to the facility in 11/2015 with diagnoses including transient cerebral ischemic attack (TIA) and chronic obstructive pulmonary disease (COPD).



Clinical records, including temporary service plans (TSP) and progress notes dated 06/20/24-09/11/24, were reviewed, and interviews with facility staff were conducted and revealed the following:



*09/11/24 TSP - return from ER.



There was no documented evidence the facility monitored the changes of condition at least weekly until resolved.



The need to monitor and document at least weekly until changes of condition were resolved was discussed with Staff 1 (Administrator) and Staff 2 (RN) at 4:00 pm on 09/19/24. They acknowledged the findings.



4. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, chronic obstructive pulmonary disease and congestive heart failure.



Staff were interviewed and the resident's record was reviewed including the current service plan dated 12/01/23, temporary care plans and progress notes dated 06/17/24 through 09/17/24.



The facility failed to determine resident-specific actions or interventions needed, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:



* 07/03/24 – Resident expressed concern regarding inability to swallow solid foods;

* 07/07/24 – Hallucinations of son in bathroom;

* 07/13/24 – New medication;

* 07/16/24 – Rash under breast folds;

* 07/18/24 – New medication;

* 07/21/24 – Vaginal bleeding for multiple days;

* 07/22/24 – Emergency room visit;

* 08/12/24 – Emergency room visit;

* 08/16/24 – Catheter placement;

* 08/28/24 – New medications;

* 09/05/24 – Rash in groin;

* 09/09/24 – Increased confusion;

* 09/10/24 – Change in urine color to dark orange;

* 09/10/24 – New medication; and

* 09/16/24 – Unwitnessed fall with pain to left leg.



During an interview on 09/19/24 at 2:45 pm, Staff 1 (Administrator) stated she was not able to provide documentation of written policies which ensured a resident monitoring and reporting system was implemented 24-hours a day which specified staff responsibilities and identified criteria for notifying the administrator, registered nurse, or healthcare provider.



The facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed when Resident 4 experienced the following significant changes of condition:



*08/16/24 – Significant decline including multiple emergency room visits resulting in admission to hospice; and

*09/01/24 – Severe weight gain.



The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift with monitoring at least weekly through resolution, written policies were in place which ensured a monitoring and reporting system was implemented, and significant changes of condition were referred to the facility nurse was discussed with Staff 1 and Staff 2 (RN) at 4:00 pm on 09/19/24. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
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 care and services, and was consistently implemented by staff for 5 of 6 sampled residents (#s 7, 8, 9, 11, and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 05/2021 with diagnoses including bipolar disorder.

Observations of the resident, interviews with staff and review of the service plan, dated 12/18/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was consistently implemented by staff in the following areas:

* Transfer assistance, gait belt and transfer pole use;
* Dressing, hygiene, and bathing;
* Toileting assistance and incontinence care;
* Refusals of care and medications;
* Evacuation assistance;
* Behaviors including agitation and aggression during care;
* Grooming including hair and teeth brushing;
* Ability to bare weight and ambulate; and
* Hearing aids.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

2. Resident 12 was admitted to the facility in 05/2023 with diagnoses including pancreatic cancer.

Observations of the resident, interviews with staff, and review of the service plan, dated 12/03/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or consistently implemented by staff in the following areas:

* Dressing, hygiene, oral care, and bathing;

* Toileting assistance and incontinence care;
* Evacuation assistance;
* Hallucinations, agitation, and aggression with staff;
* Non-insulin dependent diabetes;
* Chronic pain and discomfort related to diagnoses;
* Oxygen use and resident non-compliance; and
* Mental health concerns.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

3. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 7's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Fall interventions;
* Behavioral interventions;
* What triggered the resident to have behaviors;
* How the resident exhibited sexual behaviors;
* Two caregivers with all ADLs;
* Who provideed nail care;
* Access to snacks;
* Urinal care;
* Assistance needed for refilling his/her water bottle;
* Wearing shoes in the shower to prevent slipping;
* Daily blood pressures;
* Leisure activities and assistance needed from staff;
* Ability to communicate in English and in Spanish;
* Religious affiliations;
* Person centered evacuation plan; and
* Preference of female caregivers.

The need to ensure service plans provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

4. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 8's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Assistance needed for hearing devices;
* Assistance needed relating to a "lazy eye;”
* Full assistance required for grooming;
* Preferred beverages;
* Choice to only take meals in his/her unit unless family was visiting;
* Right sided weakness;
* Over the counter medications used;
* Direction to staff on who they should notify if the resident started "choking" on his/her food and/or beverages;
* Person centered direction to staff for evacuation;
* Conflicting information related to safety checks;
* Assistance needed with making phone calls;
* Leisure activities and assistance needed from staff;
* Smoking status; and
* Oxygen use.

The need to ensure service plans were reflective of the resident’s needs and provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

5. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes and atrial fibrillation.

During the survey, the resident was observed spending most of the time in bed and required assistance from two staff for bed mobility and personal care, as well as one staff to assist with food intake.

Observation of the resident, interviews with staff, and the 12/13/24 service plan reviewed during the survey showed the service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:

* Use of an air mattress while in bed;
* Required assistance from two staff members for transfer, utilizing a Hoyer lift;
* Conflicting information regarding the resident’s eating status;
* Use of full dentures;
* Dressing status including assistance from two staff members;
* Bed mobility including assistance from two staff members;
* Toileting status;
* Conflicting information regarding mobility;
* Use of oxygen, including care instructions and oxygen setting;
* Use of psychotropic medication, including the signs, symptoms, or specific behaviors;
* Wandering status;
* Emergency evacuation status, including detailed instruction for staff to follow; * Pain status, including the location of pain and non-pharmacological interventions to address the pain; and
* Use of side rails, including clear instructions on what to monitor and who to report if any issues arise.

The need to ensure the service plan reflected the resident’s current care needs and provided clear instructions for staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN) and Witness 1 (RN Consultant) on 01/15/25 at 10:00 am. The staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:
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 care and services, and was consistently implemented by staff for 5 of 6 sampled residents (#s 7, 8, 9, 11, and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 05/2021 with diagnoses including bipolar disorder.

Observations of the resident, interviews with staff and review of the service plan, dated 12/18/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was consistently implemented by staff in the following areas:

* Transfer assistance, gait belt and transfer pole use;
* Dressing, hygiene, and bathing;
* Toileting assistance and incontinence care;
* Refusals of care and medications;
* Evacuation assistance;
* Behaviors including agitation and aggression during care;
* Grooming including hair and teeth brushing;
* Ability to bare weight and ambulate; and
* Hearing aids.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

2. Resident 12 was admitted to the facility in 05/2023 with diagnoses including pancreatic cancer.

Observations of the resident, interviews with staff, and review of the service plan, dated 12/03/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or consistently implemented by staff in the following areas:

* Dressing, hygiene, oral care, and bathing;

* Toileting assistance and incontinence care;
* Evacuation assistance;
* Hallucinations, agitation, and aggression with staff;
* Non-insulin dependent diabetes;
* Chronic pain and discomfort related to diagnoses;
* Oxygen use and resident non-compliance; and
* Mental health concerns.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

3. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 7's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Fall interventions;
* Behavioral interventions;
* What triggered the resident to have behaviors;
* How the resident exhibited sexual behaviors;
* Two caregivers with all ADLs;
* Who provideed nail care;
* Access to snacks;
* Urinal care;
* Assistance needed for refilling his/her water bottle;
* Wearing shoes in the shower to prevent slipping;
* Daily blood pressures;
* Leisure activities and assistance needed from staff;
* Ability to communicate in English and in Spanish;
* Religious affiliations;
* Person centered evacuation plan; and
* Preference of female caregivers.

The need to ensure service plans provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

4. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 8's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Assistance needed for hearing devices;
* Assistance needed relating to a "lazy eye;”
* Full assistance required for grooming;
* Preferred beverages;
* Choice to only take meals in his/her unit unless family was visiting;
* Right sided weakness;
* Over the counter medications used;
* Direction to staff on who they should notify if the resident started "choking" on his/her food and/or beverages;
* Person centered direction to staff for evacuation;
* Conflicting information related to safety checks;
* Assistance needed with making phone calls;
* Leisure activities and assistance needed from staff;
* Smoking status; and
* Oxygen use.

The need to ensure service plans were reflective of the resident’s needs and provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

5. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes and atrial fibrillation.

During the survey, the resident was observed spending most of the time in bed and required assistance from two staff for bed mobility and personal care, as well as one staff to assist with food intake.

Observation of the resident, interviews with staff, and the 12/13/24 service plan reviewed during the survey showed the service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:

* Use of an air mattress while in bed;
* Required assistance from two staff members for transfer, utilizing a Hoyer lift;
* Conflicting information regarding the resident’s eating status;
* Use of full dentures;
* Dressing status including assistance from two staff members;
* Bed mobility including assistance from two staff members;
* Toileting status;
* Conflicting information regarding mobility;
* Use of oxygen, including care instructions and oxygen setting;
* Use of psychotropic medication, including the signs, symptoms, or specific behaviors;
* Wandering status;
* Emergency evacuation status, including detailed instruction for staff to follow; * Pain status, including the location of pain and non-pharmacological interventions to address the pain; and
* Use of side rails, including clear instructions on what to monitor and who to report if any issues arise.

The need to ensure the service plan reflected the resident’s current care needs and provided clear instructions for staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN) and Witness 1 (RN Consultant) on 01/15/25 at 10:00 am. The staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:
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 care and services, and was consistently implemented by staff for 5 of 6 sampled residents (#s 7, 8, 9, 11, and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 05/2021 with diagnoses including bipolar disorder.

Observations of the resident, interviews with staff and review of the service plan, dated 12/18/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was consistently implemented by staff in the following areas:

* Transfer assistance, gait belt and transfer pole use;
* Dressing, hygiene, and bathing;
* Toileting assistance and incontinence care;
* Refusals of care and medications;
* Evacuation assistance;
* Behaviors including agitation and aggression during care;
* Grooming including hair and teeth brushing;
* Ability to bare weight and ambulate; and
* Hearing aids.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

2. Resident 12 was admitted to the facility in 05/2023 with diagnoses including pancreatic cancer.

Observations of the resident, interviews with staff, and review of the service plan, dated 12/03/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or consistently implemented by staff in the following areas:

* Dressing, hygiene, oral care, and bathing;

* Toileting assistance and incontinence care;
* Evacuation assistance;
* Hallucinations, agitation, and aggression with staff;
* Non-insulin dependent diabetes;
* Chronic pain and discomfort related to diagnoses;
* Oxygen use and resident non-compliance; and
* Mental health concerns.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

3. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 7's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Fall interventions;
* Behavioral interventions;
* What triggered the resident to have behaviors;
* How the resident exhibited sexual behaviors;
* Two caregivers with all ADLs;
* Who provideed nail care;
* Access to snacks;
* Urinal care;
* Assistance needed for refilling his/her water bottle;
* Wearing shoes in the shower to prevent slipping;
* Daily blood pressures;
* Leisure activities and assistance needed from staff;
* Ability to communicate in English and in Spanish;
* Religious affiliations;
* Person centered evacuation plan; and
* Preference of female caregivers.

The need to ensure service plans provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

4. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 8's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Assistance needed for hearing devices;
* Assistance needed relating to a "lazy eye;”
* Full assistance required for grooming;
* Preferred beverages;
* Choice to only take meals in his/her unit unless family was visiting;
* Right sided weakness;
* Over the counter medications used;
* Direction to staff on who they should notify if the resident started "choking" on his/her food and/or beverages;
* Person centered direction to staff for evacuation;
* Conflicting information related to safety checks;
* Assistance needed with making phone calls;
* Leisure activities and assistance needed from staff;
* Smoking status; and
* Oxygen use.

The need to ensure service plans were reflective of the resident’s needs and provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

5. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes and atrial fibrillation.

During the survey, the resident was observed spending most of the time in bed and required assistance from two staff for bed mobility and personal care, as well as one staff to assist with food intake.

Observation of the resident, interviews with staff, and the 12/13/24 service plan reviewed during the survey showed the service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:

* Use of an air mattress while in bed;
* Required assistance from two staff members for transfer, utilizing a Hoyer lift;
* Conflicting information regarding the resident’s eating status;
* Use of full dentures;
* Dressing status including assistance from two staff members;
* Bed mobility including assistance from two staff members;
* Toileting status;
* Conflicting information regarding mobility;
* Use of oxygen, including care instructions and oxygen setting;
* Use of psychotropic medication, including the signs, symptoms, or specific behaviors;
* Wandering status;
* Emergency evacuation status, including detailed instruction for staff to follow; * Pain status, including the location of pain and non-pharmacological interventions to address the pain; and
* Use of side rails, including clear instructions on what to monitor and who to report if any issues arise.

The need to ensure the service plan reflected the resident’s current care needs and provided clear instructions for staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN) and Witness 1 (RN Consultant) on 01/15/25 at 10:00 am. The staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:
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 care and services, and was consistently implemented by staff for 5 of 6 sampled residents (#s 7, 8, 9, 11, and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 05/2021 with diagnoses including bipolar disorder.

Observations of the resident, interviews with staff and review of the service plan, dated 12/18/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was consistently implemented by staff in the following areas:

* Transfer assistance, gait belt and transfer pole use;
* Dressing, hygiene, and bathing;
* Toileting assistance and incontinence care;
* Refusals of care and medications;
* Evacuation assistance;
* Behaviors including agitation and aggression during care;
* Grooming including hair and teeth brushing;
* Ability to bare weight and ambulate; and
* Hearing aids.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

2. Resident 12 was admitted to the facility in 05/2023 with diagnoses including pancreatic cancer.

Observations of the resident, interviews with staff, and review of the service plan, dated 12/03/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or consistently implemented by staff in the following areas:

* Dressing, hygiene, oral care, and bathing;

* Toileting assistance and incontinence care;
* Evacuation assistance;
* Hallucinations, agitation, and aggression with staff;
* Non-insulin dependent diabetes;
* Chronic pain and discomfort related to diagnoses;
* Oxygen use and resident non-compliance; and
* Mental health concerns.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/15/25. The staff acknowledged the findings.

3. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 7's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Fall interventions;
* Behavioral interventions;
* What triggered the resident to have behaviors;
* How the resident exhibited sexual behaviors;
* Two caregivers with all ADLs;
* Who provideed nail care;
* Access to snacks;
* Urinal care;
* Assistance needed for refilling his/her water bottle;
* Wearing shoes in the shower to prevent slipping;
* Daily blood pressures;
* Leisure activities and assistance needed from staff;
* Ability to communicate in English and in Spanish;
* Religious affiliations;
* Person centered evacuation plan; and
* Preference of female caregivers.

The need to ensure service plans provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

4. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome.

Observations of the resident, interviews with staff, review of the current service plan and Temporary Service Plans were completed during the survey, from 01/13/25 through 01/15/25, and revealed Resident 8's service plan was not reflective of the resident's needs and/or did not provide clear instruction in the following areas:

* Assistance needed for hearing devices;
* Assistance needed relating to a "lazy eye;”
* Full assistance required for grooming;
* Preferred beverages;
* Choice to only take meals in his/her unit unless family was visiting;
* Right sided weakness;
* Over the counter medications used;
* Direction to staff on who they should notify if the resident started "choking" on his/her food and/or beverages;
* Person centered direction to staff for evacuation;
* Conflicting information related to safety checks;
* Assistance needed with making phone calls;
* Leisure activities and assistance needed from staff;
* Smoking status; and
* Oxygen use.

The need to ensure service plans were reflective of the resident’s needs and provided clear direction to staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

5. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes and atrial fibrillation.

During the survey, the resident was observed spending most of the time in bed and required assistance from two staff for bed mobility and personal care, as well as one staff to assist with food intake.

Observation of the resident, interviews with staff, and the 12/13/24 service plan reviewed during the survey showed the service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:

* Use of an air mattress while in bed;
* Required assistance from two staff members for transfer, utilizing a Hoyer lift;
* Conflicting information regarding the resident’s eating status;
* Use of full dentures;
* Dressing status including assistance from two staff members;
* Bed mobility including assistance from two staff members;
* Toileting status;
* Conflicting information regarding mobility;
* Use of oxygen, including care instructions and oxygen setting;
* Use of psychotropic medication, including the signs, symptoms, or specific behaviors;
* Wandering status;
* Emergency evacuation status, including detailed instruction for staff to follow; * Pain status, including the location of pain and non-pharmacological interventions to address the pain; and
* Use of side rails, including clear instructions on what to monitor and who to report if any issues arise.

The need to ensure the service plan reflected the resident’s current care needs and provided clear instructions for staff was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN) and Witness 1 (RN Consultant) on 01/15/25 at 10:00 am. The staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to determine what actions or interventions were needed for changes of condition, communicate these instructions to staff each shift, and document on the progress of the conditions at least weekly until resolved, for 3 of 3 sampled residents (#s 14, 15 and 16) with changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 14 was admitted to the facility in 06/2024, with diagnoses including hypertension, congestive heart failure, and osteoarthritis.

Review of Resident 14's progress notes, dated 03/01/25 through 03/31/25, and interviews with staff revealed the following changes of condition:

* On 03/24/25, the resident took a fall and was transported by EMS to the hospital; and
* The resident had an infestation of bed bugs in his/her apartment.

On 03/31/25, the surveyor observed PPE supplies outside Resident 14’s door. In an interview immediately after the observation, Staff 29 (MT/CG) stated the resident had bed bugs in his/her apartment, and this was the reason for the supplies.

There was no documentation of the bed bugs in the resident’s clinical record, no interventions implemented for infection control or fall prevention, and the conditions were not monitored to resolution.

On 04/01/25, the need to evaluate short-term changes of condition, determine and implement necessary interventions, communicate these instructions to staff, and monitor the conditions to resolution was discussed with Staff 17 (ED) and Staff 35 (RN). They acknowledged the findings.

2. Resident 15 moved into the assisted living community in 11/2021 with diagnoses including Type 2 diabetes mellitus with diabetic chronic kidney disease and dementia. During the acuity interview it was reported the resident had a right heel wound.

Observations of the resident, interviews with staff and the resident, review of observation notes (the facility’s tool for charting on a resident’s condition) and Interim Service Plans (ISP’s used by the facility to communicate changes of condition) dated 03/01/25 through 03/31/25 were reviewed.

The following change of condition lacked what actions or interventions was needed and the action or intervention communicated to staff on each shift:

Hospice RN documented on a coordination of care note the resident had a right heel wound measuring approximately 2.5 cm X 2 cm.

During an interview with Staff 35 (RN) on 03/31/25 at 5:00 pm it was reported “we don’t have any skin monitoring notes or an ISP...”.

The need to ensure the facility identified changes of condition, determined what actions or interventions were needed, communicated the action or intervention to staff on each shift and documented weekly progress in the residents’ record until the condition resolved was discussed with Staff 17 (ED), Staff 35 (RN) and Witness 2 (RCD sister community) on 04/01/25 at 11:00 am. They acknowledged the findings.

3. Resident 16 moved into the assisted living community in 04/2020 with diagnoses including Type 2 diabetes mellitus, unspecified psychosis and major depressive disorder.

Observations of the resident, interviews with staff and the resident, review of observation notes (the facility’s tool for charting on a resident’s condition) and Interim Service Plans (ISP’s used by the facility to communicate changes of condition) dated 03/01/25 through 03/31/25 were reviewed.

The facility failed to communicate changes of condition to staff on each shift and monitor the condition through resolution for the following changes of condition:

* Missed medications including insulin for diabetes management, eliquis for atrial fibrillation, furosemide for hypertension, and multiple psychotropic medications on 03/11/25 and 03/22/25; and
* Behavioral symptoms and expressions on 03/11/25.

The need to ensure the facility identified changes of condition, determined what actions or interventions were needed, communicated the action or intervention to staff on each shift and documented weekly progress in the residents’ record until the condition resolved was discussed with Staff 17 (ED), Staff 35 (RN) and Witness 2 (RCD sister community) on 04/01/25 at 11:00 am. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, for 2 of 2 sampled residents (#s 1 and 4) who experienced significant changes of condition. Findings include, but are not limited to:



1.Resident 1 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes mellitus, and cerebrovascular accident (stroke).



Physician orders dated 04/11/24 and 06/26/24 revealed the following:



* Admit to hospice; and

* Change to puree diet.



There was no documented evidence a significant change of condition assessment was completed by an RN, including findings, resident status, and interventions made as a result of the assessment.



The need to ensure an RN assessed all significant changes of condition, including findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (Administrator) and Staff 2 (RN) at 4:00 pm on 09/19/24. They acknowledged the findings.



2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, chronic obstructive pulmonary disease and congestive heart failure.



The resident's clinical record was reviewed, including weight records dated 03/01/24 through 09/17/24, service plan dated 12/01/23, and progress notes dated 06/17/24 through 09/17/24. The resident was observed and interviews with staff and the resident were conducted.



a. Review of weight records revealed the following:



* 05/15/24 - 212 pounds; and

* 09/04/24 - 236 pounds.



This constituted a severe weight gain of 24 pounds, or 11.3%, in six months.



There was no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN.



During an interview on 09/19/24 at 3:50 pm, Staff 2 (RN) stated he was not aware of the resident’s weight increase.



During interviews with medication technicians and caregivers on 09/18/24 and 09/19/24, staff stated the resident had not had a change in the amount of food s/he was eating over the past six months. They stated they were unaware of the resident’s diagnosis of congestive heart failure and had not been monitoring the resident for swelling or edema. They noted that s/he does use continuous oxygen to assist with her/his shortness of breath and were not aware of any changes in breathing in the past six months.



At the survey team’s request, the resident was weighed on 09/19/24 and weighed 213 pounds.



b. Resident 4 experienced a significant decline and was admitted to hospice on 08/16/24.



There was no documented evidence a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment, was completed by an RN.



The need to ensure a significant change of condition assessment was completed and documented by the RN, including findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (Administrator) and Staff 2 (RN) at 4:00 pm on 09/19/24. They acknowledged the findings, and no additional information was provided.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 5) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:



According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task.



During the acuity interview on 09/17/24, Staff 1 (Administrator) and Staff 2 (RN) identified nine residents who were administered insulin injections from unlicensed staff, including Resident 5, who was identified as receiving sliding scale insulin.



Resident 5 moved into the memory care community in 09/2021 with diagnoses including right and left lower extremity amputation and Type 2 diabetes.



Resident 5's MARs, reviewed from 09/01/24 through 09/16/24, revealed the resident received Lantus Solostar injections (insulin for diabetes) twice daily and Humalog injections (insulin for diabetes) three times daily as needed based on blood sugar result. The insulin had been administered by Staff 9 (Med Aid/CG), Staff 13 (Med Aid/CG), Staff 15 (Med Aid/CG) and Staff 16 (Med Aid/CG) on multiple occasions.



Review of delegation records and the MAR, showed the following:



RN assessment, dated 06/03/24, indicated that Resident 5's diabetes condition included irregular readings, with readings greater than 400 and as low as 53. The assessment stated care staff would be instructed in providing insulin injections to the resident. There was no documentation of the resident’s condition being stable or predictable;

There was no documentation of the rationale for the frequency for reassessing the resident's condition based on the resident's needs;

The initial evaluation for Staff 9, 13, 15, and 16’s skills and ability was completed on 07/16/24, 06/12/24, 06/04/24 and 06/04/24. However, there was no documentation of the rationale for deciding the task could be safely delegated to Staff 9, 13, 15 and 16; and

Additionally, Staff 9, 13, 15 and 16 lacked documentations of the rationale for the frequency for supervising and reevaluating the unlicensed person based on the unlicensed person's skills and abilities.



During the survey on 09/18/24 at 4:30 pm, Staff 2 was directed to assess Resident 5’s diabetes condition and ability to be delegated.



On 09/20/24 at 9:30 am, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Administrator) and Staff 14 (Senior Executive Director). They acknowledged the findings.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

(1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure staff were informed of new interventions, adjust the service plan if necessary and ensure reporting protocols were in place for 2 of 4 sampled residents (#'s 3 and 4) who received outside services. Findings include, but are not limited to:



1. Resident 3 was admitted to the facility in 08/2024 with diagnoses including hypertension and history of cerebrovascular accident with right sided weakness.



Resident 3’s progress notes, dated 08/16/24 through 09/17/24, were reviewed, as well as all outside provider communications. The following was identified:



a. The facility did not have documentation of coordinating care with hospice care providers, including receiving potential recommendations and informing staff of new interventions, on the following dates:



* 08/20/24 - Social worker;

* 08/20/24 - RN;

* 08/22/24 - Aide;

* 08/23/24 - RN;

* 08/26/24 – Social Worker;

* 08/27/24 – RN;

* 09/01/24 – RN

* 09/03/24 – Social Worker;

* 09/12/24 – Aide;

* 09/13/24 – RN;

* 09/16/24 – Social Worker; and

* 09/16/24 – Aide.



In an interview with Staff 1 (Administrator) on 09/19/24, she stated the facility had a system for outside providers to leave notes but that they were not consistently reviewed by staff.



The need to coordinate care with outside providers and ensure staff were informed of new interventions if necessary was discussed with Staff 1 (Administrator) and Staff 14 (Senior Executive Director) at 9:45 on 09/20/24. They acknowledged the findings.





2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, chronic obstructive pulmonary disease and congestive heart failure.



Resident 4’s progress notes, dated 03/17/24 through 09/17/24, were reviewed, as well as all outside provider communications. The following was identified:



a. The facility did not have documentation of coordinating care with hospice care providers, including receiving potential recommendations and informing staff of new interventions, on the following dates:



* 08/19/24 – Social Worker;

* 08/20/24 – RN;

* 08/22/24 – Aide;

* 08/23/24 – RN;

* 08/26/24 – Social Worker;

* 08/27/24 – RN;

* 08/29/24 – RN;

* 09/01/24 – RN;

* 09/03/24 – Social Worker;

* 09/03/24 – RN;

* 09/05/24 – Social Worker;

* 09/06/24 – RN;

* 09/09/24 – RN;

* 09/11/24 – Social Worker;

* 09/12/24 – Aide; and

* 09/12/24 – RN.



The need to coordinate care with outside providers and ensure staff were informed of new interventions if necessary was discussed with Staff 1 (Administrator) and Staff 14 (Senior Executive Director) at 9:45 on 09/20/24. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc

(2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs.

This Rule is not met as evidenced by:

Based on observation, interview, and record review it was determined that the facility failed to ensure they had established and maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment including protocols to prevent the development and transmission of communicable diseases, and failed to establish and maintain effective infection prevention and control protocols for 1 of 1 sampled resident (# 1) while performing ADL care. Findings include, but are not limited to:



a. On 09/17/24 the survey team requested a copy of the facility's infection prevention and control protocols. In an interview with Staff 1 (Administrator) on 09/17/24 at 10:15 am it was confirmed that the facility did not have any written policy around infection control protocols to prevent the development and transmission of communicable diseases including Norovirus and other gastrointestinal outbreaks.



b. Resident 1 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes mellitus, and cerebrovascular accident (stroke).



Observations of the resident and interviews with staff from 09/17/24 through 09/18/24 revealed Resident 1 relied on two staff for incontinence care needs.



On 09/18/24 at 1:25 pm, Staff 4 (CG) and Staff 7 (CG) provided ADL incontinence care for Resident 1. Staff 4 and 7 donned gloves prior to providing incontinence care. Staff 4 removed the resident's soiled brief and performed perineal care without doffing soiled gloves. Staff 4 then placed a pillow between the resident’s knees, placed two blankets on the resident and held the resident’s water bottle while the resident sipped her/his water all while wearing the same gloves. Staff 7 was observed to doff gloves with no hand hygiene.



The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment including protocols to prevent the development and transmission of communicable diseases including gastrointestinal outbreaks and maintain effective infection prevention and control protocols while performing ADL care was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. They acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure staff practiced appropriate infection control procedures related to ADL care, used incontinence products, and processing of soiled laundry for 1 of 1 sampled resident (# 12) while performing ADL care and facility wide soiled laundry. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 05/2021 with diagnoses including bipolar disorder.

a. Observations of the resident and interviews with staff from 01/13/25 through 01/15/25 revealed Resident 9 required two staff assistance for incontinence care. The resident needed full support while standing at a transfer pole. The staff supported the resident on each side and reminded him/her to stand as straight as s/he could. The resident was not able to stand fully straight and would begin to fold into a sitting position the longer s/he was expected to stand.

On 01/14/25 at 9:23 am, Staff 24 (CG/MT) and Staff 26 (CG) provided ADL care including incontinence care for the resident. Staff 24 and 26 donned gloves prior to providing the resident care. Staff 24 and Staff 26 removed the resident's soiled brief and Staff 24 wiped the resident’s bottom numerous times to provide perineal care and get the resident clean. The used wipes, which were visibly soiled, were stacked on top of the resident’s brief which was also visibly soiled. The brief was placed on top of the pad on the resident’s bed. There were no trash bags in the room, Staff 26 left the room with the brief and pile of used wipes in her gloved hands. The brief was carried, unbagged, out the door and through two hallways to the garbage can. Staff 25 stepped in to assist with the resident while Staff 26 was out of the room. Staff 24 did not remove her soiled gloves prior to touching the clean brief and the resident’s clean pants. Staff 24 changed her gloves prior to completing the next part of the resident’s transfer needs.

The staff were reminded by the surveyor that gloves must be changed between clean and dirty tasks. In addition, staff were reminded soiled items must be bagged prior to being transported out of the apartment.

b. Observations of the three facility laundry rooms on 01/13/25, showed there was no soiled linen receptacle.

Interviews with multiple facility staff on 01/13/25, between 09:30 am and 2:30 pm, showed the following:

Staff 4 and Staff 26 (CGs) indicated there was no bin to place soiled items into when taken to the laundry rooms. The staff both indicated when the resident had soiled items, they were put directly on top of whatever was in a residents’ laundry basket and taken to the laundry room to be washed. The staff indicated if they could not get the laundry put into a machine right away, they would leave the basket and all items in the laundry room. The staff indicated if something was significantly soiled, they would throw it away.

Staff 21, 22, 23 (CGs) confirmed there was no bin or container to place soiled items into in the laundry room. The staff stated soiled resident items were put into their individual hampers and taken to the laundry room for washing. The staff indicated they did not separately bag soiled items. Staff 23 indicated if the soilage was “really bad” then she would bag it before putting it in the resident’s laundry hamper.

Staff 19 and Staff 24 (CG/MTs) indicated there was no place to put soiled items in the laundry room. The goal was always to get the soiled items directly into the wash as soon as possible. The staff both indicated when there were soiled items, they bagged them and took them separately to the laundry room. Staff 19 and Staff 24 both indicated they would place the bagged items on the floor in the laundry room until a machine was available. Staff 19 stated if something was significantly soiled, she may toss it in the outside garbage and get the item replaced for the resident. Staff 24 indicated she would wash several bags of soiled items, from multiple residents, together if there were multiple bags of items waiting to be washed.

Staff 5 (Housekeeping) indicated she would bag soiled items before taking them to the laundry room. In the event a machine was not available she would leave the items in the laundry room, most likely on the floor. Staff 5 stated there wasn’t anywhere else to put the soiled items. She further indicated if items were badly soiled, she would bag and throw them away.

The need to ensure facility staff utilized appropriate infection control practices during incontinence care, and that staff handled soiled items, including laundry, within infection control standards was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/14/25. The staff acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure staff practiced appropriate infection control procedures related to ADL care, used incontinence products, and processing of soiled laundry for 1 of 1 sampled resident (# 12) while performing ADL care and facility wide soiled laundry. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 05/2021 with diagnoses including bipolar disorder.

a. Observations of the resident and interviews with staff from 01/13/25 through 01/15/25 revealed Resident 9 required two staff assistance for incontinence care. The resident needed full support while standing at a transfer pole. The staff supported the resident on each side and reminded him/her to stand as straight as s/he could. The resident was not able to stand fully straight and would begin to fold into a sitting position the longer s/he was expected to stand.

On 01/14/25 at 9:23 am, Staff 24 (CG/MT) and Staff 26 (CG) provided ADL care including incontinence care for the resident. Staff 24 and 26 donned gloves prior to providing the resident care. Staff 24 and Staff 26 removed the resident's soiled brief and Staff 24 wiped the resident’s bottom numerous times to provide perineal care and get the resident clean. The used wipes, which were visibly soiled, were stacked on top of the resident’s brief which was also visibly soiled. The brief was placed on top of the pad on the resident’s bed. There were no trash bags in the room, Staff 26 left the room with the brief and pile of used wipes in her gloved hands. The brief was carried, unbagged, out the door and through two hallways to the garbage can. Staff 25 stepped in to assist with the resident while Staff 26 was out of the room. Staff 24 did not remove her soiled gloves prior to touching the clean brief and the resident’s clean pants. Staff 24 changed her gloves prior to completing the next part of the resident’s transfer needs.

The staff were reminded by the surveyor that gloves must be changed between clean and dirty tasks. In addition, staff were reminded soiled items must be bagged prior to being transported out of the apartment.

b. Observations of the three facility laundry rooms on 01/13/25, showed there was no soiled linen receptacle.

Interviews with multiple facility staff on 01/13/25, between 09:30 am and 2:30 pm, showed the following:

Staff 4 and Staff 26 (CGs) indicated there was no bin to place soiled items into when taken to the laundry rooms. The staff both indicated when the resident had soiled items, they were put directly on top of whatever was in a residents’ laundry basket and taken to the laundry room to be washed. The staff indicated if they could not get the laundry put into a machine right away, they would leave the basket and all items in the laundry room. The staff indicated if something was significantly soiled, they would throw it away.

Staff 21, 22, 23 (CGs) confirmed there was no bin or container to place soiled items into in the laundry room. The staff stated soiled resident items were put into their individual hampers and taken to the laundry room for washing. The staff indicated they did not separately bag soiled items. Staff 23 indicated if the soilage was “really bad” then she would bag it before putting it in the resident’s laundry hamper.

Staff 19 and Staff 24 (CG/MTs) indicated there was no place to put soiled items in the laundry room. The goal was always to get the soiled items directly into the wash as soon as possible. The staff both indicated when there were soiled items, they bagged them and took them separately to the laundry room. Staff 19 and Staff 24 both indicated they would place the bagged items on the floor in the laundry room until a machine was available. Staff 19 stated if something was significantly soiled, she may toss it in the outside garbage and get the item replaced for the resident. Staff 24 indicated she would wash several bags of soiled items, from multiple residents, together if there were multiple bags of items waiting to be washed.

Staff 5 (Housekeeping) indicated she would bag soiled items before taking them to the laundry room. In the event a machine was not available she would leave the items in the laundry room, most likely on the floor. Staff 5 stated there wasn’t anywhere else to put the soiled items. She further indicated if items were badly soiled, she would bag and throw them away.

The need to ensure facility staff utilized appropriate infection control practices during incontinence care, and that staff handled soiled items, including laundry, within infection control standards was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/14/25. The staff acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure staff practiced appropriate infection control procedures related to ADL care, used incontinence products, and processing of soiled laundry for 1 of 1 sampled resident (# 12) while performing ADL care and facility wide soiled laundry. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 05/2021 with diagnoses including bipolar disorder.

a. Observations of the resident and interviews with staff from 01/13/25 through 01/15/25 revealed Resident 9 required two staff assistance for incontinence care. The resident needed full support while standing at a transfer pole. The staff supported the resident on each side and reminded him/her to stand as straight as s/he could. The resident was not able to stand fully straight and would begin to fold into a sitting position the longer s/he was expected to stand.

On 01/14/25 at 9:23 am, Staff 24 (CG/MT) and Staff 26 (CG) provided ADL care including incontinence care for the resident. Staff 24 and 26 donned gloves prior to providing the resident care. Staff 24 and Staff 26 removed the resident's soiled brief and Staff 24 wiped the resident’s bottom numerous times to provide perineal care and get the resident clean. The used wipes, which were visibly soiled, were stacked on top of the resident’s brief which was also visibly soiled. The brief was placed on top of the pad on the resident’s bed. There were no trash bags in the room, Staff 26 left the room with the brief and pile of used wipes in her gloved hands. The brief was carried, unbagged, out the door and through two hallways to the garbage can. Staff 25 stepped in to assist with the resident while Staff 26 was out of the room. Staff 24 did not remove her soiled gloves prior to touching the clean brief and the resident’s clean pants. Staff 24 changed her gloves prior to completing the next part of the resident’s transfer needs.

The staff were reminded by the surveyor that gloves must be changed between clean and dirty tasks. In addition, staff were reminded soiled items must be bagged prior to being transported out of the apartment.

b. Observations of the three facility laundry rooms on 01/13/25, showed there was no soiled linen receptacle.

Interviews with multiple facility staff on 01/13/25, between 09:30 am and 2:30 pm, showed the following:

Staff 4 and Staff 26 (CGs) indicated there was no bin to place soiled items into when taken to the laundry rooms. The staff both indicated when the resident had soiled items, they were put directly on top of whatever was in a residents’ laundry basket and taken to the laundry room to be washed. The staff indicated if they could not get the laundry put into a machine right away, they would leave the basket and all items in the laundry room. The staff indicated if something was significantly soiled, they would throw it away.

Staff 21, 22, 23 (CGs) confirmed there was no bin or container to place soiled items into in the laundry room. The staff stated soiled resident items were put into their individual hampers and taken to the laundry room for washing. The staff indicated they did not separately bag soiled items. Staff 23 indicated if the soilage was “really bad” then she would bag it before putting it in the resident’s laundry hamper.

Staff 19 and Staff 24 (CG/MTs) indicated there was no place to put soiled items in the laundry room. The goal was always to get the soiled items directly into the wash as soon as possible. The staff both indicated when there were soiled items, they bagged them and took them separately to the laundry room. Staff 19 and Staff 24 both indicated they would place the bagged items on the floor in the laundry room until a machine was available. Staff 19 stated if something was significantly soiled, she may toss it in the outside garbage and get the item replaced for the resident. Staff 24 indicated she would wash several bags of soiled items, from multiple residents, together if there were multiple bags of items waiting to be washed.

Staff 5 (Housekeeping) indicated she would bag soiled items before taking them to the laundry room. In the event a machine was not available she would leave the items in the laundry room, most likely on the floor. Staff 5 stated there wasn’t anywhere else to put the soiled items. She further indicated if items were badly soiled, she would bag and throw them away.

The need to ensure facility staff utilized appropriate infection control practices during incontinence care, and that staff handled soiled items, including laundry, within infection control standards was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/14/25. The staff acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure staff practiced appropriate infection control procedures related to ADL care, used incontinence products, and processing of soiled laundry for 1 of 1 sampled resident (# 12) while performing ADL care and facility wide soiled laundry. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 05/2021 with diagnoses including bipolar disorder.

a. Observations of the resident and interviews with staff from 01/13/25 through 01/15/25 revealed Resident 9 required two staff assistance for incontinence care. The resident needed full support while standing at a transfer pole. The staff supported the resident on each side and reminded him/her to stand as straight as s/he could. The resident was not able to stand fully straight and would begin to fold into a sitting position the longer s/he was expected to stand.

On 01/14/25 at 9:23 am, Staff 24 (CG/MT) and Staff 26 (CG) provided ADL care including incontinence care for the resident. Staff 24 and 26 donned gloves prior to providing the resident care. Staff 24 and Staff 26 removed the resident's soiled brief and Staff 24 wiped the resident’s bottom numerous times to provide perineal care and get the resident clean. The used wipes, which were visibly soiled, were stacked on top of the resident’s brief which was also visibly soiled. The brief was placed on top of the pad on the resident’s bed. There were no trash bags in the room, Staff 26 left the room with the brief and pile of used wipes in her gloved hands. The brief was carried, unbagged, out the door and through two hallways to the garbage can. Staff 25 stepped in to assist with the resident while Staff 26 was out of the room. Staff 24 did not remove her soiled gloves prior to touching the clean brief and the resident’s clean pants. Staff 24 changed her gloves prior to completing the next part of the resident’s transfer needs.

The staff were reminded by the surveyor that gloves must be changed between clean and dirty tasks. In addition, staff were reminded soiled items must be bagged prior to being transported out of the apartment.

b. Observations of the three facility laundry rooms on 01/13/25, showed there was no soiled linen receptacle.

Interviews with multiple facility staff on 01/13/25, between 09:30 am and 2:30 pm, showed the following:

Staff 4 and Staff 26 (CGs) indicated there was no bin to place soiled items into when taken to the laundry rooms. The staff both indicated when the resident had soiled items, they were put directly on top of whatever was in a residents’ laundry basket and taken to the laundry room to be washed. The staff indicated if they could not get the laundry put into a machine right away, they would leave the basket and all items in the laundry room. The staff indicated if something was significantly soiled, they would throw it away.

Staff 21, 22, 23 (CGs) confirmed there was no bin or container to place soiled items into in the laundry room. The staff stated soiled resident items were put into their individual hampers and taken to the laundry room for washing. The staff indicated they did not separately bag soiled items. Staff 23 indicated if the soilage was “really bad” then she would bag it before putting it in the resident’s laundry hamper.

Staff 19 and Staff 24 (CG/MTs) indicated there was no place to put soiled items in the laundry room. The goal was always to get the soiled items directly into the wash as soon as possible. The staff both indicated when there were soiled items, they bagged them and took them separately to the laundry room. Staff 19 and Staff 24 both indicated they would place the bagged items on the floor in the laundry room until a machine was available. Staff 19 stated if something was significantly soiled, she may toss it in the outside garbage and get the item replaced for the resident. Staff 24 indicated she would wash several bags of soiled items, from multiple residents, together if there were multiple bags of items waiting to be washed.

Staff 5 (Housekeeping) indicated she would bag soiled items before taking them to the laundry room. In the event a machine was not available she would leave the items in the laundry room, most likely on the floor. Staff 5 stated there wasn’t anywhere else to put the soiled items. She further indicated if items were badly soiled, she would bag and throw them away.

The need to ensure facility staff utilized appropriate infection control practices during incontinence care, and that staff handled soiled items, including laundry, within infection control standards was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/14/25. The staff acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to designate an individual to be the facility' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. This is a repeat citation. Findings include but are not limited to:

During an interview with Staff 17 (ED) on 03/31/25 at 4:06 pm, the facility did not currently have an Infection Control Specialist who had completed the required specialized, Department-approved training in infection control prevention and control protocols.

The need to ensure the facility had a designated Infection Control Specialist who had completed all required training was discussed with Staff 17 on 03/31/25 at 4:06 pm. She acknowledged the findings.

Based on 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:



1.Resident 5 moved into the facility in 09/2021 with diagnoses including right and left lower extremity amputation and Type 2 diabetes.



During the acuity interview on 09/17/24, Resident 5 was identified to be administered insulin injections by non-licensed staff.



a. Review of the resident’s 09/01/24 – 09/16/24 MAR and delegation record showed the following:



The resident was prescribed Lantus Solostar (insulin to treat diabetes) twice daily and Humalog (short-acting insulin) on a sliding scale (a method of adjusting the insulin dose based on blood sugar levels) three times daily before meals;

The MAR showed on 42 occasions that there was no blood sugar result to determine the Humalog dose before administering the insulin to the resident; and

The delegation record indicated rotating the insulin injection site to prevent tissue damage and instructing staff to choose a different site. However, the injection site was not documented when staff administered insulin to the resident. Therefore, there was no documented evidence staff chose a different insulin injection site as directed.



The need to ensure a safe medication and treatment system was discussed with Staff 1 (Administrator) and Staff 14 (Senior Executive Director) at 9:45 AM on 09/20/24. They acknowledged the findings.



2. Refer to:



C 282: RN Delegation and Teaching;

C 302: Systems: Tracking Controlled Substances

C 303: Systems: Medication and Treatment Orders;

C 305: Systems: Resident Right to Refuse;

C 310: Systems: Medication Administration; and

C 325: Systems: Self-Administration of Medications.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

(1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#4) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:



Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, chronic obstructive pulmonary disease and congestive heart failure.



The resident's physician orders, the Controlled Substance Disposition logs and the MAR, dated 09/01/23 through 09/16/24, were reviewed.



Resident 4 had physician orders for the following controlled medications:



* Tramadol 50 mg – Take one tablet by mouth every eight hours as needed for pain.



On the following dates, the Controlled Substance Disposition log showed that the medication had been administered, though the MAR did not have any documentation of the medication being given to the resident:



*09/09/24 at 5:00 am;

*09/09/24 at 5:00 pm; and

*09/10/24 at 1:45 pm.



During an interview on 09/19/24 at 2:30 pm, Staff 13 (Med Aid/CG) and Staff 1 (Administrator), acknowledged there were currently two separate log books and two medication cards for this medication, and there was no instruction to Medication Aids on which book or card to use. Staff 1 and Staff 13 were unable to describe why multiple cards and log books were being used for the same medication.



The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 and Staff 14 (Senior Executive Director) at 9:45 am on 09/20/24. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

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



1. Resident 3 was admitted to the facility in 08/2024 with diagnoses including hypertension and history of cerebrovascular accident (stroke) with right sided weakness.



Resident 3's MAR dated 09/01/24 through 09/16/24 and physician orders were reviewed.



As of survey entrance on 09/17/24, there were no written signed physician orders in Resident 3's chart for the following medications:



* Tramadol 50 mg (for pain) – One tablet every four hours as needed; and

* Sertraline 25 mg (for depression) – One tablet with evening meal.



During an interview with Staff 1 (Administrator) on 09/18/24, she confirmed that she could not located a written signed physician order for the above medications and would reach out to hospice to ensure a copy was included in the resident’s record.



The need to ensure written signed physician orders were documented in the resident's record for all medications administered by the facility was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:45 am on 09/20/24. They acknowledged the findings.



2. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, chronic obstructive pulmonary disease and congestive heart failure.



Resident 4's MAR dated 09/01/24 through 09/16/24 and most recent written signed physician orders, dated 04/04/24, were reviewed.



a. As of survey entrance on 09/17/24, there were no signed physician orders in Resident 4's chart for the following medications and/or treatments which were being administered:



* Lorazepam 0.5 mg as needed (for anxiety);

* Morphine 100 mg/5 ml as needed (for shortness of breath or pain);

* Haloperidol 2 mg/ml as needed (for agitation or nausea);

* Risperidone 0.5 mg twice per day (for hallucinations);

* Sulfamethoxazole-Trimethoprim 800-160 mg twice per day (for urinary tract infection); and

* Oxygen 2L/minute (for chronic obstructive pulmonary disease).



b. The resident had an order for ferosul 325 mg (for iron deficiency), to be taken by mouth every morning with breakfast.



According to the MAR, staff documented on multiple occasions between 09/02/24 and 09/12/24 that the medication was not available. However, there were also multiple occasions that staff initialed that the medication was administered during the same time period. Staff interviewed were unable to confirm whether or not the medication was available or administered to the resident during this time period.



The need to ensure written signed physician orders were documented in the resident's record for all medications and treatments administered by the facility and all orders were carried out as prescribed was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:45 am on 09/20/24. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 4 of 7 sampled residents (#s 7, 8, 11, and 13) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

Review of the resident's 12/19/24 through 01/13/25 MARs, current orders, and observation notes revealed the following:

* Resident 7's physician included a parameter for his/her scheduled Metformin (for diabetes) to "give with meals.” The resident was administered the 5:00 pm dose of Metformin on 12/28/24 and 01/01/25 with documentation that the resident "refused dinner" both evenings.

* Resident 7 was not administered the following medications during the evening med pass on 12/24/24 as s/he was "out with family:”

- Atorvastatin calcium (for high cholesterol);
- Tamsulosin (for an enlarged prostate);
- Quetiapine (for behaviors) twice;
- Metformin;
- Acetaminophen (for pain); and
- Voltarin gel (for pain).

* The resident was not administered the following medications during the night med pass on 12/31/24 as s/he was "out with family:”

- Quetiapine; and
- Voltarin gel.

On 01/15/25 at 1:30 pm, Staff 17 (ED) confirmed the facility did not have a policy in place for sending medications with residents when they were out of the community.

The need to ensure physician orders were followed as prescribed was discussed with Staff 2 (RN), Staff 17, Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

2. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

Review of the resident's 12/19/24 through 01/13/25 MARs, current orders, and observation notes revealed the following medications were not administered as the facility did not have the medication or the resident was sleeping:

* Morphine (for pain): Nine times;
* Aspirin (for heart health): Once; and
* Trintellix (for depression): Once.

The need to ensure physician orders were followed as prescribed was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

3. Resident 13 was admitted to the facility in 11/2021 with diagnoses including insulin dependent diabetes.

The resident's 12/19/24 through 01/14/25 physician communications, 11/26/24 signed physician orders, and the 12/19/24 through 01/14/25 MAR/TAR were reviewed.

The 12/19/24 through 01/14/25 MAR/TARs showed the following:

* Novolog Flexpen 100 units/ml, sliding scale dosage as follows: blood glucose 100-129 inject 10 units, 130-150 inject 15 units, for blood glucose 151 and above inject 15 units plus 2 units for every 50 points of blood glucose above 151, twice daily.

12/19/24 through 12/31/24:

* On 20 occasions there was no documentation of the resident’s blood sugar level to determine what dosage of insulin was required, no injection site was noted, and the number of units of insulin given was not documented.

* On 12/19/24 a dose of 17 units of insulin was recorded on the MAR as administered. Based on the resident’s recorded blood sugar, 15 units should have been given.

01/01/25 through 01/14/25:

* On 24 occasions there was no documentation of the resident’s blood sugar level to determine what dosage of insulin was required, no injection site was noted, and the number of units of insulin given was not documented.

The need to ensure blood sugar levels were documented prior to administering sliding scale insulin and that dosages were accurately administered as ordered, was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/14/25. The staff acknowledged the findings.

4. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes, hypertension, and atrial fibrillation.

Review of the resident’s current signed physician orders, dated 12/23/24, the MAR from 12/01/24 through 01/13/25, and observation notes, dated from 12/19/24 to 01/13/25, showed the following:

* The physician ordered Clonidon 0.1 mg to be administered every eight hours for high blood pressure. However, the MAR showed that the medication was administered every 12 hours instead of the prescribed eight-hour schedule.

* The physician ordered to hold the Clonidine and Lisinopril for hypertension when the systolic (top number) pressure was below 100 or the diastolic (bottom number) was below 50. However, the MAR showed on 12/19/24, with a blood pressure of 114/49, and on 12/25/24, with a blood pressure of 154/47, the medications were administered when they should have been withheld.

* The physician ordered any blood glucose (BG) results greater than 350 be reported. However, the MAR sowed the resident had a BG of 413 on 01/06/25, a BG of 354 on 01/07/25, and a BG of 372 on 01/08/25. There was no documented evidence that these results were reported to the physician as prescribed.

* The physician prescribed insulin administration according to the following blood glucose levels (BG): Two units for a BG of 201-250, five units for a BG of 351-400, and six units for a BG of 410 or greater. However, the MAR show the following discrepancies:

- On 01/06/25, with a BG of 413, four units of insulin were administered, instead of the prescribed six units;
- On 01/07/25, with a BG of 354, four units of insulin were administered instead of the prescribed five units; and
- On 01/09/25, with a BG of 214, four units of insulin were administered, when only two units should have been given as prescribed.

* The physician ordered Glutose 40 % to be administered when the resident’s blood glucose (BG) level was less than 65. On three occasions, 12/27/24 (BG of 51), 12/31/24 (BG of 53), and 01/01/25 (BG of 42) the MAR showed that the medication was not administered, despite the order indicating that it should have been given in such cases.

* The physician ordered Incruse Ellipta 62.5 mg inhaler to be administered daily. However, the MAR showed the inhaler was not administered, with the notes indicating “na” or “not on noc [night shift].”

* The physician ordered to apply Lidocaine 5 % for 12 hours on and then off for 12 hours. However, the MAR showed the medication was placed on hold without a clear physician’s order explaining the reason.

On 01/14/25 at 4:30 pm, the physician orders and the MARs were reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 4 of 7 sampled residents (#s 7, 8, 11, and 13) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

Review of the resident's 12/19/24 through 01/13/25 MARs, current orders, and observation notes revealed the following:

* Resident 7's physician included a parameter for his/her scheduled Metformin (for diabetes) to "give with meals.” The resident was administered the 5:00 pm dose of Metformin on 12/28/24 and 01/01/25 with documentation that the resident "refused dinner" both evenings.

* Resident 7 was not administered the following medications during the evening med pass on 12/24/24 as s/he was "out with family:”

Atorvastatin calcium (for high cholesterol);
Tamsulosin (for an enlarged prostate);
Quetiapine (for behaviors) twice;
Metformin;
Acetaminophen (for pain); and
Voltarin gel (for pain).

* The resident was not administered the following medications during the night med pass on 12/31/24 as s/he was "out with family:”

Quetiapine; and
Voltarin gel.

On 01/15/25 at 1:30 pm, Staff 17 (ED) confirmed the facility did not have a policy in place for sending medications with residents when they were out of the community.

The need to ensure physician orders were followed as prescribed was discussed with Staff 2 (RN), Staff 17, Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

2. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

Review of the resident's 12/19/24 through 01/13/25 MARs, current orders, and observation notes revealed the following medications were not administered as the facility did not have the medication or the resident was sleeping:

* Morphine (for pain): Nine times;
* Aspirin (for heart health): Once; and
* Trintellix (for depression): Once.

The need to ensure physician orders were followed as prescribed was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

2. Resident 13 was admitted to the facility in 11/2021 with diagnoses including insulin dependent diabetes.

The resident's 12/19/24 through 01/14/25 physician communications, 11/26/24 signed physician orders, and the 12/19/24 through 01/14/25 MAR/TAR were reviewed.

The 12/19/24 through 01/14/25 MAR/TARs showed the following:

* Novolog Flexpen 100 units/ml, sliding scale dosage as follows: blood glucose 100-129 inject 10 units, 130-150 inject 15 units, for blood glucose 151 and above inject 15 units plus 2 units for every 50 points of blood glucose above 151, twice daily.

12/19/24 through 12/31/24:

* On 20 occasions there was no documentation of the resident’s blood sugar level to determine what dosage of insulin was required, no injection site was noted, and the number of units of insulin given was not documented.

* On 12/19/24 a dose of 17 units of insulin was recorded on the MAR as administered. Based on the resident’s recorded blood sugar, 15 units should have been given.

01/01/25 through 01/14/25:

On 24 occasions there was no documentation of the resident’s blood sugar level to determine what dosage of insulin was required, no injection site was noted, and the number of units of insulin given was not documented.

The need to ensure blood sugar levels were documented prior to administering sliding scale insulin and that dosages were accurately administered as ordered, was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/14/25. The staff acknowledged the findings.

3. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes, hypertension, and atrial fibrillation.

Review of the resident’s current signed physician orders, dated 12/23/24, the MAR from 12/01/24 through 01/13/25, and observation notes, dated from 12/19/24 to 01/13/25, showed the following:

* The physician ordered Clonidon 0.1 mg to be administered every eight hours for high blood pressure. However, the MAR showed that the medication was administered every 12 hours instead of the prescribed eight-hour schedule.

* The physician ordered to hold the Clonidine and Lisinopril for hypertension when the systolic (top number) pressure was below 100 or the diastolic (bottom number) was below 50. However, the MAR showed on 12/19/24, with a blood pressure of 114/49, and on 12/25/24, with a blood pressure of 154/47, the medications were administered when they should have been withheld.

* The physician ordered any blood glucose (BG) results greater than 350 be reported. However, the MAR sowed the resident had a BG of 413 on 01/06/25, a BG of 354 on 01/07/25, and a BG of 372 on 01/08/25. There was no documented evidence that these results were reported to the physician as prescribed.

* The physician prescribed insulin administration according to the following blood glucose levels (BG): Two units for a BG of 201-250, five units for a BG of 351-400, and six units for a BG of 410 or greater. However, the MAR show the following discrepancies:

- On 01/06/25, with a BG of 413, four units of insulin were administered, instead of the prescribed six units;
- On 01/07/25, with a BG of 354, four units of insulin were administered instead of the prescribed five units; and
- On 01/09/25, with a BG of 214, four units of insulin were administered, when only two units should have been given as prescribed.

* The physician ordered Glutose 40 % to be administered when the resident’s blood glucose (BG) level was less than 65. On three occasions, 12/27/24 (BG of 51), 12/31/24 (BG of 53), and 01/01/25 (BG of 42) the MAR showed that the medication was not administered, despite the order indicating that it should have been given in such cases.

* The physician ordered Increase Ellipta 62.5 mg inhaler to be administered daily. However, the MAR showed the inhaler was not administered, with the notes indicating “na” or “not on noc [night shift].”

* The physician ordered to apply Lidocaine 5 % for 12 hours on and then off for 12 hours. However, the MAR showed the medication was placed on hold without a clear physician’s order explaining the reason.

On 01/14/25 at 4:30 pm, the physician orders and the MARs were reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 4 of 7 sampled residents (#s 7, 8, 11, and 13) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

Review of the resident's 12/19/24 through 01/13/25 MARs, current orders, and observation notes revealed the following:

* Resident 7's physician included a parameter for his/her scheduled Metformin (for diabetes) to "give with meals.” The resident was administered the 5:00 pm dose of Metformin on 12/28/24 and 01/01/25 with documentation that the resident "refused dinner" both evenings.

* Resident 7 was not administered the following medications during the evening med pass on 12/24/24 as s/he was "out with family:”

- Atorvastatin calcium (for high cholesterol);
- Tamsulosin (for an enlarged prostate);
- Quetiapine (for behaviors) twice;
- Metformin;
- Acetaminophen (for pain); and
- Voltarin gel (for pain).

* The resident was not administered the following medications during the night med pass on 12/31/24 as s/he was "out with family:”

- Quetiapine; and
- Voltarin gel.

On 01/15/25 at 1:30 pm, Staff 17 (ED) confirmed the facility did not have a policy in place for sending medications with residents when they were out of the community.

The need to ensure physician orders were followed as prescribed was discussed with Staff 2 (RN), Staff 17, Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

2. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

Review of the resident's 12/19/24 through 01/13/25 MARs, current orders, and observation notes revealed the following medications were not administered as the facility did not have the medication or the resident was sleeping:

* Morphine (for pain): Nine times;
* Aspirin (for heart health): Once; and
* Trintellix (for depression): Once.

The need to ensure physician orders were followed as prescribed was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

3. Resident 13 was admitted to the facility in 11/2021 with diagnoses including insulin dependent diabetes.

The resident's 12/19/24 through 01/14/25 physician communications, 11/26/24 signed physician orders, and the 12/19/24 through 01/14/25 MAR/TAR were reviewed.

The 12/19/24 through 01/14/25 MAR/TARs showed the following:

* Novolog Flexpen 100 units/ml, sliding scale dosage as follows: blood glucose 100-129 inject 10 units, 130-150 inject 15 units, for blood glucose 151 and above inject 15 units plus 2 units for every 50 points of blood glucose above 151, twice daily.

12/19/24 through 12/31/24:

* On 20 occasions there was no documentation of the resident’s blood sugar level to determine what dosage of insulin was required, no injection site was noted, and the number of units of insulin given was not documented.

* On 12/19/24 a dose of 17 units of insulin was recorded on the MAR as administered. Based on the resident’s recorded blood sugar, 15 units should have been given.

01/01/25 through 01/14/25:

* On 24 occasions there was no documentation of the resident’s blood sugar level to determine what dosage of insulin was required, no injection site was noted, and the number of units of insulin given was not documented.

The need to ensure blood sugar levels were documented prior to administering sliding scale insulin and that dosages were accurately administered as ordered, was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/14/25. The staff acknowledged the findings.

4. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes, hypertension, and atrial fibrillation.

Review of the resident’s current signed physician orders, dated 12/23/24, the MAR from 12/01/24 through 01/13/25, and observation notes, dated from 12/19/24 to 01/13/25, showed the following:

* The physician ordered Clonidon 0.1 mg to be administered every eight hours for high blood pressure. However, the MAR showed that the medication was administered every 12 hours instead of the prescribed eight-hour schedule.

* The physician ordered to hold the Clonidine and Lisinopril for hypertension when the systolic (top number) pressure was below 100 or the diastolic (bottom number) was below 50. However, the MAR showed on 12/19/24, with a blood pressure of 114/49, and on 12/25/24, with a blood pressure of 154/47, the medications were administered when they should have been withheld.

* The physician ordered any blood glucose (BG) results greater than 350 be reported. However, the MAR sowed the resident had a BG of 413 on 01/06/25, a BG of 354 on 01/07/25, and a BG of 372 on 01/08/25. There was no documented evidence that these results were reported to the physician as prescribed.

* The physician prescribed insulin administration according to the following blood glucose levels (BG): Two units for a BG of 201-250, five units for a BG of 351-400, and six units for a BG of 410 or greater. However, the MAR show the following discrepancies:

- On 01/06/25, with a BG of 413, four units of insulin were administered, instead of the prescribed six units;
- On 01/07/25, with a BG of 354, four units of insulin were administered instead of the prescribed five units; and
- On 01/09/25, with a BG of 214, four units of insulin were administered, when only two units should have been given as prescribed.

* The physician ordered Glutose 40 % to be administered when the resident’s blood glucose (BG) level was less than 65. On three occasions, 12/27/24 (BG of 51), 12/31/24 (BG of 53), and 01/01/25 (BG of 42) the MAR showed that the medication was not administered, despite the order indicating that it should have been given in such cases.

* The physician ordered Incruse Ellipta 62.5 mg inhaler to be administered daily. However, the MAR showed the inhaler was not administered, with the notes indicating “na” or “not on noc [night shift].”

* The physician ordered to apply Lidocaine 5 % for 12 hours on and then off for 12 hours. However, the MAR showed the medication was placed on hold without a clear physician’s order explaining the reason.

On 01/14/25 at 4:30 pm, the physician orders and the MARs were reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 4 of 7 sampled residents (#s 7, 8, 11, and 13) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

Review of the resident's 12/19/24 through 01/13/25 MARs, current orders, and observation notes revealed the following:

* Resident 7's physician included a parameter for his/her scheduled Metformin (for diabetes) to "give with meals.” The resident was administered the 5:00 pm dose of Metformin on 12/28/24 and 01/01/25 with documentation that the resident "refused dinner" both evenings.

* Resident 7 was not administered the following medications during the evening med pass on 12/24/24 as s/he was "out with family:”

Atorvastatin calcium (for high cholesterol);
Tamsulosin (for an enlarged prostate);
Quetiapine (for behaviors) twice;
Metformin;
Acetaminophen (for pain); and
Voltarin gel (for pain).

* The resident was not administered the following medications during the night med pass on 12/31/24 as s/he was "out with family:”

Quetiapine; and
Voltarin gel.

On 01/15/25 at 1:30 pm, Staff 17 (ED) confirmed the facility did not have a policy in place for sending medications with residents when they were out of the community.

The need to ensure physician orders were followed as prescribed was discussed with Staff 2 (RN), Staff 17, Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

2. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

Review of the resident's 12/19/24 through 01/13/25 MARs, current orders, and observation notes revealed the following medications were not administered as the facility did not have the medication or the resident was sleeping:

* Morphine (for pain): Nine times;
* Aspirin (for heart health): Once; and
* Trintellix (for depression): Once.

The need to ensure physician orders were followed as prescribed was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

2. Resident 13 was admitted to the facility in 11/2021 with diagnoses including insulin dependent diabetes.

The resident's 12/19/24 through 01/14/25 physician communications, 11/26/24 signed physician orders, and the 12/19/24 through 01/14/25 MAR/TAR were reviewed.

The 12/19/24 through 01/14/25 MAR/TARs showed the following:

* Novolog Flexpen 100 units/ml, sliding scale dosage as follows: blood glucose 100-129 inject 10 units, 130-150 inject 15 units, for blood glucose 151 and above inject 15 units plus 2 units for every 50 points of blood glucose above 151, twice daily.

12/19/24 through 12/31/24:

* On 20 occasions there was no documentation of the resident’s blood sugar level to determine what dosage of insulin was required, no injection site was noted, and the number of units of insulin given was not documented.

* On 12/19/24 a dose of 17 units of insulin was recorded on the MAR as administered. Based on the resident’s recorded blood sugar, 15 units should have been given.

01/01/25 through 01/14/25:

On 24 occasions there was no documentation of the resident’s blood sugar level to determine what dosage of insulin was required, no injection site was noted, and the number of units of insulin given was not documented.

The need to ensure blood sugar levels were documented prior to administering sliding scale insulin and that dosages were accurately administered as ordered, was discussed with Staff 2 (RN), Staff 17 (ED) and Witness 1 (RN Consultant) on 01/14/25. The staff acknowledged the findings.

3. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes, hypertension, and atrial fibrillation.

Review of the resident’s current signed physician orders, dated 12/23/24, the MAR from 12/01/24 through 01/13/25, and observation notes, dated from 12/19/24 to 01/13/25, showed the following:

* The physician ordered Clonidon 0.1 mg to be administered every eight hours for high blood pressure. However, the MAR showed that the medication was administered every 12 hours instead of the prescribed eight-hour schedule.

* The physician ordered to hold the Clonidine and Lisinopril for hypertension when the systolic (top number) pressure was below 100 or the diastolic (bottom number) was below 50. However, the MAR showed on 12/19/24, with a blood pressure of 114/49, and on 12/25/24, with a blood pressure of 154/47, the medications were administered when they should have been withheld.

* The physician ordered any blood glucose (BG) results greater than 350 be reported. However, the MAR sowed the resident had a BG of 413 on 01/06/25, a BG of 354 on 01/07/25, and a BG of 372 on 01/08/25. There was no documented evidence that these results were reported to the physician as prescribed.

* The physician prescribed insulin administration according to the following blood glucose levels (BG): Two units for a BG of 201-250, five units for a BG of 351-400, and six units for a BG of 410 or greater. However, the MAR show the following discrepancies:

- On 01/06/25, with a BG of 413, four units of insulin were administered, instead of the prescribed six units;
- On 01/07/25, with a BG of 354, four units of insulin were administered instead of the prescribed five units; and
- On 01/09/25, with a BG of 214, four units of insulin were administered, when only two units should have been given as prescribed.

* The physician ordered Glutose 40 % to be administered when the resident’s blood glucose (BG) level was less than 65. On three occasions, 12/27/24 (BG of 51), 12/31/24 (BG of 53), and 01/01/25 (BG of 42) the MAR showed that the medication was not administered, despite the order indicating that it should have been given in such cases.

* The physician ordered Increase Ellipta 62.5 mg inhaler to be administered daily. However, the MAR showed the inhaler was not administered, with the notes indicating “na” or “not on noc [night shift].”

* The physician ordered to apply Lidocaine 5 % for 12 hours on and then off for 12 hours. However, the MAR showed the medication was placed on hold without a clear physician’s order explaining the reason.

On 01/14/25 at 4:30 pm, the physician orders and the MARs were reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 3 sampled residents (#s 15 and 16) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 15 moved into the assisted living community in 11/2021 with diagnoses including Type 2 diabetes mellitus with diabetic chronic kidney disease, dementia and chronic obstructive pulmonary disease (COPD).

Resident 15’s 03/01/25 through 03/31/25 MAR, current signed physician orders and observation notes (the facility’s tool for charting on a resident’s condition) were reviewed. The following was identified:

The resident was prescribed the following medications:

* Haloperidol 1 ml syringe every 2 hours as needed for end of life, to treat agitation and nausea;
* Lorazepam 0.5 mg tablet every 2 hours as needed for end of life, to treat anxiety;
* Unlicensed staff administered PRN haloperidol and lorazepam on multiple occasions between 03/01/25 and 03/31/25; and
* There was no documented evidence the resident was experiencing the specific circumstances/parameters for end of life agitation, nausea and/or anxiety during the days and times the medications were administered.

The need to ensure physician orders including physician written parameters were carried out as prescribed was discussed with Staff 17 (ED), Staff 35 (RN) and Witness 2 (RCD sister community) on 04/01/25 at 11:00 am. They acknowledged the findings.

2. Resident 16 moved into the assisted living community in 04/2020 with diagnoses including Type 2 diabetes mellitus, unspecified psychosis, major depressive disorder and pain.

Resident 16’s 03/01/25 through 03/31/25 MAR, current signed physician orders and observation notes (the facility’s tool for charting on a resident’s condition) were reviewed. The following was identified:

a. The resident was prescribed the following PRN pain medications:

* Hydrocodone- Acetaminophen 10-325mg, give 1 tablet daily PRN musculoskeletal pain rated 6-10/10 or pain not relieved by Acetaminophen;
* Acetaminophen 325 mg, give two tablets by mouth every four hours as needed for complaints of headache, musculoskeletal pain rated 1-5/10, or fever greater than 100;
* Unlicensed staff administered PRN Hydrocodone- Acetaminophen every day between 03/01/25 and 03/31/25 and acetaminophen 325 mg on three occasions; and
* There was no documented evidence the resident was experiencing the resident specific parameters of pain indicated by a 1-10 pain scale, headache or fever greater than 100 during the days and times the medications were administered.

b. The resident was prescribed alcohol prep pads to be used before BG (blood glucose) checks and insulin administration. There were no initials on the MAR indicating unlicensed staff followed the order from 03/09/25 - 03/31/25.?

The need to ensure physician orders including physician written parameters were carried out as prescribed was discussed with Staff 17 (ED), Staff 35 (RN) and Witness 2 (RCD sister community) on 04/01/25 at 11:00 am. They acknowledged the findings.

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 2 sampled residents (#s 3 and 5) who had documented medication refusals. Findings include, but are not limited to:



1. Resident 3 was admitted to the facility in 08/2024 with diagnoses including hypertension and history of cerebrovascular accident (stroke) with right sided weakness.



The resident's 09/01/24 through 09/16/24 MARs and all physician orders were reviewed.



The resident was documented as refusing acetaminophen 500 mg tablet (for pain) on 09/01/24 and 09/11/24. There was no documentation that the facility notified the resident’s physician/practitioner of these refusals.



During an interview on 09/18/24 at 2:45 pm, Staff 1 (Administrator) confirmed that she was unable to find documentation of notification.



The need to notify the practitioner when a resident refused to consent to orders was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:45 am on 09/20/24. They acknowledged the findings.





2. Resident 5 was admitted to the facility in 09/2021 with diagnoses including right and left lower extremity amputation and Type 2 diabetes.



The resident's 09/01/24 through 09/16/24 MARs and all physician orders were reviewed.



The resident was documented as refusing the following medications:



* Lantus Solostar Insulin Pen 55 ml (for diabetes), refused on 09/04/24, 09/06/24, and 09/10/24; and

* Lantus Solostar Insulin Pen 60 ml (for diabetes), refused on 09/09/24.



During an interview on 09/18/24 at 2:45 pm, Staff 1 (Administrator) confirmed that she was unable to find documentation that the physician/prescriber had been notified.



The need to notify the practitioner when a resident refused to consent to orders was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:45 am on 09/20/24. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order, for 3 of 6 sampled residents (#s 7, 8, and 11) with documented medication refusals. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

The resident's facility records, including the 12/19/24 through 01/13/25 MARs, physician's orders, and observation notes were reviewed, and the following refusals were identified:

* Aspirin (for heart health): Four occasions;
* Ferosul (for iron deficiency): Three occasions;
* Hydrochlorothiazide (for high blood pressure): Four occasions;
* Losartan (for high blood pressure): Four occasions;
* Metformin (for diabetes): Four occasions;
* Paroxetine (for depression): Four occasions;
* Amlodipine (for high blood pressure): Four occasions;
* Acetaminophen (for pain): Six occasions;
* Voltaren gel (for pain): Once;
* Quetiapine (for depression): Five occasions; and
* Medroxyprogesterone (for behaviors): Three occasions.

Although there was documented evidence that some refusals were communicated to the physician, the notification was up to four days after the resident refused to consent to orders. There was no documented evidence the facility attempted to notify Resident 7's physician on all occasions when s/he refused to consent to orders.

In an interview with Staff 24 (CG/MA) on 01/14/25 at 1:32 pm, she reported her process for when residents refused their medications was to document what the resident said and “no pass” in the MAR.

The need to notify the provider when a resident refused to consent to an order was discussed with reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

2. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

The resident's facility records, including the 12/19/24 through 01/13/25 MARs, physician's orders, and observation notes were reviewed, and the following refusals were identified:

* Eye allergy itch relief (for itchy eyes): Ten occasions;
* Morphine (for pain): Six occasions;
* Visine dry eye relief (for dry eyes): Seven occasions;
* Trazodone (for insomnia): Three occasions;
* Atorvastatin calcium (for lowering cholesterol): Two occasions;
* Gabapentin (for pain): Seven occasions;
* Amlodipine (for high blood pressure): Six occasions;
* Aspirin (for heart health): Six occasions;
* Chlorthalidone (for high blood pressure): Six occasions;
* Ferosul (for iron deficiency): Six occasions;
* Lisinopril (for hypertension): Six occasions;
* Loratadine (for allergies): Six occasions;
* Sertraline (for depression): Six occasions; and
* Trinellix (for depression): Six occasions.

There was no documented evidence the above refusals were reported to the prescriber.

The need to notify the provider when a resident refused to consent to an order was discussed with reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

3. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes, hypertension and atrial fibrillation.

A review of the resident’s current signed physician orders dated 12/23/24, and the MAR from 12/19/24 through 01/13/25 showed that staff documented the resident’s refusal of the following physician ordered medications on multiple occasions:

* Clonidine (for hypertension):12/19/24 through 12/25/24, 12/28/24, and 01/07/25;
* Donepezil (for dementia): 12/20/24 through 12/23/24;
* Eliquis (for atrial fibrillation): 12/19/24 through 12/22/24, 12/24/24, and 01/07/25;
* Metoprolol (for hypertension): 12/20/24, 12/21/24 and 12/23/24;
* Omeprazole (for acid reflux): 12/19/24 though 12/22/24, 12/24/24, and 01/07/24
* Amelog Solostar insulin (for diabetes): 12/20/24, 12/21/24, 12/28/24, 12/30/24 and 01/01/25;
* Amlodipine (for hypertension): 12/20/24, 01/01/25 and 01/03/25;
* Levothyroxine (for thyroid) and lisinopril (for hypertension): 12/20/24, 12/21/24, and 12/23/24;
* Lantus (for diabetes): 12/19/24, 12/20/24, 12/22/24 through 12/25/24, and 12/28/24;
* Venlafaxine (for depression): 12/19/24 through 12/24/24 and 01/07/25;
* Januvia (for diabetes) on 12/20/24;
* Potassium (for supplement) 12/20/24 and 12/22/24;
* Clearlax (for constipation) 12/19/24 through 12/26/24, 12/28/24, 01/05/25, 01/06/25, 01/08/25 and 01/12/25;
* Gabapentin (for chronic pain): 12/19/24 through 12/26/24, 12/28/24, and 01/07/25;
* Lasix (diuretic): 12/20/24, 12/21/24, and 12/23/24; and
* Artificial tears (for dry eyes): 12/19/24 through 12/26/24 and 12/28/24.

There was no documented evidence the facility notified the physician when the resident refused to consent to the order.

On 01/15/25 at 12:15 pm, the refusals were reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant). They acknowledged the findings. No further information was provided.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order, for 3 of 6 sampled residents (#s 7, 8, and 11) with documented medication refusals. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

The resident's facility records, including the 12/19/24 through 01/13/25 MARs, physician's orders, and observation notes were reviewed, and the following refusals were identified:

* Aspirin (for heart health): Four occasions;
* Ferosul (for iron deficiency): Three occasions;
* Hydrochlorothiazide (for high blood pressure): Four occasions;
* Losartan (for high blood pressure): Four occasions;
* Metformin (for diabetes): Four occasions;
* Paroxetine (for depression): Four occasions;
* Amlodipine (for high blood pressure): Four occasions;
* Acetaminophen (for pain): Six occasions;
* Voltaren gel (for pain): Once;
* Quetiapine (for depression): Five occasions; and
* Medroxyprogesterone (for behaviors): Three occasions.

Although there was documented evidence that some refusals were communicated to the physician, the notification was up to four days after the resident refused to consent to orders. There was no documented evidence the facility attempted to notify Resident 7's physician on all occasions when s/he refused to consent to orders.

In an interview with Staff 24 (CG/MA) on 01/14/25 at 1:32 pm, she reported her process for when residents refused their medications was to document what the resident said and “no pass” in the MAR.

The need to notify the provider when a resident refused to consent to an order was discussed with reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

2. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

The resident's facility records, including the 12/19/24 through 01/13/25 MARs, physician's orders, and observation notes were reviewed, and the following refusals were identified:

* Eye allergy itch relief (for itchy eyes): Ten occasions;
* Morphine (for pain): Six occasions;
* Visine dry eye relief (for dry eyes): Seven occasions;
* Trazodone (for insomnia): Three occasions;
* Atorvastatin calcium (for lowering cholesterol): Two occasions;
* Gabapentin (for pain): Seven occasions;
* Amlodipine (for high blood pressure): Six occasions;
* Aspirin (for heart health): Six occasions;
* Chlorthalidone (for high blood pressure): Six occasions;
* Ferosul (for iron deficiency): Six occasions;
* Lisinopril (for hypertension): Six occasions;
* Loratadine (for allergies): Six occasions;
* Sertraline (for depression): Six occasions; and
* Trinellix (for depression): Six occasions.

There was no documented evidence the above refusals were reported to the prescriber.

The need to notify the provider when a resident refused to consent to an order was discussed with reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

3. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes, hypertension and atrial fibrillation.

A review of the resident’s current signed physician orders dated 12/23/24, and the MAR from 12/19/24 through 01/13/25 showed that staff documented the resident’s refusal of the following physician ordered medications on multiple occasions:

* Clonidine (for hypertension):12/19/24 through 12/25/24, 12/28/24, and 01/07/25;
* Donepezil (for dementia): 12/20/24 through 12/23/24;
* Eliquis (for atrial fibrillation): 12/19/24 through 12/22/24, 12/24/24, and 01/07/25;
* Metoprolol (for hypertension): 12/20/24, 12/21/24 and 12/23/24;
* Omeprazole (for acid reflux): 12/19/24 though 12/22/24, 12/24/24, and 01/07/24
* Amelog Solostar insulin (for diabetes): 12/20/24, 12/21/24, 12/28/24, 12/30/24 and 01/01/25;
* Amlodipine (for hypertension): 12/20/24, 01/01/25 and 01/03/25;
* Levothyroxine (for thyroid) and lisinopril (for hypertension): 12/20/24, 12/21/24, and 12/23/24;
* Lantus (for diabetes): 12/19/24, 12/20/24, 12/22/24 through 12/25/24, and 12/28/24;
* Venlafaxine (for depression): 12/19/24 through 12/24/24 and 01/07/25;
* Januvia (for diabetes) on 12/20/24;
* Potassium (for supplement) 12/20/24 and 12/22/24;
* Clearlax (for constipation) 12/19/24 through 12/26/24, 12/28/24, 01/05/25, 01/06/25, 01/08/25 and 01/12/25;
* Gabapentin (for chronic pain): 12/19/24 through 12/26/24, 12/28/24, and 01/07/25;
* Lasix (diuretic): 12/20/24, 12/21/24, and 12/23/24; and
* Artificial tears (for dry eyes): 12/19/24 through 12/26/24 and 12/28/24.

There was no documented evidence the facility notified the physician when the resident refused to consent to the order.

On 01/15/25 at 12:15 pm, the refusals were reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant). They acknowledged the findings. No further information was provided.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order, for 3 of 6 sampled residents (#s 7, 8, and 11) with documented medication refusals. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

The resident's facility records, including the 12/19/24 through 01/13/25 MARs, physician's orders, and observation notes were reviewed, and the following refusals were identified:

* Aspirin (for heart health): Four occasions;
* Ferosul (for iron deficiency): Three occasions;
* Hydrochlorothiazide (for high blood pressure): Four occasions;
* Losartan (for high blood pressure): Four occasions;
* Metformin (for diabetes): Four occasions;
* Paroxetine (for depression): Four occasions;
* Amlodipine (for high blood pressure): Four occasions;
* Acetaminophen (for pain): Six occasions;
* Voltaren gel (for pain): Once;
* Quetiapine (for depression): Five occasions; and
* Medroxyprogesterone (for behaviors): Three occasions.

Although there was documented evidence that some refusals were communicated to the physician, the notification was up to four days after the resident refused to consent to orders. There was no documented evidence the facility attempted to notify Resident 7's physician on all occasions when s/he refused to consent to orders.

In an interview with Staff 24 (CG/MA) on 01/14/25 at 1:32 pm, she reported her process for when residents refused their medications was to document what the resident said and “no pass” in the MAR.

The need to notify the provider when a resident refused to consent to an order was discussed with reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

2. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

The resident's facility records, including the 12/19/24 through 01/13/25 MARs, physician's orders, and observation notes were reviewed, and the following refusals were identified:

* Eye allergy itch relief (for itchy eyes): Ten occasions;
* Morphine (for pain): Six occasions;
* Visine dry eye relief (for dry eyes): Seven occasions;
* Trazodone (for insomnia): Three occasions;
* Atorvastatin calcium (for lowering cholesterol): Two occasions;
* Gabapentin (for pain): Seven occasions;
* Amlodipine (for high blood pressure): Six occasions;
* Aspirin (for heart health): Six occasions;
* Chlorthalidone (for high blood pressure): Six occasions;
* Ferosul (for iron deficiency): Six occasions;
* Lisinopril (for hypertension): Six occasions;
* Loratadine (for allergies): Six occasions;
* Sertraline (for depression): Six occasions; and
* Trinellix (for depression): Six occasions.

There was no documented evidence the above refusals were reported to the prescriber.

The need to notify the provider when a resident refused to consent to an order was discussed with reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

3. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes, hypertension and atrial fibrillation.

A review of the resident’s current signed physician orders dated 12/23/24, and the MAR from 12/19/24 through 01/13/25 showed that staff documented the resident’s refusal of the following physician ordered medications on multiple occasions:

* Clonidine (for hypertension):12/19/24 through 12/25/24, 12/28/24, and 01/07/25;
* Donepezil (for dementia): 12/20/24 through 12/23/24;
* Eliquis (for atrial fibrillation): 12/19/24 through 12/22/24, 12/24/24, and 01/07/25;
* Metoprolol (for hypertension): 12/20/24, 12/21/24 and 12/23/24;
* Omeprazole (for acid reflux): 12/19/24 though 12/22/24, 12/24/24, and 01/07/24
* Amelog Solostar insulin (for diabetes): 12/20/24, 12/21/24, 12/28/24, 12/30/24 and 01/01/25;
* Amlodipine (for hypertension): 12/20/24, 01/01/25 and 01/03/25;
* Levothyroxine (for thyroid) and lisinopril (for hypertension): 12/20/24, 12/21/24, and 12/23/24;
* Lantus (for diabetes): 12/19/24, 12/20/24, 12/22/24 through 12/25/24, and 12/28/24;
* Venlafaxine (for depression): 12/19/24 through 12/24/24 and 01/07/25;
* Januvia (for diabetes) on 12/20/24;
* Potassium (for supplement) 12/20/24 and 12/22/24;
* Clearlax (for constipation) 12/19/24 through 12/26/24, 12/28/24, 01/05/25, 01/06/25, 01/08/25 and 01/12/25;
* Gabapentin (for chronic pain): 12/19/24 through 12/26/24, 12/28/24, and 01/07/25;
* Lasix (diuretic): 12/20/24, 12/21/24, and 12/23/24; and
* Artificial tears (for dry eyes): 12/19/24 through 12/26/24 and 12/28/24.

There was no documented evidence the facility notified the physician when the resident refused to consent to the order.

On 01/15/25 at 12:15 pm, the refusals were reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant). They acknowledged the findings. No further information was provided.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order, for 3 of 6 sampled residents (#s 7, 8, and 11) with documented medication refusals. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

The resident's facility records, including the 12/19/24 through 01/13/25 MARs, physician's orders, and observation notes were reviewed, and the following refusals were identified:

* Aspirin (for heart health): Four occasions;
* Ferosul (for iron deficiency): Three occasions;
* Hydrochlorothiazide (for high blood pressure): Four occasions;
* Losartan (for high blood pressure): Four occasions;
* Metformin (for diabetes): Four occasions;
* Paroxetine (for depression): Four occasions;
* Amlodipine (for high blood pressure): Four occasions;
* Acetaminophen (for pain): Six occasions;
* Voltaren gel (for pain): Once;
* Quetiapine (for depression): Five occasions; and
* Medroxyprogesterone (for behaviors): Three occasions.

Although there was documented evidence that some refusals were communicated to the physician, the notification was up to four days after the resident refused to consent to orders. There was no documented evidence the facility attempted to notify Resident 7's physician on all occasions when s/he refused to consent to orders.

In an interview with Staff 24 (CG/MA) on 01/14/25 at 1:32 pm, she reported her process for when residents refused their medications was to document what the resident said and “no pass” in the MAR.

The need to notify the provider when a resident refused to consent to an order was discussed with reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

2. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

The resident's facility records, including the 12/19/24 through 01/13/25 MARs, physician's orders, and observation notes were reviewed, and the following refusals were identified:

* Eye allergy itch relief (for itchy eyes): Ten occasions;
* Morphine (for pain): Six occasions;
* Visine dry eye relief (for dry eyes): Seven occasions;
* Trazodone (for insomnia): Three occasions;
* Atorvastatin calcium (for lowering cholesterol): Two occasions;
* Gabapentin (for pain): Seven occasions;
* Amlodipine (for high blood pressure): Six occasions;
* Aspirin (for heart health): Six occasions;
* Chlorthalidone (for high blood pressure): Six occasions;
* Ferosul (for iron deficiency): Six occasions;
* Lisinopril (for hypertension): Six occasions;
* Loratadine (for allergies): Six occasions;
* Sertraline (for depression): Six occasions; and
* Trinellix (for depression): Six occasions.

There was no documented evidence the above refusals were reported to the prescriber.

The need to notify the provider when a resident refused to consent to an order was discussed with reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

3. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes, hypertension and atrial fibrillation.

A review of the resident’s current signed physician orders dated 12/23/24, and the MAR from 12/19/24 through 01/13/25 showed that staff documented the resident’s refusal of the following physician ordered medications on multiple occasions:

* Clonidine (for hypertension):12/19/24 through 12/25/24, 12/28/24, and 01/07/25;
* Donepezil (for dementia): 12/20/24 through 12/23/24;
* Eliquis (for atrial fibrillation): 12/19/24 through 12/22/24, 12/24/24, and 01/07/25;
* Metoprolol (for hypertension): 12/20/24, 12/21/24 and 12/23/24;
* Omeprazole (for acid reflux): 12/19/24 though 12/22/24, 12/24/24, and 01/07/24
* Amelog Solostar insulin (for diabetes): 12/20/24, 12/21/24, 12/28/24, 12/30/24 and 01/01/25;
* Amlodipine (for hypertension): 12/20/24, 01/01/25 and 01/03/25;
* Levothyroxine (for thyroid) and lisinopril (for hypertension): 12/20/24, 12/21/24, and 12/23/24;
* Lantus (for diabetes): 12/19/24, 12/20/24, 12/22/24 through 12/25/24, and 12/28/24;
* Venlafaxine (for depression): 12/19/24 through 12/24/24 and 01/07/25;
* Januvia (for diabetes) on 12/20/24;
* Potassium (for supplement) 12/20/24 and 12/22/24;
* Clearlax (for constipation) 12/19/24 through 12/26/24, 12/28/24, 01/05/25, 01/06/25, 01/08/25 and 01/12/25;
* Gabapentin (for chronic pain): 12/19/24 through 12/26/24, 12/28/24, and 01/07/25;
* Lasix (diuretic): 12/20/24, 12/21/24, and 12/23/24; and
* Artificial tears (for dry eyes): 12/19/24 through 12/26/24 and 12/28/24.

There was no documented evidence the facility notified the physician when the resident refused to consent to the order.

On 01/15/25 at 12:15 pm, the refusals were reviewed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant). They acknowledged the findings. No further information was provided.

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

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order, for 1 of 3 sampled residents (#15) with documented medication refusals. This is a repeat citation. Findings include, but are not limited to:

Resident 15 moved into the assisted living community in 11/2021 with diagnoses including Type 2 diabetes mellitus with diabetic chronic kidney disease, dementia and chronic obstructive pulmonary disease (COPD).

Resident 15’s 03/01/25 through 03/31/25 MAR and current signed physician orders were reviewed, and the following was identified:

* Written and signed physician orders instructed staff to notify each time the resident refused medications;
* The resident refused to consent to physician orders on 03/02/25, 03/04/25, 03/05/25, and 03/23/25; and
* There was no documented evidence the facility notified the physician of each medication refusal.

The need to ensure the facility notified the physician when a resident refused to consent to an order was discussed with Staff 17 (ED), Staff 35 (RN) and Witness 2 (RCD sister community) on 04/01/25 at 11:00 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication-specific instructions, and had resident-specific parameters and instructions for PRN medications for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:



1.Resident 1 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes mellitus, and cerebrovascular accident (stroke).



Resident 1's 09/01/24 through 09/17/24 MAR was reviewed. The following PRN medications lacked resident-specific parameters for administration:



* Gavilax powder (for constipation);

* Gentle laxative suppository (for constipation);

* Milk of Magnesia (for constipation); and

* Stimulant laxative plus (for constipation).



The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Administrator) and Staff 2 (RN) at 4:00 pm on 09/19/24. They acknowledged the findings.



2. Resident 2 was admitted to the facility in 11/2015 with diagnoses including transient cerebral ischemic attack (TIA) and chronic obstructive pulmonary disease (COPD).



Resident 2's 09/01/24 through 09/17/24 MAR was reviewed. The following PRN medications lacked resident-specific parameters for administration:



* Gavilax powder (for constipation);

* Milk of Magnesia (for constipation); and

* Stimulant laxative plus (for constipation).



The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Administrator) and Staff 2 (RN) at 4:00 pm on 09/20/24. They acknowledged the findings.



3. Resident 3 was admitted to the facility in 08/2024 with diagnoses including hypertension and history of cerebrovascular accident (stroke) with right sided weakness.



Resident 3's 09/01/24 through 09/17/24 MAR was reviewed.

a. The following PRN medications lacked resident-specific parameters for administration:



*Morphine 100 mg/5 ml (for pain); and

*Tramadol 50 mg (for pain).



b. The following PRN medications lacked resident-specific parameters for administration:



*Haloperidol 2mg/ml (for agitation); and

*Lorazepam 0.5 mg (for anxiety/restlessness).



c. The resident had an order for Acetaminophen 500 mg (for pain), two tablets to be taken every eight hours. On 09/02/24 administration notes stated “hold/see progress notes.” No additional documentation was included in the MAR or progress notes. In an interview with Staff 1 (Administrator) on 09/20/24, she confirmed that no notes were present and staff were unable to confirm whether or not the medication was administered or the reason for the note.



The need to ensure the MAR included resident-specific parameters and instructions for PRN medications and was accurate was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:45 am on 09/20/24. They acknowledged the findings.



4. Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, chronic obstructive pulmonary disease and congestive heart failure.



Resident 4’s MAR, dated 09/01/24 through 09/16/24, was reviewed.



a. The following PRN medications lacked resident-specific parameters for administration and/or was not administered according to the parameters provided on the MAR:



*Acetaminophen 325 mg, 2 tablets every 6 hours as needed for pain. The parameters stated to use the medication for mild pain or moderate pain. On 09/03/24 and 09/06/24, documentation showed the medication was administered when the resident’s pain was rated 9 out of 10.

*Tramadol 50 mg, one tablet every eight hours as needed for pain. The parameters stated to use for moderate pain or severe pain. On 09/03/24, documentation showed the medication was administered when the resident’s pain was rated 5 out of 10.

*Morphine 100 mg/5 ml, one syringe by mouth every hour as needed for pain. There were no additional parameters listed.



b. The following PRN medications lacked resident-specific parameters for administration:


*Combivent Mist Inhaler, one puff four times a day as needed (for shortness of breath);

*Morphine 100 mg/5 ml, one syringe by mouth every hour as needed (for shortness of breath); and

* Ipratropium-albuterol, nebulize one vial every six hours as needed (for shortness of breath).



c. The following PRN medications lacked resident-specific parameters for administration:
*Lorazepam 0.5 mg, one tablet every two hours as needed (for anxiety); and

*Haloperidol 2mg/ml, one syringe by mouth every two hours as needed (for agitation).



In an interview with Staff 13 (Med Aid/CG), she confirmed she often administered PRN medications to residents. She was unable to state how the resident would present anxiety versus agitation or how she would decide which medication to administer.



The need to ensure the MAR included resident-specific parameters and instructions for PRN medications and the MAR was accurate was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:45 am on 09/20/24. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters, staff instruction, and reasons for use for 3 of 7 sampled residents (#s 7, 8 and 11) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes and chronic pain.

Resident 11’s 12/19/24 through 01/13/25 MAR was reviewed. The following PRN medications lacked resident-specific parameters for administration:

* Acetaminophen (for pain); and
* Hydrocodone-Acetaminophen (for pain).

Both PRN pain medications were administered during the review period.

The need to ensure the MAR included resident-specific parameters and instructions for PRN medication was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 12:15 pm. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

The resident’s MARs dated 12/19/24 through 01/13/25 and prescriber orders were reviewed. The following medications lacked a reason for use:

* Ferosul;
* Metformin; and
* Vitamin D3.

The requirement for MARs to be accurate and include reasons for use was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

3. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

The resident's MARs dated 12/19/24 through 01/13/25 and prescriber orders were reviewed. The following inaccuracies were identified:

a. The following medications lacked a reason for use:

* Amlodipine;
* Aspirin;
* Chlorthalidone;
* Ferosul;
* Loratadine; and
* Atorvastatin.

b. There were no clear parameters to direct unlicensed staff on the sequential order of Resident 8's PRN pain medications:

* Acetaminophen; and
* Morphine.

The requirement for MARs to be accurate, including resident-specific parameters for PRN medications and reasons for use, was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters, staff instruction, and reasons for use for 3 of 7 sampled residents (#s 7, 8 and 11) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes and chronic pain.

Resident 11’s 12/19/24 through 01/13/25 MAR was reviewed. The following PRN medications lacked resident-specific parameters for administration:

* Acetaminophen (for pain); and
* Hydrocodone-Acetaminophen (for pain).

Both PRN pain medications were administered during the review period.

The need to ensure the MAR included resident-specific parameters and instructions for PRN medication was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 12:15 pm. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

The resident’s MARs dated 12/19/24 through 01/13/25 and prescriber orders were reviewed. The following medications lacked a reason for use:

* Ferosul;
* Metformin; and
* Vitamin D3.

The requirement for MARs to be accurate and include reasons for use was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

3. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

The resident's MARs dated 12/19/24 through 01/13/25 and prescriber orders were reviewed. The following inaccuracies were identified:

a. The following medications lacked a reason for use:

* Amlodipine;
* Aspirin;
* Chlorthalidone;
* Ferosul;
* Loratadine; and
* Atorvastatin.

b. There were no clear parameters to direct unlicensed staff on the sequential order of Resident 8's PRN pain medications:

* Acetaminophen; and
* Morphine.

The requirement for MARs to be accurate, including resident-specific parameters for PRN medications and reasons for use, was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters, staff instruction, and reasons for use for 3 of 7 sampled residents (#s 7, 8 and 11) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes and chronic pain.

Resident 11’s 12/19/24 through 01/13/25 MAR was reviewed. The following PRN medications lacked resident-specific parameters for administration:

* Acetaminophen (for pain); and
* Hydrocodone-Acetaminophen (for pain).

Both PRN pain medications were administered during the review period.

The need to ensure the MAR included resident-specific parameters and instructions for PRN medication was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 12:15 pm. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

The resident’s MARs dated 12/19/24 through 01/13/25 and prescriber orders were reviewed. The following medications lacked a reason for use:

* Ferosul;
* Metformin; and
* Vitamin D3.

The requirement for MARs to be accurate and include reasons for use was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

3. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

The resident's MARs dated 12/19/24 through 01/13/25 and prescriber orders were reviewed. The following inaccuracies were identified:

a. The following medications lacked a reason for use:

* Amlodipine;
* Aspirin;
* Chlorthalidone;
* Ferosul;
* Loratadine; and
* Atorvastatin.

b. There were no clear parameters to direct unlicensed staff on the sequential order of Resident 8's PRN pain medications:

* Acetaminophen; and
* Morphine.

The requirement for MARs to be accurate, including resident-specific parameters for PRN medications and reasons for use, was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters, staff instruction, and reasons for use for 3 of 7 sampled residents (#s 7, 8 and 11) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 03/2023 with diagnoses including Type II diabetes and chronic pain.

Resident 11’s 12/19/24 through 01/13/25 MAR was reviewed. The following PRN medications lacked resident-specific parameters for administration:

* Acetaminophen (for pain); and
* Hydrocodone-Acetaminophen (for pain).

Both PRN pain medications were administered during the review period.

The need to ensure the MAR included resident-specific parameters and instructions for PRN medication was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 12:15 pm. They acknowledged the findings.

2. Resident 7 was admitted to the facility in 12/2023 with diagnoses including Type 2 diabetes and transient cerebral ischemic attack, unspecified.

The resident’s MARs dated 12/19/24 through 01/13/25 and prescriber orders were reviewed. The following medications lacked a reason for use:

* Ferosul;
* Metformin; and
* Vitamin D3.

The requirement for MARs to be accurate and include reasons for use was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

3. Resident 8 was admitted to the facility in 04/2020 with diagnoses including anterior cerebral artery syndrome, major depressive disorder, and systolic/diastolic heart failure.

The resident's MARs dated 12/19/24 through 01/13/25 and prescriber orders were reviewed. The following inaccuracies were identified:

a. The following medications lacked a reason for use:

* Amlodipine;
* Aspirin;
* Chlorthalidone;
* Ferosul;
* Loratadine; and
* Atorvastatin.

b. There were no clear parameters to direct unlicensed staff on the sequential order of Resident 8's PRN pain medications:

* Acetaminophen; and
* Morphine.

The requirement for MARs to be accurate, including resident-specific parameters for PRN medications and reasons for use, was discussed with Staff 2 (RN), Staff 17 (ED), Staff 27 (LPN), and Witness 1 (RN Consultant) on 01/15/25 at 1:30 pm. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

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

This Rule is not met as evidenced by:
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for 2 of 3 sampled residents (#s 15 and 16) whose MAR’s were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 15 moved into the assisted living community in 11/2021 with diagnoses including Type 2 diabetes mellitus with diabetic chronic kidney disease, dementia and chronic obstructive pulmonary disease (COPD).

Resident 15’s 03/01/25 through 03/31/25 MAR, current signed physician orders and observation notes (the facility’s tool for charting on a resident’s condition) were reviewed. The following was identified:

* The resident was prescribed three liters of oxygen for COPD, to be administered every shift, continuous; and
* There was no documented evidence the oxygen was transcribed on the MAR.

The need to ensure the MAR included resident-specific parameters and instructions for PRN treatment orders was discussed with Staff 17 (ED), Staff 35 (RN) and Witness 2 (RCD sister community) on 04/01/25 at 11:00 am. They acknowledged the findings.

2. Resident 16 moved into the assisted living community in 04/2020 with diagnoses including Type 2 diabetes mellitus, unspecified psychosis and major depressive disorder.

a. Resident 16’s 03/01/25 through 03/31/25 MAR and current signed physician orders were reviewed. The following MAR inaccuracies were identified:

* The resident had a signed physician order for Hydrocodone- Acetaminophen 10-325mg. Give 1 tablet daily PRN musculoskeletol pain rated 6-10/10 or pain not relieved by acetaminophen.; and
* The physician ordered parameters and instructions for the PRN Hydrocodone- Acetaminophen 10-325mg were not transcribed on the MAR.

The MAR showed unlicensed staff administered the PRN Hydrocodone- Acetaminophen 10-325mg to the resident every day between 03/01/25 - 03/31/25.?

b. The resident was prescribed Insta – Glucose 24 gram/31/gram for hypoglycemia. Instructions to administer if BG (blood glucose) is 70 or below and patient is able to swallow safely, administer 1 tube into mouth until dissolved. Repeat every 15 minutes X 3 until BG is greater than 70. If BG remains less than 70 after 3 doses in 45 minutes, call 911and notify RN and PCP. Hold Lantus if BG is less than 70 and notify PCP.

There was no documented evidence the Insta -Glucose was transcribed onto the MAR.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to ensure their ability to safely self-administer medications for 1 of 1 sampled resident (#4). Findings include, but are not limited to:



Resident 4 was admitted to the facility in 08/2022.



During the acuity interview on 09/17/24, Resident 4 was identified as self-administering his/her own medications.



On 09/20/24, Staff 1 (Administrator) acknowledged that Resident 6 did not have a quarterly evaluation completed to ensure s/he could safely self-administer his/her own medications.
The need to ensure residents who chose to self-administer medications were evaluated at least quarterly to ensure their ability to do so safely was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure there were written, resident-specific parameters for PRN psychotropic medication and that non-pharmacological interventions were attempted and documented as ineffective prior to PRN psychotropic medication being administered for 1 of 1 sampled resident (#5) whose MAR and physician orders were reviewed. Findings include, but are not limited to:



Resident 5 was admitted to the facility in 09/2021 with diagnoses including right and left lower extremity amputation and Type 2 diabetes.



Review of the resident's 08/01/24 through 09/16/24 MAR, current physician orders, and 08/01/24 through 09/16/24 progress notes identified the following:



* Resident 5 had a signed physician order for risperidone 0.5 mg, one tablet by mouth twice daily as needed for hallucinations;

* There were no resident-specific parameters or non-pharmacological interventions;

* The resident was administered the medication on 08/03/24 and 08/15/24; and

* There were no non-pharmacological interventions documented in the resident's chart as having been attempted and ineffective prior to the medication being administered.



The need to have written, resident-specific parameters for PRN psychotropic medications, and to document non-pharmacological interventions attempted and ineffective prior to administration of a PRN psychotropic was discussed with Staff 1 (Administrator) and Staff 14 (Senior Executive Director) at 9:45 am on 09/20/24. They acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

This Rule is not met as evidenced by:

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, and failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (# 4) who used a supportive device with restraining qualities. Findings include, but are not limited to:



Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia, chronic obstructive pulmonary disease and congestive heart failure.



Observations of the resident and interviews with the resident and staff indicated the resident had a quarter-length side rail on one side of his/her bed. On 09/18/24 and 09/19/24, the side rail was observed in the middle of the bed. Staff stated that the side rail was often at the head of the bed, but was loose and would slide down to the middle of the bed at times. Neither staff nor the resident were able to identify when the side rail was installed.



There was no documented evidence that an assessment was completed prior to the use of the device, that less restrictive alternatives were evaluated prior to use of the device, or that caregivers had been instructed on the correct use of and precautions related to the device.



The resident’s most recent service plan, dated 12/01/23, did not include any information about the use of a side rail.



On 09/20/24, Staff 1 (Administrator) confirmed the resident did not have any evaluations or assessments related to the side rail.



The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff 1 and Staff 14 (Senior Executive Director) at 9:45 am on 09/20/24. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices

Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 10, 11, and 12) completed all required pre-service orientation training. Findings include, but are not limited to:



Training records were reviewed on 09/18/24 and the following was identified:



There was no documented evidence Staff 10 (Med Aid/CG), Staff 11 (CG) and Staff 12 (Cook), hired 07/02/24, 06/26/24, and 05/06/24, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities:



* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Fire safety and emergency procedures; and

* Infectious disease prevention training.



The need for staff to complete all required pre-service orientation training was discussed with Staff 1 (Administrator), and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. They acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts

(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES.(a) Prior to beginning their job responsibilities, all employees must complete an orientation that includes training regarding:(A) Residents' rights and the values of community-based care.(B) Abuse and reporting requirements.(C) Standard precautions for infection control.(D) Fire safety and emergency procedures.(b) If the staff member's duties include preparing food, they must have a food handler's certificate.(c) All staff must receive a written description of their job responsibilities.(d) PRE-SERVICE INFECTIOUS DISEASE PREVENTION TRAINING. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-monthperiod prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:(A) Transmission of communicable disease and infections, including:(i) Policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Respiratory hygiene and coughing etiquette.(B) Standard precautions.(C) Hand hygiene.(D) Use of personal protective equipment.(E) Cleaning of physical environment, including, but not limited to:(i) Disinfecting high-touch surfaces and equipment.(ii) Handling, storing, processing and transporting linens to prevent the spread of infection.(F) Isolating and cohorting of residents during a disease outbreak.(G) 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. (H) Facilities will be required t have all staff trained, as described in this rule, by July 1, 2022.(e) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.(A) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.(B) Online training will be made available by the Department by January 1, 2022.(C) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.(D) The Department will review training from facilities or other entities with the goal of making training available to facilities by January 1, 2022.(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete theDepartment-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 jobresponsibilities.(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.(a) Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.(b) Pre-service dementia care training requirements for:(A) 2018 - Direct care staff hired on or before December 31, 2018 shall complete pre-service dementia care training outlined in OAR 411-054-0070 by December 31, 2018, regardless of when they first provide direct care to residents.(B) 2019 and beyond - Direct care staff hired on or after January 1, 2019 shall complete required pre-service dementia training prior to providing direct care to residents.(c) Documentation of dementia training:(A) 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.(B) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.(d) 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.(e) A certificate of completion must be made available to the Department upon request.(f) Pre-service dementia care training must include the following subject areas:(A) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.(B) 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.(C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.(D) 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.(g) 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) 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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 10, and 11) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:



Staff training records were reviewed on 09/18/24. The following deficiencies were identified:



a. Staff 10 (Med Aid/CG), hired 07/02/24, lacked documented evidence of demonstrated knowledge and performance in the following areas:



* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* First Aid/Abdominal Thrust.



b. Staff 11 (CG), hired 06/26/24, lacked documented evidence of demonstrated knowledge and performance in the following areas:



* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* First Aid/Abdominal Thrust.



The need to ensure the facility verified and documented that direct care staff demonstrated knowledge and performance in all required areas within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 14 (Senior Executive Director) at 9:00 am on 09/20/24. They acknowledged the findings.

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff
"Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (6) 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."

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and had documentation of all required components. Findings include, but are not limited to:



Review of fire and life safety records from 03/01/24 through 09/16/24 revealed the facility completed a fire drill on 04/11/24 and 09/05/24. The drills lacked documentation of one or more of the following required components:



* Date and time of fire drill;

* Location of simulated fire origin; and

* Escape route used.



There was no documented evidence that alternate routes were used during the fire drills as the escape route used was not documented.



The need to ensure fire drills were conducted according to the OFC and documentation included required components was reviewed with Staff 1 (Administrator) and Staff 3 (Maintenance) at 11:30 am on 09/19/24. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures at least annually. Findings include, but are not limited to:



Fire and life safety records were requested and reviewed during the survey. There was no documentation of annual instruction to residents on general safety procedures, evacuation methods, responsibilities during the fire and designated meeting places inside or outside the building in the event of an actual fire.



During an interview at 11:10 am on 09/19/24, Staff 1 (Administrator) stated that although they had a process for instructing residents at move-in, they did not currently have a process for re-instructing residents of the above information annually.



The need to ensure residents received fire and life safety training at least annually was discussed with Staff 1 and Staff 3 (Maintenance) at 11:30 am on 09/19/24. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

Refer to C156, C260, C270, C295, C303, C305 and C310.

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

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

This Rule is not met as evidenced by:
Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C156, C260, C270, C295, C303, C305, C310 and C 455.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair and the interior of the facility was kept free from unpleasant odors. Findings include, but are not limited to:



Observations of the facility from 09/17/24 through 09/20/24 revealed the following:



a. Exterior

* Multiple areas of the exterior siding had pieces missing measuring up to eight inches in length; and

* Wood framing around an exterior vent and multiple exterior doors was warped, splintering, or had significant amounts of peeling paint.



b. Facility Wide

* Multiple resident rooms and facility doors and doorframes had scrapes, gouges, and scuffs, especially noted on the front doors when exiting the building;

* The wall leading to hall 3 had a large gouge and peeling drywall;

* The carpet throughout the building, most notably in the dining room, activity/seating area adjacent to the dining room and halls 1, 2 and 3 had significant staining; and

* Handrails throughout the building were worn to a rough an uncleanable surface and had areas of gouged and/or splintering wood.



c. There was a pervasive unpleasant odor in hall 2 which worsened near room 26 that did not dissipate during the survey.



The above areas were toured with Staff 1 (Administrator) and Staff 3 (Maintenance) on 09/19/24 at 11:15 am. They acknowledged the findings.

OAR 411-054-0300 (3)(a-h) General Building Exterior

(3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair and the interior of the facility was kept free from unpleasant odors. Findings include, but are not limited to:



Observations of the facility from 09/17/24 through 09/20/24 revealed the following:



a. Exterior

* Multiple areas of the exterior siding had pieces missing measuring up to eight inches in length; and

* Wood framing around an exterior vent and multiple exterior doors was warped, splintering, or had significant amounts of peeling paint.



b. Facility Wide

* Multiple resident rooms and facility doors and doorframes had scrapes, gouges, and scuffs, especially noted on the front doors when exiting the building;

* The wall leading to hall 3 had a large gouge and peeling drywall;

* The carpet throughout the building, most notably in the dining room, activity/seating area adjacent to the dining room and halls 1, 2 and 3 had significant staining; and

* Handrails throughout the building were worn to a rough an uncleanable surface and had areas of gouged and/or splintering wood.

c. There was a pervasive unpleasant odor in hall 2 which worsened near room 26 that did not dissipate during the survey.



The above areas were toured with Staff 1 (Administrator) and Staff 3 (Maintenance) on 09/19/24 at 11:15 am. They acknowledged the findings.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable

(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure washers reached a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to:



Three facility laundry rooms, one on each resident hall, were identified when touring the facility 09/17/24 through 09/19/24. There were two residential type washing machines located in each laundry room. The washing machines had no indication of wash temperature. A liquid residential laundry detergent in a purple plastic container was located in each laundry room, which staff identified as the detergent used for washing all materials. There was no indication the detergent contained a chemical disinfectant.



In an interview with Staff 1 (Administrator) and Staff 14 (Senior Executive Director) on 09/20/24 at 9:00 am, Staff 2 confirmed that the detergent being used did not have a chemical disinfectant.



The need to ensure that a chemical disinfectant was used if facility washers did not reach a minimum rinse temperature of 140 degrees Fahrenheit was discussed with Staff 1 and Staff 14 at 9:45 am on 09/20/24. They acknowledged the findings.

OAR 411-054-0300 (7)(b-d) House Keeping and Sanitation

(b) HOUSEKEEPING AND SANITATION.(A) An ALF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use when a time schedule for resident-use is provided and equipment is of residential type.(A) If the primary laundry facility is not suitable for resident-use, an ALF must provide separate resident laundry facilities.(B) Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) An ALF must provide covered or enclosed clean linen storage that may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(E) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, and blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linen and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen area must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base of the laundry facilities must be continuous and coved with the floor, tightly sealed to the wall and constructed without voids that may harbor insects or moisture.

This Rule is not met as evidenced by:

Based on interview and record review, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:Onsite facility review, on 09/11/24, of the facilities Medication Incident Form dated 04/02/24 revealed that Resident 1 was administered medication without a current order. Documentation revealed the facility immediately notified the facility LPN. APS referral was dated 04/05/24 and stated Resident 1 had no negative effects from the medication error. In an interview on 09/11/24 with Staff 1 (Administrator) s/he stated an internal investigation was conducted and the incident was reported to APS. Staff 1 confirmed the med aide involved in the error was pulled from the med cart and was provided additional training.The above information was shared on 09/11/24 and acknowledged by Staff 1.It was determined the facility failed to carry out medication and treatment orders as prescribed. Facility Plan of Correction: The Med Aide that administered the wrong medications to the wrong resident was removed from the med cart and was provided additional training.

The findings of the kitchen inspection, conducted 12/19/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 12/19/23, conducted 06/11/24, are documented in this report. The facility was found to be in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 12/19/23, the facility's kitchen was observed to need cleaning and/or repair in the following areas:* Spills and splatters were noted on walls and the ceiling throughout the kitchen;* Wall corners were gouged or missing pieces of plaster;* Multiple cupboards and drawers inside the kitchen had spills, debris or peeling surfaces;* Shelving throughout the kitchen had food spills, dust, rust and/or debris;* A white shelf was over the three compartment sink with two large plastic containers on top. The shelf had multiple areas of peeling paint/laminate surface with exposed particle board;* The side of the dishwasher had a black substance draining down the side of the small lower panel and pooling on the floor;* Shelves in the side-by-side refrigerator had spills, debris and a white/brown substance on the upper shelves;* Three large baking sheets had a thick build up of black debris along the underside and edges of the pan;* Two pots and a deep-frying pan had scraped and/or discolored cooking surfaces and a brown build up on the outer surfaces of the pans;* A large top load freezer, stored outside of the main kitchen, had multiple broken pieces along the top edge of the unit and damaged seal around the edges;* The blender base had brown discoloration along the back side of the base, a broken button on the control panel and the lid to the mixer was missing the center piece to prevent contents from entering or exiting the blender when in use;* Both ovens had black accumulation and debris on the bottom of the oven;* Black accumulation was noted along the floor edges under the cabinets and along the front walls of the kitchen;* Debris was noted on the floor and under dry storage shelves, and at the side of the freezer unit;* Cupboards under the drink center in the dining room had large stains, spills, debris and chipped/peeling shelves with exposed particle board; and* Two large gouges with bits of protruding drywall were noted on the wall in the dry storage room.The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 2 (Cook) on 12/19/23. Staff 1 (Administrator) was notified via email on 12/19/23 of the areas in need of cleaning and/or repair as she was out of the building at the time of survey. The staff acknowledged the findings.

The findings of the kitchen inspection, conducted 10/24/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 10/24/22, conducted on 01/25/23 through 01/26/23, are documented in this report. The facility was found to be in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 10/24/22 at 10:00 am, the facility kitchen was observed to need cleaning and repair in the following areas:a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:* Caulking behind the hand wash sink;* Wall surrounding hand wash sink;* Cabinet shelves and floor drain near hand wash sink;* Ceiling vents and areas surrounding them;* Oven interior, knobs, doors and handles;* Bottom shelf of metal island;* Shelf to left of stove;* Exterior and interior of several cabinet doors and drawers;* Floor drains;* Top surface of dish machine; * Shelves, wheels and castors of black rolling cart next to stove; and * Flooring perimeter throughout. b. The following areas needed repair:* Laminate was missing from edges of several cabinet shelves rendering the surfaces uncleanable;* Peeling caulking from around hand wash sink;* A ceiling light fixture was missing a covering;* Dry storage room shelves had peeling contact paper which exposed uncleanable wood surfaces;* The dry storage room floor had an approximate 2 X 4 foot area missing vinyl; * A cabinet door had come off the hinges and was placed inside the cabinet; and * The kitchen entrance door jambs had scraped paint in several areas. The areas that required cleaning and repair were observed and discussed with Staff 1 (Administrator) and Staff 2 (Director of Culinary Services) on 10/24/22 at 11:15 am. The findings were acknowledged.

The findings of the re-licensure survey, conducted 7/27/21 to 7/28/21, 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 Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 7/28/21, conducted 11/08/21, 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 Home and Community Based Services Regulations OARs 411 Division 004.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the re-licensure survey of 07/28/21, conducted on 02/16/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities OARs 411 Division 004 Home and Community Based Services.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#3) whose orders were reviewed. Findings include, but are not limited to:Resident 3 was admitted in 2016 with diagnoses which included diabetes.Resident 3 had an order for Lispro insulin; 9 units before breakfast, 15 units before lunch and 7 units before dinner. If the CBG (blood sugar) was less than 130, staff were to hold the insulin. Resident 3's MARs, reviewed from 6/1/21 - 7/27/21, revealed the following insulin orders were not followed:* The MARs indicated seven occasions when the CBG was less than 130. Staff gave the insulin when it should have been held; and * On 6/26/21, the morning CBG was 130. Staff held the insulin when it should have been given. During an interview on 7/28/21 at 10:25 am, Staff 2 (RN/Health and Wellness Director) reviewed the MARs. She confirmed staff had not followed orders. Staff 2 stated MAR audits had not included a review for accurate insulin administration. She said she would update their audit process to ensure insulin administration was reviewed. The need to ensure orders were followed was reviewed with Staff 1 (Executive Director) on 7/28/21 at 10:45 am. She acknowledged the findings. No further information was provided.

2. Resident 3 was admitted in 2016 with diagnoses which included diabetes and glaucoma.Residents 3's MARs were reviewed from 6/1/21 through 7/27/21 and the following was noted:* Lack of specific administration instructions for multiple eye medications; and* Reasons for use was not indicated for all medications.In an interview on 7/28/21 at 10:30 am, Staff 2 (RN/Health and Wellness Director) reviewed the resident's MAR. She confirmed several medications were lacking reasons for use and multiple eye medications lacked specific administration instructions for staff. No further information was provided. On 7/28/21, the need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 1 (Executive Director). She acknowledged the findings. No further information was provided.
Based on interview and record review, it was determined the facility failed to keep an accurate medication administration record (MAR) of all medications that were ordered by a legally recognized prescriber and administered by the facility for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to:1. Review of Resident 1's MAR, dated 7/1/21 to 7/27/21 identified the following deficiencies:*The MAR lacked reasons for use of the following four medications: Bupropion HCL SR 100 mg (antidepressant), Eliquis 5 mg (anticoagulant), furosemide 40 mg (diuretic) and gabapentin 100 mg (anticonvulsant or for nerve pain); and*The MAR lacked accurate parameters for the following PRN bowel medications: enema disposable 19-7 gram/118 ml and Milk of Magnesia 400 mg/5 ml. The current parameters provided instructions to staff involving a medication (bisacodyl suppository) for which there was no order.On 7/28/21, the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (Executive Director) and Staff 2 (RN/ Health and Wellness Director). They acknowledged the findings.
3. Residents 2's 7/1/21 through 7/27/21 MAR was reviewed and the following was noted:* Multiple medications were missing the reasons for use.On 7/28/21, the need to ensure reasons for use were listed for all medications was discussed with Staff 1 (Executive Director) and Staff 2 (RN/ Health and Wellness Director). They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure MARs included parameters and clear instructions for 2 of 2 sampled residents (#s 5 and 6) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 09/2021 with diagnoses including diabetes and received daily insulin injections by unlicensed staff.Review of Resident 5's 10/01/21 through 11/08/21 MAR revealed orders for:* Polyethylene glycol, magnesium hydroxide, and enema all for constipation. There were no clear instructions for which medication should be used first or in what order the remaining medications should be utilized. Resident 5 was given an enema in 11/2021. * Acetaminophen and Oxycodone 10 mg both for pain. There were no clear instructions for which medication should be used first for the resident's pain. Resident 5 was administered both medications in 11/2021.* Glucagon 1 mg and Glucose-15 40% gel both ordered to "Use as directed as needed for hypoglycemia". The MAR lacked specific symptoms or blood sugars to indicate use and clear instruction for which glucose gel to utilize first.2. Resident 6 had diagnoses including diabetes and received daily insulin injections by unlicensed staff.Review of Resident 6's 10/01/21 through 11/08/21 MAR revealed orders for:* CBGs (blood glucose levels) check in the evening. Staff were directed to provide orange juice and a snack if blood sugars were "low". The MAR lacked clear instruction to staff on what a low blood sugar level was. * Glucose Gel 15 gm gel for blood sugar less than 80 to be taken with carbohydrates, and Insta-glucose 24 gram may use 2 tubes when blood glucose below 70. The MAR lacked clear instruction for which glucose gel utilize first.The need to ensure there were clear instructions on the MAR about what constituted abnormal CBGs and resident specific parameters for PRN medications was reviewed with Staff 1 (ED) and Staff 2 (RN/Health and Wellness Director) on 11/08/21. They acknowledged the findings.
). What action will be taken to correct the rule violation? The rule violation occurred due to unclear parameters or clear instructions for resident's PRN medications such as pain medications, bowel care and in the event of a low blood sugar. Another additional review of all medication lists will be completed by residents MD & Dorian Place nursing team to ensure medications is correct with use, reason for use and clear direction for administration. 2). How will the system be corrected so this violation will not happen?An additional Medication review will be completed with the assistance of Residents physician's. Community will send a standard clear direction for PRN medications along with clear direction regarding clear parameters in the event of a low blood glucose level. The community will utilize the second information box in the EMAR to include exact direction specific to each resident as ordered by the MD. Training of Med Aides when processing orders to ensure medication changes include specific direction when received and a last check of orders by Administrator or DHW.3). How often will the area needing correction be evaluated?Weekly reviews done by the Administrator along with Quarterly Medication Reviews are completed by residents MD & Dorian Place Nursing team. No additional Medication Administration program changes are planned at this time. 4). Who will be responsible to see that the correction area completed / monitored?Dorian Place Administrator will complete a full medication review involving residents MD's, appropriate pharmacy along with the community DHW.

Based on interview and record review, it was determined the facility failed to include all required components on fire drill records. Findings include, but are not limited to:Fire and life safety records, dated 5/2021 through 7/2021, were reviewed and revealed the following fire drill components were not documented:* Escape route used;* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;* Evacuation time period needed; and * Number of occupants evacuated.The need for fire drill records to be documented and kept that include all required information was discussed with Staff 1 (ED) and Staff 4 (Maintenance Technician) on 7/27/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to meet requirements for Fire and Life Safety instruction and documentation, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Fire and Life safety documentation from 5/20201 through 7/2021 was reviewed and lacked the following documentation:* Evidence that alternate evacuation routes were used during fire drills;* Staff interviewed know the designated point of safety; and * Identification of which residents attended the annual fire safety training.On 7/27/21, the need to ensure Fire and Life Safety instruction and documentation were completed was reviewed with Staff 1 (ED). She acknowledged the findings.

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 Department. Findings include, but are not limited to:Refer to C 310.