Klamath Falls Senior Living

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

Based on observation, interview, and record review, it was determined the facility failed to ensure food was stored, and the kitchen was maintained, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen, food storage areas, food preparation, and food service with Staff 1 (Executive Director) on 11/19/24 revealed: Multiple food containers were stacked on the refrigerator shelves preventing air circulation. The thermometer in the reach in refrigerator on the right side of the kitchen was at 50 degrees Fahrenheit. The temperatures of the refrigerator were documented above 42 degrees on multiple occasions in November 2024. Multiple foods in the refrigerator were tested with the facility digital thermometer and were above 42 degrees. Staff 1 agreed to dispose of the protein-based items in the refrigerator and move items to the other refrigerator in the kitchen. The garbage can in the kitchen had no lid. Staff 1 explained the lid was broken and the garbage can needed to be replaced. The food storage findings were reviewed with Staff 1 on 10/11/24. She acknowledged the findings.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure food was stored, and the kitchen was maintained, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen, food storage areas, food preparation, and food service on 11/120/24 revealed splatters, spills, drips, and debris noted on: - Hand washing sink and supplies; - Can opener blade and casing; - Stand mixer; - Spice self; - Small appliance; - Exterior sides and interior of the gas range and oven; - Walls throughout the kitchen; - Flooring and cove base throughout the kitchen; - Floor drains; - Door, flooring, fan, and shelving of walk-in refrigerator - Flooring of walk in freezer; - Interior of the microwave; - Open stainless-steel shelving and metal rack shelving throughout the kitchen; - Underneath shelving and equipment throughout the kitchen; and - Dishwashing area including walls, shelving, and equipment. * There was no splash guard between the handwashing sink and the food prep area. * There were undated and unlabeled foods in the walk-in refrigerators. * Expired items were noted in the walk-in refrigerator. * There was not a working thermometer in the reach-in refrigerator. * Packaged foods were not dated when opened. * Staff were observed to prepare and serve soft-cooked eggs. There were no posturized in the shell eggs available to use for the undercooked eggs. * Open exposed foods were noted in the walk-in freezer and the dry storage area. * Food was on the floor of the walk-in freezer. * Scoops were left in bulk food bins with the handles in the food. * The color-coded cutting boards were deeply scored and stained. * There was no evidence the temperatures or the sanitizer solution ratios of the dish machine, were monitored. * The dish machine sanitizer solution and temperature were not reaching the required levels. A service technician was immediately called. Staff 1 (Executive Director) and Staff 2 (Maintenance Director) agreed to sanitize the dishes using the triple pot sanitizer until the dish machine was operating per specifications. * Staff were using a Quaternary solution for sanitizing towels. There was no evidence of testing the solution to ensure it was between 150 and 200 parts per million. The areas in need of cleaning and food storage concerns were reviewed with Staff 1 and Staff 3 (Regional Director of Operations). They acknowledged the findings.

Deep Cleaning was completed on 12/8/24, by dining service team, of all items listed. Splash guard has been installed as well as a new sink with splash guard. Expired items in the refridgerator have been removed. New containers have been purchased containing all itens that were exposed. Walk in freezer has been cleaned thoroughly and all items put on shelf. Staff have been trained to not leave scoops in bulk food bins. Color-coded cutting boards have been replaced. Ecolab service technician inspected dish washer and sanitizer and stated it is in working order according to Oregon state law. Cleaning schedule has been implimented with daily, weekly, monthly duties and staff signatures required. Staff duty list includes checking dates daily. Daily, Weekly, Monthly Executive Director, Dining Services Director

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

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.

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

Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of the facility operations and supervision, and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to: During the relicensure survey, conducted 10/21/24 through 10/24/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations. Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. An Immediate Plan of correction was requested in the following area: 1. OAR 411-054-0025 (4): Reasonable Precautions. The facility put an immediate plan of correction in place during the survey. 2. Refer to deficiencies in the report.

1) Immediate plan of correction was put into place for reasonable precautions related diet orders. 2) 5x week stand up meeting with managers. 5x week clinical meeting to review new orders. ED involved in service plan reviews and care conferences. Monthly quality assurance program. 3) Daily, Weekly, Monthly 4) ED/Designee

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

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

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: A review of resident council board meeting minutes dated 08/2024 through 10/2024 identified the following resident concerns: * “[Eight room numbers] wait a long time for… food.”; * “[Resident name] still waiting for [his/her] bed rails.”; * “Resident upset about dining times.”; * “Foods running out.”; * “Menus constantly changing order.”; * “Wait times are too long in the dining room. He [new chef] says they need more help.”; * “Every service time [mealtime] is waiting about an hour.”; * “[Room number] no room cleaning no laundry done.”; * “[Room number] bed not being made or trash out.”; * “[Room number] trash not being taken out.”; * “Residents waited for over an hour for breakfast (weekend).”; and * “[Residents] state they feel like the nurse is the principal and they feel kinda (sic) scared to talk to her.” There was no documented evidence the above concerns identified during the resident council board meetings had been responded to or resolved. On 10/22/24, the survey team conducted a group interview with 26 residents. The residents expressed complaints about the facility, including food quality and service, dissatisfaction with care giving, lack of resolution from resident council meetings, and facility administration being “not responsive” if concerns were brought forward. In an interview on 10/23/24, Staff 1 (ED) reported the facility’s “open door policy” allows residents to bring any issues to the attention of Staff 1, Staff 5 (Business Office Manager), or Staff 27 (Concierge). Staff 1 stated, “If they [residents] want to be anonymous, they will talk to Staff 5.” Staff 1 confirmed there was no written documentation of the facility’s policy. In an interview on 10/24/24, Staff 27 stated, “If residents have concerns, they come to me and I handle if I can. If they come to me and ask to not tell anybody, I wouldn’t tell. If [Staff 1] asks me who was it, I would say they didn’t want their name to be out.” The need to improve the facility's method for responding to and resolving resident complaints was reviewed with Staff 1, Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), and Staff 4 (Regional Business Office Manager) on 10/24/24. They acknowledged the findings.

1) Resident Council Concerns: Dietary- Meals served at schedule times No menu changes without 24 hr notice No running out of food with FSD ordering timely, FSD/ED reviewing menus/orders weekly. Clinical- 5x weekly clinical meeting review resident concerns/care with ED/RCC/Nursing Staffing- Hired more employees to help with care and meal service 2) All resident council meeting minutes will be sent out to managers. The manager will respond with a solution and review with ED. Notes will be posted for resident review in the common area. Grievance binder at front desk and will be reviewed by team daily. Resident council minutes reviewed in Quality Improvement meeting 3) Daily, Weekly, Monthly 4) Executive Director

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

OAR 411-054-0025 (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.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings include, but are not limited to: During the survey, conducted 10/21/24 through 10/24/24, quality improvement oversight to ensure adequate resident care, service and satisfaction was found to be ineffective. In an interview on 10/24/24 at 10:20 am, Staff 1 (ED) acknowledged the facility had not implemented a quality improvement program. The need to ensure the facility conducted ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction was discussed with Staff 1, Staff 2 (Operations Specialist) and Staff 3 (Regional Vice President of Operations) on 10/24/24 at 10:20 am. They acknowledged the findings.

1) Quality Improvement Program rolled out to all managers to ensure all systems are consistently utilized. 2) Quality improvement oversight by Executive Director to ensure adequate resident care services and satisfaction to be found effective. 3) Monthly 4) Executive Director

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.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of 2 of 2 sampled residents (#s 1 and 9) who had modified textured diets and/or thickened liquids related to swallowing risks. That placed the residents at risk for potential choking episodes and aspiration and constituted an immediate threat to the residents’ health and safety. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2018 with diagnoses including hemiplegia and traumatic brain injury. The resident’s record, which included physician orders, service plan, temporary service plans, physician communications and progress notes, was reviewed and the following was noted: * An Interim Service Plan dated 04/26/24, indicated the resident had an order for a pureed diet. The resident had declined the pureed option at times and staff were to remind the resident pureed texture was needed for safety. * Signed physician orders dated 06/11/24 and 09/04/24, indicated the resident had a pureed texture diet. The order stated, “Puree all food related to shaking.” The resident had no modifications to his/her liquid consistency. * Progress notes dated 07/20/24 through 10/20/24, showed no documentation of any concerns regarding the puree diet, resident refusals of the diet or changes made to the pureed diet order. * The current service plan dated 07/31/24, was not reflective of the resident’s physician ordered diet texture restrictions. The service plan did not provide clear directions for staff related to the diet restrictions, the resident’s potential swallowing and aspiration risk and what to do if the resident were to choke. Multiple daily observations were made between 10/21/24 and 10/24/24 and showed the following: * The resident had paralysis to the left side. The left arm was kept at the resident’s side and was not able to grasp objects due to significant contracture at the wrist. * The resident’s positioning in the wheelchair showed him/her frequently leaning to the left. The range of motion of the resident’s neck was also impaired and his/her head was not in straight alignment during meals or leisure activities. The resident’s head was primarily tipped far forward and to the left. The resident did not have upper dentures. * The resident was observed during the dinner meal on 10/21/24. The resident received cut up pasta, a cut up green vegetable and a half a piece of butter toast. The resident indicated s/he could not eat the bread and would usually try to soak it in whatever sauce s/he had to soften it. The resident demonstrated what s/he does but there was no excess sauce on the noodles. The resident stated the pasta was “pretty dry,” “not much to soak up.” * The resident was observed during the breakfast meal on 10/22/24. The resident received a diced-up pancake and a poached egg in a small bowl. The resident dumped the egg onto the pancakes and mashed the items together. The resident then added syrup to the mixture. The resident ate very slowly, scooping items with some difficulty. The resident alternated fluids with the bites of food, using a straw in each of his/her fluids. The resident coughed twice during the meal. * The resident was observed briefly at the lunch meal on 10/22/24. The resident received a bowl of egg salad and several packages of round crackers, not the puree texture as ordered. The resident’s coffee cup had the opened/empty wrappers, and s/he declared s/he ate all the crackers. The resident was not observed to eat the crackers. Interviews conducted between 10/21/24 and 10/24/24 showed the following: Staff 12 (MT) and Staff 13 (MT) identified the resident as having a “sometimes” pureed diet during the acuity interview. Resident 1 indicated s/he received “mostly pureed” items for meals, sometimes s/he would eat a regular peanut butter or egg salad sandwich. The resident stated the peanut butter sandwiches would get “stuck” and it was “scary.” Resident 1 further indicated there were times when s/he choked but she had not needed any help from anyone. The resident stated s/he wasn’t sure exactly what s/he would do if “choked hard,” besides lifting his/her arm up above his/her head. Staff 9 (Cook) indicated salads were pureed so easier for the resident to eat. She believed the other items were more of a mechanical soft texture. Staff 9 stated the resident’s foods were cut up into pieces and were usually a softer texture. They did their best to give the resident what s/he wanted. Staff 9 was unsure what the resident’s current physician’s ordered diet texture was. Staff 14 (Personal Care Assistant) indicated the resident received soft, easy to chew foods at meals. She was not sure of any other textures the resident received. Staff 14 stated she delivered whatever the kitchen sent out when she was assigned to the dining room. The resident had poor safety awareness but could make his/her needs known. Staff 14 was unsure of the resident’s current diet order. Staff 15 (Personal Care Assistant) indicated the resident had mechanical soft foods, items were a softer texture. She believed the resident received puree salads, but she was not sure. Staff 14 stated care staff rotated through working in the dining room and assisting the kitchen with meal delivery and preparation. Staff 14 further indicated after food was plated, she would cut up the different items for the resident before delivering the meal. The resident could make his/her needs known but had poor safety awareness. She was unsure what diet order the resident had currently. Staff 19 (MT) indicated the resident had a mechanical soft texture and ate whatever the kitchen sent out for him/her. Sometimes the salads or other greens were pureed/ground up so easier to chew. The staff stated the resident occasionally had coughing episodes during meals. The staff indicated the resident could make his/her needs known but had poor safety awareness and did not recognize his/her limits. Staff 17 (Acting DM/Cook) indicated the resident previously received puree for all items, but they had only been giving the resident pureed salads/greens in the more recent months. Staff 17 was unsure what the resident’s current; physician ordered diet was. He was familiar with different diet textures and how to make them. Staff 17 stated some of the other kitchen staff were not as comfortable with the different textures and he was working with them as requested by Staff 1 (ED) at the time of survey. Staff 1 (ED) indicated the resident had an order for a pureed diet. There were no other physician orders regarding the diet or any recent changes. Staff 1 indicated the staff needed to follow the orders prescribed by the physician for resident safety. Staff 1 stated s/he wanted only cooks preparing any modified textures and no longer wanted care staff involved in that process. Staff 1 and Staff 17 provided hand outs and training to kitchen staff to ensure all understood what the different diet textures looked like and how to prepare it. Resident 1 was at risk for choking and potential aspiration related to paralysis, contractures and body position. The resident had a signed physician order for a puree diet to provide easy to chew and swallow items. The facility inconsistently provided pureed items to the resident. Meal observations should food textures provided which ranged from diced pancakes and whole garlic toast to whole poached eggs and crackers. The survey team requested immediate action to address the resident’s need for an altered diet which was observed not to be provided on multiple occasions. The facility began a review of all diet orders and education with kitchen staff regarding altered diet textures. An immediate plan of correction to ensure residents with modified diet textures received the proper diet, was requested by the survey team and was received on 10/22/24 at 3:15 pm. The resident was then observed to receive appropriate pureed items for the dinner meal on 10/22/24 and the breakfast meal on 10/23/24. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents and provided altered diet textures and thickened liquids as ordered was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Witness 1 (RN Consultant) on 10/22/24. The staff acknowledged the findings. 2. Resident 9 was admitted to the facility in 12/2023 with diagnoses including stroke, dysphagia (difficulty swallowing) and dementia. The resident’s record, which included physician orders, service plan, temporary service plans, physician communications and progress notes, was reviewed and the following was noted: * A signed physician order dated 04/21/24, indicated the resident’s liquids needed to be nectar thick consistency. The resident’s food textures were not modified. * The resident’s hospital discharge instructions dated 04/21/24, indicated the resident was seen for a stroke and difficulty swallowing. The resident was diagnosed with dysphagia of thin liquids and the need for a swallow study. The resident was to “have thickened liquids at medium thick until this has occurred.” * Progress notes dated 07/23/24 through 10/12/24, contained no documentation of any concerns regarding the nectar thick fluid consistency, resident refusals of the nectar thick liquids or changes made to the fluid order. * The current service plan dated 09/20/24, was not reflective of the resident’s physician ordered nectar thick liquids. The service plan did not provide clear directions for staff related to the fluid consistency, the resident’s swallowing or potential aspiration risk. * No documentation was found in the resident’s record to show the swallow study had been followed up on. The resident’s thickened liquid orders had not been changed at the time of review. Multiple daily observations were made between 10/22/24 and 10/23/24 and showed the following: * The resident was observed during part of the dinner meal on 10/22/24. The resident had a cup of thickened water on the table and a cup of thin juice that was partially gone. * The resident was observed during the full breakfast meal on 10/23/24. The resident had a cup of orange juice and a cup of coffee that were thin in consistency. There was a cup of water on the table that was thickened. * Staff 11 (Cook) was observed with a drink cart delivering requested fluids to the residents who had arrived in the dining room for breakfast. No thickened liquids were noted on the cart. Nectar thick liquids were observed in the kitchen in a pre-made, prepackaged form. The facility did not make its own thickened liquids but purchased them already thickened to the correct consistency. Interviews conducted between 10/21/24 and 10/24/24 showed the following: *Staff 12 (MT) and Staff 13 (MT) identified the resident as having thickened liquids during the acuity interview. *Staff 17 (Acting DM/Cook) indicated the kitchen buys premade thickened liquids so there were no concerns with the consistency that was provided. *Staff 11 (Cook) indicated the kitchen had juice and water in nectar thick form for the resident. Staff 11 further indicated he did not give the resident any thickened liquids for 10/23/24 breakfast. The resident’s spouse frequently requested no thickened liquids at different meals. Staff 11 would provide thin liquids for the resident when requested. *Staff 15 (Personal Care Assistant) and Staff 19 (MT) indicated the resident had thickened liquids. The resident or his/her spouse often declined the thickened liquids and selected regular consistency fluids. Resident 9 had a diagnosis of dysphagia (difficulty swallowing) thin liquids related to a stroke with hemiplegia. The resident was at risk for choking and aspiration of thin fluids. An immediate plan of correction was previously requested by the survey team on 10/22/24 at 3:15 pm. The plan addressed specific diet textures. In addition, the facility addressed following physician orders for Resident 9’s liquid consistency. The facility provided additional documentation on 10/23/24, which were specific to thickened liquids and Resident 9. * Staff 1 (ED) indicated the resident had an order for nectar thick fluid. There were no other physician orders regarding the thickened liquids or any recent changes. Staff 1 indicated the staff needed to follow the orders prescribed by the physician for resident safety. Staff 1 stated the thickened fluids were ordered several months previous with instructions to get a swallow evaluation. The swallow evaluation was not completed nor were the fluid orders followed up on. Hospice was contacted regarding the current nectar thick fluid orders. Staff 1 indicated until a new order was received the resident would receive the thickened liquids as previously ordered. The resident was observed for the lunch meal on 10/23/24, after facility administration began immediate correction regarding the provision of thickened liquids. The resident received a cup of thickened juice and a cup of thickened water, both poured straight from premade cartons purchased by the facility. As part of the immediate plan to correct the deficiency, hospice was contacted. A new order was received on 10/23/24 at 1:59 pm which indicated the thickened liquids could be discontinued. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents and provided altered diet textures and thickened liquids as ordered was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), Staff 4 (Regional Business Office Manager), Witness 2 (RN Consultant) on 10/23/24. The staff acknowledged the findings.

1) Requested updates on dietary orders, confirmed care plan, assessment and diet board for consistency. Dietary/All staff completed training on special diets and diet board on 10/22. Assigned and completed training on special diets in oregon care partners. Resident #1 received updated pureed diet order, updaterd diet board. Resident #9 received updated diet order, nector thick liquids discontinued. 2) Diet Board up to date. Manager on Duty in place with oversight over meals. ED will review with FSD during weekly one on one any changes and confirm. RCC/ED/Nursing will review/confirm any changes during clinical meetis 3) Daily, Weekly, Monthly 4) ED/RCC/FSD

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were treated with dignity and respect related to pervasive odors and meal delivery to apartments and that residents were treated with respect related to a safe and homelike environment related to room odors and room damage for 2 of 2 sampled residents (#s 2 and 7), pervasive hallway/stairwell odors and multiple non-sampled residents who received significantly late meal delivery. Findings include, but are not limited to: 1. During the survey on 10/21/24 through 10/24/24, the facility was found to have severe and pervasive urine odors that did not dissipate. The odors were strongest inside Resident 2’s apartment but were also strongly present in the hall near the resident’s room. The odors were present throughout the resident’s apartment with the strongest areas noted to be in the bedroom and living room. The odors were present all days of the survey regardless of housekeeping services completed in the resident’s apartment. Additionally, strong pervasive odors of urine, feces and marijuana were noted in the first-floor hallways and the ends of the hallways near the east and west stairwells on the first floor. The need to ensure residents were treated with dignity and respect, and had a safe, clean, and home-like environment was discussed with Staff 1 (ED) and Staff 2 (Operations Specialist) on 10/22/24 and 10/23/24. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 05/2024 with diagnoses including type 2 diabetes mellitus and cystitis. During observation on 10/22/24 and 10/23/24, breakfast in the main dining area was served at 8:00 am. The facility care staff delivered food trays with breakfast to Resident 5’s room at 9:48 am and 9:44 am, respectively. That was almost two hours after the scheduled time. Lunch service on those dates was scheduled for 12:00 pm. In a typical home environment, breakfast and lunch are consumed more than two hours apart. The need to create a safe and homelike environment for residents was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), and Staff 4 (Regional Business Office Manager) on 10/24/24. They acknowledged the findings. No further information was provided. 3. Resident 7 was admitted to the facility in 09/2022 with diagnoses including multiple sclerosis. During the interview on 10/23/24 with Resident 7, it was observed the walls, doorways and baseboards in the living room and bedroom of Resident 7’s apartment was damaged, revealing underlying wood frame and drywall. Also, the hanging closet door in Resident 7’s bedroom was loose and subject to falling. Resident 7 stated he/she had asked the facility to fix the damaged areas, and facility staff had patched some damaged walls with duct tape. The need to create a homelike environment for residents was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), and Staff 4 (Regional Business Office Manager) on 10/24/24. They acknowledged the findings.

1) Maintenance Director is walking community daily to ensure any damage in/or around residents rooms is repaired and/or scheduled for repairs. Mainentance work order binder in place. Staff have been trained to properly document in work order binder. Maintenance is reviewing work order binder daily and report's in daily stand up plan to complete and sign off as completed. Resident #7- Maintenance has repaired holes in walls and walks room daily, repairs will be noted when completed. Resident #2 and #7- Housekeeping is checking for odors daily and addressing as needed. Caregivers are removing trash and soiled laundry from residents rooms and washing daily and as needed. Staff have been trained on proper meal delivery. 2) Maintence Director will report in stand up if there are any findings as well as review work order binder 5x weekly. ED/Designee will follow up daily to ensure building smells good, work orders are up to date and we are providing a safe, homelike environment for the residents. 3) Daily, Weekly, Monthly 4) ED/MD

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure injuries of unknown cause and allegations of abuse were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office when required, for 1 of 5 sampled residents (#1). Findings include, but are not limited to: Resident 1 was admitted to the facility in 03/2018 with diagnoses including hemiplegia. Observations of the resident, interviews with staff, and review of the resident's 07/31/24 service plan, 07/20/24 through 10/20/24 interim service plans, progress notes, physician communications, and incident investigations were completed. The resident was able to communicate needs to staff and required full assistance of one staff for ADL care and transfers. The resident was forgetful and did not fully recognize his/her limitations and had poor safety awareness. The resident could move his/her wheelchair around the facility at will. The resident was paralyzed on the left side but had good use of the right extremities. Review of the resident's records showed the following: * A progress note dated 09/28/24, indicated the resident told staff, s/he had hit his/her head during a transfer the night before. No other information about the resident was provided. No investigation was completed regarding the incident. Staff 1 (ED) indicated she could not locate any investigation of the incident. She spoke to the staff who made the original note, and it was determined the resident hit his/her head during a transfer with a staff member present. There was no other information about the incident or if the service plan was followed. The facility was asked to report the incident to the local SPD office. A confirmation of the report was provided to the surveyor. The need to ensure all incidents were promptly investigated to rule out abuse and/or neglect was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Witness 2 (RN Consultant) on 10/24/24. The staff acknowledged the findings.

1) Incident Reports to be completed by med tech or designee and reported to ED/RCC. ED/RCC review/investigate incident and determine if abuse and/or neglect should be ruled out. Interventions are reviewed and updated in care plan accordingly. If abuse and/or neglect is not ruled out ED/RCC will send self report to APS within 24 hours. Resident #1- ED completed a fall investigation and found fall investigation form was completed by med tech on duty on 9/28/24. Physicians communication was also completed and faxed on 9/28/24 regaurding incident. TPS/Service Plan is/was updated as needed. 2) ED/RCC and/or designee will inquire during daily stand up. Conversations/Investigations will continue during clinical meetings and communication with med techs to ensure this system is followed and addressed accordingly. 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

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

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

Based on observation, interview and record review, it was determined the facility failed to ensure the move-in evaluation was dated, contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident’s needs, for 1 of 1 sampled resident (# 4) who was recently admitted to the facility, the resident evaluations were performed with updates and changes as appropriate within the first 30 days to correspond with the quarterly service plan updates, for 2 of 2 sampled residents (#s 4 and 5) whose records were reviewed, and the most recent quarterly evaluations, with documented change of condition updates, were in the resident’s current record for 2 of 6 sampled residents (#s 5 and 6) whose records were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 05/2024 with diagnoses including type 2 diabetes mellitus and cystitis. Observation of the resident, interview with staff and the resident, and review of the resident’s 08/14/24 through 10/20/24 progress notes, physician communications, and temporary service plans were completed. The resident had experienced a decline in multiple ADLs, three falls without injury, and multiple changes to the medication regimen. There was no documented evidence of any evaluation completed after the move-in evaluation in 05/2024. The need to ensure the resident evaluations were performed with updates and changes as appropriate within the first 30 days and at least quarterly was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), and Staff 4 (Regional Business Office Manager) on 10/24/24. They acknowledged the findings. 2. Resident 4 moved into the facility in 07/2024 with diagnoses including major neurocognitive disorder and bipolar disorder. a. The initial evaluation was reviewed and failed to address the following required elements: * Customary routines including sleeping, eating and bathing; * Interests, hobbies, social, leisure activities; * Spiritual, cultural preferences and traditions; * Physical health status including list of current diagnoses, list of medications and PRN use, visits to health practitioner(s), ER, hospital or NF in the past year and vital signs if indicated by diagnosis, health problems or medications; * Mental Health issues including, presence of depression, thought disorders or behavioral or mood problems, history of treatment and effective non-drug interventions; * Cognition, including memory, orientation, confusion and decision making abilities; * Personality including how the person copes with change or challenging situations; * Activities of daily living including eating and assistive devices; * Independent activity of daily living including ability to use call system and transportation; * Pain including pharmaceutical and non-pharmaceutical interventions and how a person expressed pain or discomfort; * Nutrition habits and fluid preference; * List of treatments, type, frequency and level of assistance needed; * Indicators of nursing needs including potential for delegated nursing tasks; * Emergency evaluation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Alcohol and drug use; and * Environmental factors that impact the resident’s behavior including, but not limited to: noise, lighting and room temperature. b. Observations of the resident and interviews with staff and the resident indicated the resident had experienced a decline in multiple ADLs and eight falls without injury between 08/31/24 and 10/18/24. There was no documented evidence the facility ensured 30-days evaluation had been completed after move-in in 07/2024. The need to ensure the move-in evaluation included all required elements and was updated with changes as appropriate within the first 30 days was discussed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 9:05 am. Staff acknowledged the findings. 3. Resident 6 was admitted to the facility in 12/2022 with diagnoses including autism, anxiety, depression, and schizoaffective disorder. Observations of the resident, interviews with staff and the resident, and review of the resident’s 08/15/24 through 10/20/24 progress notes, and temporary service plans were completed. Resident 6's service plan evaluation was dated with an "effective date" of 12/07/22, with the most recent area updated 07/22/24. During an interview with Staff 7 (RCC) the most current evaluation was provided dated 07/11/23. There was no documented evidence an evaluation had been completed quarterly. During an interview with Staff 1 (ED) and Staff 2 (Operations Specialist) on 10/23/24 at 3:40 pm, Staff 2 stated the previous RN did evaluations on a yearly basis and not quarterly. The need to ensure quarterly evaluations were completed was discussed with Staff 1, Staff 2, Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 10:20 am. They acknowledged the findings.

1) Person centered service plans will be up to date quarterly, annually and upon change of condition. Resident #4, 5, 6 service plans have been reviewed and updated to reflect there current needs and will continue to be quarterly or as needed. ED/RCC will continue reviewing up coming service plans and schedule care conferences with residents and their responsible parties. 2) ED/RCC will review initial evaluations/assessments for completeion prior to admissions and confirm all categories are answered, dated, signed and filed in resident charts appropriately. ED/RCC will review calendars for up coming quarterly service plans 5x weekly during clinical meetings, reviewed and updated. Care conferences will be scheduled a month in advance either in person, over the phone, face time or email. 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services, were readily available to staff, and/or changes and entries made to the service plan were dated and initialed for 7 of 9 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 05/2024 with diagnoses including type 2 diabetes mellitus and cystitis. Interviews with the resident and facility staff were conducted. The current service plan dated 05/30/24 was reviewed. Resident 5's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Presence of depression, thought disorders, behavioral and mood problems; * How a person expresses pain or discomfort; * Personality, including how the person copes with change or challenging situations; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * How a person expresses memory loss; * Number of staff needed to assist with emergency evacuations; * Number of staff needed to assist with activities of daily living; * Instructions for bleeding precautions and interventions while on anticoagulation therapy (Eliquis); * Instructions to staff on blood glucose monitoring protocol when resident sleeps late and skips breakfast; * Instructions on signs and symptoms of hypo- and hyperglycemia to report; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Instructions on fall prevention; * Skin integrity and instructions on to whom to report skin impairments; * Incorrect reference to having a pet; * Incontinence care and maintenance of supplies; * Instructions for signs and symptoms of adverse effects to report while resident is on antibiotic therapy; * Instructions for signs and symptoms of post-fall injury to report; and * Instructions for signs and symptoms of dehydration to report related to the recent urinary tract infections. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), and Staff 4 (Regional Business Office Manager) on 10/24/24. They acknowledged the findings. No further information was provided. 2. Resident 7 was admitted to the facility in 09/2022 with diagnoses including multiple sclerosis. Service plans were available to staff in the medication room on the second floor. There was no documented evidence Resident 7’s service plan was included in the binder and was not available to staff at the time of the survey. The need to ensure service plans were readily available to staff was reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), and Staff 4 (Regional Business Office Manager) on 10/24/24. They acknowledged the findings. 3. Resident 3 moved into the facility in 01/2023 with diagnoses including mild cognitive impairment. Observations of the resident, interviews with the resident and staff, the 07/01/24 service plan and Interim Service Plan (ISPs), from 07/26/24 thru 10/17/24, reviewed during the survey, revealed Resident 3's service plan was not reflective of his/her status and did not provide clear directions regarding the delivery of services including what, when, how and how often the service should be provided in the following areas: * 2-person assist with transfer status; * Use of a wheelchair for ambulation; * Use of a urinal status for bladder elimination; * Level of toileting assistance status; * Use of glasses; * Dressing assistance; * Personal hygiene assistance ; * Shower assistance; * Use of side rails; * Pain status including location of pain; and * Hospice services. On 10/24/24 at 9:05 am, the service plan was discussed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager). Staff acknowledged the service plan was not reflective of the resident's status and lacked clear direction to staff. 4. Resident 4 moved into the facility in 07/2024 with diagnoses including major neurocognitive disorder and bipolar disorder. Observations of the resident, interviews with the resident and staff, the 07/24/24 service plan and Interim Service Plan (ISPs), from 07/29/24 thru 10/19/24 reviewed during the survey, revealed Resident 4's service plan was not reflective of the resident's status and did not provide clear directions regarding the delivery of services including what, when, how and how often the service should be provided in the following: * Customary routines including sleeping and eating; * Interests, hobbies, social, leisure activities; * Spiritual, cultural preferences and traditions; * Cognition, including memory, orientation, confusion and decision making abilities; * Use of glasses; * Mental health status including non-drug interventions; * Personality including how the person copes with change or challenging situations; * Toileting assistance; * 2-person assist with transfers; * Use of a wheelchair for ambulation; * Dressing assistance; * Shower assistance; * Personal hygiene assistance; * Nutrition habits and fluid preference; * Emergency evaluation ability; and * Environmental factors that impact the resident’s behavior including, but not limited to noise, lighting and room temperature. On 10/24/24 at 9:05 am, the service plan was discussed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager). Staff acknowledged the service plan was not reflective of the resident's status and lacked clear directions to staff. 5. Resident 6 was admitted to the facility in 12/2022 with diagnoses including autism, anxiety, depression, and schizoaffective disorder. The service plan with updates dated 07/22/24, temporary service plans and narrative charting notes dated 08/15/24 through 10/20/24 were reviewed. Interviews with care staff, the resident and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas: * Ambulation regarding use of walker; * Bathing regarding refusals/interventions; * Behavioral Management; * Meals/Nutrition regarding preferences; * Medications regarding what can be left at bedside; * Resident 6’s desire to have door propped open on occasion; and * Family involvement. The need to ensure service plans were reflective of the resident's care needs and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 10:20 am. They acknowledged the findings. 6. Resident 1 was admitted to the facility in 03/2018 with diagnoses including hemiplegia. Observations of the resident, interviews with staff, and review of the resident's 07/31/24 service plan, 07/20/24 through 10/20/24 progress notes showed the service plan was not reflective of the resident's current care needs, inconsistently implemented and/or did not provide clear direction to staff in the following areas: * Puree diet, coughing/choking concerns; * Behaviors and refusals of care; * Toileting assistance; * Transfer assistance; * Device use including seat belt, halo rails and transfer pole; * Electric wheelchair use and care; * Seizures; and * Suicidal ideations and anxiety. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), Staff 4 (Regional Business Office Manager) and Witness 2 (RN Consultant) on 10/24/24. The staff acknowledged the findings. 7. Resident 2 was admitted to the facility in 01/2024 with diagnoses including weakness. a. Observations of the resident, interviews with staff, and review of the resident's 09/18/24 service plan, and 08/15/24 through 10/18/24 progress notes showed the service plan was not reflective of the resident's current care needs, inconsistently implemented and/or did not provide clear direction to staff in the following areas: * Dressing assistance; * Toileting assistance, incontinence, and brief changes; * Grooming assistance, oral care and hygiene; * Pet care needs, frequency and who was responsible; * Alcohol use; * Eye glass care and use; * Fall and safety interventions; * Chronic urine odors and urination in areas other than the toilet; * Ambulation assistance and stability; and * Device use including wheelchair, cane and walker. b. Multiple handwritten entries were noted on the service plan which did not have dates and/or initials with the entries. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), Staff 4 (Regional Business Office Manager) and Witness 2 (RN Consultant) on 10/24/24. The staff acknowledged the findings.

1) Service plan reports reviewed by ED, RCC, Nursing 5x weekly during clinical meetings and upon change of condition. Service plans will be updated with current resident changing needs to remain in compliance. Including annual, quarterly and change of condition. Residents #1, 2, 3, 4, 5, and 6 service plans were reviewed and updated to reflect the current needs. Resident #7's service plan has been updated to reflect current needs and placed in the service plan binder. 2) ED/RCC will be reviewing calendars durng clinical meetings 5x weekly to see what is due and update as needed. 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

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

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

Based on observation, interview, and record review, it was determined the facility failed to have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who could determine if a change in the resident’s condition required further action, and to ensure changes of condition were evaluated and referred to the RN when needed, interventions were determined, documented, communicated to staff, and implemented and interventions were monitored for effectiveness and to monitor and document weekly progress of short-term changes of condition until resolved for 4 of 8 sampled residents (#s 1, 2, 4 and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 07/2024 with diagnoses including major neurocognitive disorder and bipolar disorder. Review of the resident's clinical record including Narrative Charting from 07/29/24 through 10/20/24, the 07/24/24 service plan and interim service plans (ISP’s) from 07/29/24 thru 10/19/24 were completed during the survey. The resident had eight non-injury falls between 08/31/24 and 10/18/24. The facility failed to monitor the resident’s repeated falls consistent with his/her evaluated needs and service plan. There was no documented evidence the facility determined the cause of falls, ensured interventions were implemented and monitored the interventions for effectiveness. The need to ensure the facility determined, ensured interventions were implemented and monitored the interventions for effectiveness was discussed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 9:05 am. Staff acknowledged the findings. 2. Resident 6 was admitted to the facility in 12/2022 with diagnoses including autism, anxiety, depression, and schizoaffective disorder. A review of the resident’s service plan dated 07/22/24, interim service plans, and narrative charting from 08/15/24 through 10/20/24 indicated the following changes of condition: * 10/18/24 narrative charting note staff indicated a “wound on [his/her] ankle”. There was no evidence the change of condition was evaluated and referred to the facility nurse for assessment and determined what actions and interventions were needed for the resident, and provided written instructions to staff. In an interview with Staff 12 (MT) on 10/22/24 at 3:55 pm she stated they were without a facility RN when the wound was discovered. The need to ensure significant changes of condition be evaluated and referred to the facility RN was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 10:20 am. The findings were acknowledged. 3. Resident 1 was admitted to the facility in 03/2018 with diagnoses including hemiplegia. Observations of the resident, interviews with staff, and review of the resident's 07/31/24 service plan, 07/20/24 through 10/20/24 progress notes, interim service plans and incident investigations were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Non-injury falls; * Skin breakdown and injury; * Neck pain; and * Urinalysis and urinary tract infection. The need to ensure short-term changes of condition had weekly progress documented until resolution, provided clear and resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), Staff 4 (Regional Business Office Manager) and Witness 2 (RN Consultant) on 10/24/24. The staff acknowledged the findings. 4. Resident 2 was admitted to the facility in 01/2024 with diagnoses including weakness. Observations of the resident, interviews with staff, and review of the resident's 09/18/24 service plan, 08/15/24 through 10/18/24 progress notes, interim service plans and incident investigations were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Injury and non-injury falls; * Emergency room visits; * Urinary tract infection and antibiotic use; and * Skin issues including skin tears. The need to ensure short-term changes of condition had weekly progress documented until resolution, provided clear, and resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), Staff 4 (Regional Business Office Manager) and Witness 2 (RN Consultant) on 10/24/24. The staff acknowledged the findings.

Community will maintain a montoring and reporting system through the use of an end of shift report. The report will be reviewed 5x weekly in clinical meeting ensuring COC are identified, evaluated and documented. Community RN to review and document until resolution is found. Resident #1- nursing assessment and evaluation to be completed prior to date of compliance Resident #2 is under RN monitoring for significant change of condition. Resident #4 is under RN monitoring for significant change of condition. Resident #6 is under RN monitoring for significant change of condition. 2) Staff will be trained on incidents and significant change of condition reporting. Staff will be trained on the use of the end of shift report. Staff will be trained on the use of the ISP's and interventions for significant change of condition. ED/RCC reviewing incident reports completeing investigations when needed and confirming appropriate resident specific interventions 5x weekly. ED/RCC and nursing support is available 24/7. Any significant change of condition will be discussed during clinical meeting between ED,RCC,Nursing and all documentation will be updated accordingly. 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

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

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for 4 of 4 sampled residents (#s 2, 3, 4 and 9) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 01/2023 with diagnoses including mild cognitive impairment. During the acuity interview on 10/21/24 it was reported the resident had a hospital stay and discharged with hospice services. Observation of the resident and interview with the resident and staff were conducted. Review of the resident's clinical record including Narrative Charting from 07/29/24 through 10/20/24, the 07/24/24 service plan and interim service plans (ISP’s) from 07/29/24 thru 10/19/24 were completed during the survey. The resident’s clinical record indicated the resident was admitted to the hospital from 10/14/24 to 10/16/24 and was discharged to the facility with hospice services on 10/16/24. During an observation of the resident on 10/22/24 at 8:54 am, the resident required 2-person assistance with transfer and toileting care. In an interview on 10/22/24 at 11:43 am, Staff 19 (Personal Care Assistant) reported the resident currently required 2-person assistance with transfers, toileting and dressing care. The resident no longer used a walker for ambulation, s/he now used a wheelchair to ambulate. The resident was independent in ADLs prior to the last hospital stay. This constituted a significant change of condition which required an RN assessment. There was no documented evidence an RN assessed and documented Resident 3's condition, status or the findings made as a result of an RN assessment. The need to ensure an RN assessment was completed for a significant change of condition was discussed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 9:05 am. Staff acknowledged the findings. 2. Resident 4 moved into the facility in 07/2024 with diagnoses including major neurocognitive disorder and bipolar disorder. During the acuity interview on 10/21/24, it was reported the resident experienced a significant decline in his/her ADL status. Observation of the resident and interview with the resident and staff were conducted. Review of the resident's clinical record including Narrative Charting from 07/29/24 through 10/20/24, the 07/24/24 service plan and interim service plans (ISP’s) from 07/29/24 thru 10/19/24 were completed during the survey. During an observation of the resident on 10/22/24 at 9:55 am, the resident required 2-person assistance with transfer. Review of the resident’s record indicated the resident had eight non-injury falls between 08/31/24 and 10/18/24. In an interview on 10/22/24 at 10:05 am, Staff 15 (Personal Care Assistant) reported approximately 2 weeks ago, the resident required 2-person assistance with transfers, toileting and dressing care. The resident was no longer able to use a walker for ambulation, s/he now used a wheelchair for ambulation. The resident was independent in ADLs when moved in 07/2024. This constituted a significant change of condition which required an RN assessment. There was no documented evidence an RN assessed and documented Resident 4's condition, status or the findings made as a result of an RN assessment. The need to ensure an RN assessment was completed for a significant change of condition was discussed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 9:05 am. Staff acknowledged the findings. 3. Resident 2 was admitted to the facility in 01/2024 with diagnoses including weakness. Observations of the resident, interviews with staff, and review of the resident's 09/18/24 service plan, and 08/15/24 through 10/18/24 progress notes, physician communications and interim service plans were completed. The resident required intermittent assistance from staff for ADL care. The resident was able to eat independently after escort to the dining room and was provided some reminders both to eat and to drink. The resident preferred to stay in bed as much as possible. The resident was unable to consistently make needs known, was a high fall risk due to instability and had ongoing confusion which had worsened over the last 1-2 months. The resident had poor safety awareness and did not recognize his/her limitations. The resident had a decline in condition that resulted in an increase in falls beginning mid-August 2024. The resident was seen in the emergency room on 08/29/24 for a scalp contusion after hitting his/her head during a fall and for a hernia. The resident was again at the hospital from 09/05/24 to 09/06/24 for a urinary tract infection. The resident had a physician follow-up on 10/04/24 for bladder infection, muscle wasting and brain injury. Multiple observations of the resident between 10/21/24 and 10/23/24 showed the resident in his/her room and in the dining room. The resident’s room had severe and pervasive odors, open food items on multiple surfaces and soiled items placed on the dresser and in the corner of the bedroom. The resident was unable to call for staff assistance on his/her own, could not answer questions regarding assistance s/he might need and was frequently asleep in the recliner chair or the bed. Interviews conducted between 10/21/24 and 10/24/24 revealed the following: The resident was not interviewable due to cognitive impairment. The facility RN was no longer with the facility and unavailable for interview. Staff 13 and 19 (MTs) indicated the resident had declined quite a bit over the last month or two and significantly since his/her admission. The staff indicated the resident previously was independent with his/her ADLs and would walk self to the dining room for meals. Staff 19 indicated the resident could no longer walk the distance to the dining room and was transported in a wheelchair. Staff 19 stated the resident needed one-person full assistance for all ADLs. The resident could help with some tasks but needed the hands on as well as the verbal cues. Staff 14 and 15 (Personal Care Assistants) indicated the resident was not able to effectively complete his/her ADLs. The resident attempted to do things on his/her own but needed staff to assist with the process especially with toileting, incontinence care, hygiene, and bathing. Staff took care of the resident’s cat as the resident was not reliable and confused the food and the litter on more than one occasion. The staff indicated the resident could feed himself/herself once taken to the dining room, all other ADLs such as toileting, dressing, incontinent care required physical staff assistance. The resident had declined in his/her abilities and cognition a lot in the last month or two. The staff indicated if the resident left the facility his/her confusion would likely prevent him/her from making it back. Staff 1 (ED) indicated the resident had declined quite a bit in the last month. The facility RN was to complete a significant change assessment prior to their departure but the assessment was not completed. The facility failed to ensure an RN assessment was completed for a decline in ADLs and an increase in assistance, which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), Staff 4 (Regional Business Office Manager) and Witness 2 (RN Consultant) on 10/24/24. The staff acknowledged the findings. 4. Resident 9 was admitted to the facility in 12/2023 with diagnoses including stroke and dementia. Observations of the resident, interviews with staff, and review of the resident's 09/20/24 service plan, and 07/23/24 through 10/12/24 progress notes, physician communications and interim service plans were completed and showed the following: The resident required one staff assistance for most ADL care, with two staff noted for dressing, transfers and bathing. The resident was able to eat independently after escort to the dining room by staff or the resident’s spouse. The resident’s left side was paralyzed, and the left arm was kept in a sling for resident comfort. The resident had chronic hip pain with several medication changes completed to best address the pain and limit side effects. Observations of the resident showed s/he attended meals with his/her spouse and spent time in their apartment. The resident was observed seated in a wheelchair or in his/her recliner chair. The resident was admitted to Hospice services on 08/07/24. The facility RN was no longer with the facility and unavailable for interview. In an interview on 10/23/24, Staff 1 (ED) indicated the resident’s spouse assisted the resident with what she/he could, and staff assisted with other ADL care needs and requests. Staff 1 was unable to locate any documentation of an RN significant change assessment. The facility failed to ensure an RN assessment was completed for Hospice admission, which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), Staff 4 (Regional Business Office Manager) and Witness 2 (RN Consultant) on 10/24/24. The staff acknowledged the findings.

1) The Community will ensure a RN assessment is completed when a resident experiences a significant change of condition. Resident #2 has been placed on significant change of condition. Resident #3 has been placed on significant change of condition. Resident #4 has been placed on significant change of condition. Resident #9 has been placed on significant change of condition. 2) Clinical staff will be trained on recognizing signs of significant change of condition. ED/RCC will be reviewing any reports of significant change of condition during clinical meetings 5x weekly. All documentation required with significant change of condition ill be completed, charts updated and filed appropriately. 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

OAR 411-054-0050(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

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 1 of 1 sampled resident (#4) related to incontinence care and failed to have an "Infection Control Specialist" qualified by education, training and experience or certification. Findings include, but are not limited to: 1. In an interview on 10/22/24 at 9:50 am, Staff 1 (ED) reported the facility did not have a designated individual to be the facility's "Infection Control Specialist," responsible for carrying out the infection prevention and control protocols, qualified by education, training, and experience or certification, and who had completed specialized training in infection prevention and control protocols. The need to ensure the facility had a designated “Infection Control Specialist,” was discussed with Staff 1, Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager), on 10/24/24 at 10:20 am. They acknowledged the findings. 2. Resident 4 moved into the facility in 07/2024 with diagnoses including major neurocognitive disorder and bipolar disorder. The surveyor observed on 10/23/24 at 10:10 am, Staff 19 (MT) and Staff 24 (Personal Care Assistant) provided incontinence care for Resident 4. During the observation, Staff 19 donned gloves without performing hand hygiene. Staff 19 then proceeded to remove the resident’s soiled brief, wipe and cleanse the resident’s perineum area and touched the resident’s body, clean incontinent product, hair, the resident’s clean clothing and wheelchair while using the soiled gloves. Staff 19 failed to change gloves between clean and dirty tasks and perform hand hygiene prior to donned gloves. The above observation was discussed with Staff 1 (ED) on 10/23/24 at 10:53 am and Staff acknowledged appropriate infection control practices were not implemented.

1) ED and BOM have completed the required course and are now Certified Infection Control Specialists for the community. Staff will be trained on proper infection control procedures upon hire and quarterly. Staff will be trained on Proper Hand Washing while providing peri/incontinence care with use of gloves by date of compliance. Staff have been observed providing incontinence care to ensure this is being done correctly with Resident #4. 2) ED/BOM/designee will ensure infection control trainings are completed upon new hire and annually by all staff. 3) All staff are going to be trained prior to date of compliance, then annually. All new hires will be trained prior to working with residents. 4) ED/BOM/Designee

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

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

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and obtained signed physician or other legally recognized practitioner orders in the resident's record for all medications and treatments that the facility was responsible to administer for 2 of 7 sampled residents (#s 3 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 01/2023 with diagnoses including mild cognitive impairment. Review of the resident’s 10/01/24 – 10/21/24 MARs and physician orders showed Resident 3 had physician orders, started on 10/17/24, to administer Acetaminophen (a medication to treat minor pain) 650 mg every four hours for 10 days and Senna S (a medication to treat constipation) 8.6 – 50 mg twice daily. The MAR showed staff circled initials which indicated these medications had not been administered to the resident and documented “waiting for delivery” from 10/17/24 through the time of the survey, 10/21/24. The need to ensure physician orders were followed as prescribed was discussed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 9:05 am. They acknowledged the findings. 2. Resident 4 moved into the facility in 07/2024 with diagnoses including major neurocognitive disorder and bipolar disorder. a. Review of the resident’s 09/01/24 – 10/21/24 MARs and providers orders showed Resident 4 had physician orders, dated 07/05/24, to administer Meclizine three times daily as needed for dizziness. The MAR showed staff administered the medication three times daily as scheduled for 49 days, not as needed as ordered. b. The MAR showed staff provided a triple antibiotic treatment daily scheduled and obtained blood sugar result daily scheduled for 52 days. There was no order for the treatment and measuring the blood sugar level. The orders were not provided prior to exit. The need to ensure physician orders were followed as prescribed for all medications and obtained treatment orders that the facility was responsible to provide was discussed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 9:05 am. They acknowledged the findings.

1) ED/RCC will review reports reflecting orders/missed meds 5x weekly to assure all medications are on hand with appropriate orders. All orders will be reviewed through triple check system starting with med tech/ED/RCC/Nursing. Orders will be sent to pharmacy timely and checked upon each shift for status of medication delivery. Family members will be notified of medication not arriving and if medication can not be received in a timely manner facility will purchase. Resident #4 Meclizine, CBGs and triple antibiotic orders have been corrected. Resident #3 Acetaminophen and Senna were received and administered. 2) We have initiated a 5x weekly clinical meeting and a three check system for all orders. New orders will be reviewed during clinical meeting for mar accuracy. 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

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

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

Based on interview and record review, it was determined the facility failed to ensure MARs were kept accurate, included reasons for use, resident-specific parameters for PRN medications and medication-specific instruction to instruct non-licensed staff for 2 of 7 sampled residents (#s 3 and 9) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 01/2023 with diagnoses including mild cognitive impairment. Resident 3's 10/01/24 through 10/21/24 MARs were reviewed and identified the following: * Triamcinolone 0.1 % daily lacked the location to apply; * Lidocaine 5 % patch daily, Fentanyl patch every three days and Scopolamine 1 mg patch every three days as needed lacked reason for use; and * Acetaminophen 650 mg every four to six hours as needed for pain lacked clear parameters on when 4 hours vs. 6 hours. The need to ensure the MAR was kept accurate and included reason for use and had clear instructions for unlicensed staff to follow was reviewed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 9:05 am. They acknowledged the findings. 2. Resident 9 was admitted to the facility in 12/2023 with diagnoses including stroke. Review of the resident's 09/01/24 through 10/21/24 MARs, 07/23/24 through 10/12/24 progress notes and 09/05/24 physician orders showed the following: * Tylenol 325 mg tablets, give 650 mg every four hours PRN for pain. * Tylenol 500 mg tablets, give 1-2 tablets three times a day PRN for pain. * Bisacodyl suppository, give once a day PRN constipation. * Hycosamine Sulfate 0.125 mg tablet, give one tablet every four hours PRN for excessive secretions. * Loperamide 2.0 mg tablet, give two tablets after first loose stool then one tablet after each consecutive stool, not to exceed eight tablets in 24 hours; and * Loperamide 2.0 mg tablet, give two tablets after first loose stool then one tablet after each consecutive stool, not to exceed four tablets in 24 hours. There were no resident specific parameters for the start of bowel medication, what to watch for related to excessive secretions, when to use one tablet vs. two tablets of Tylenol and no information was documented regarding the duplicate orders with different dosages and maximum dose administration. The need to ensure medication administration records were complete was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Witness 2 (RN Consultant) on 10/24/24. The staff acknowledged the findings.

1) Orders will be reviewed through triple check system and then during clinical meeting between the ED/RCC/Nursing. Resident #3 idetified medications have been corrected with reason for use. 90 day orders have been sent to PCP for clarification. The acetamenaphen order will be corrected by 12/23. Resident #9 90 day orders have been sent in to PCP for clarification and RN review will be completed prior to date of compliance 12/23/24. 2) Clinical meetings will be 5x weekly 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

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

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer medications had an evaluation completed at least quarterly to determine their ability to self-administer medications for 2 of 2 sampled residents (#s 8 and 9) reviewed for self-administration. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 02/2024. The resident was identified during the acuity interview on 10/21/24, as a resident who self-administered their own medication. a. The resident was considered independent with all his/her ADLs. The resident had no progress notes to review. The last signed physician orders in the resident’s record were from admission in February 2024. The orders indicated the resident was able to self-administer his own medications. There was no evaluation of the resident’s ability to safely administer his/her medications in the record. 2. Resident 9 was admitted to the facility in 12/2023 with diagnoses including stroke. Resident 9 required staff assistance of one person for ADLs and two staff for transfers. The resident shared an apartment with his/her spouse in the facility. The facility administered all of Resident 9’s medications. There was no evaluation of Resident 9’s safety related to his/her spouses self-administration of medications and storage of medications in the shared apartment. The need to ensure residents who self-administered their medications were evaluated at least quarterly and those who shared the same living space were also evaluated, was discussed with Staff 1 (ED) and Staff 7 (RCC) on 10/22/24 and 10/23/24. The staff acknowledged the findings.

1) Nursing will assure all self med assessments are completed quarterly upon service plan quarterly reviews and or as needed. Resident #8 & 9 self medication assessments have been completed. 2) All new and current residents that are identified as self med appropriate will refer to RN for initial self med eval and quartly updates. 3) Quarterly 4) ED/RCC/Nursing

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

OAR 411-054-0055 (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.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 2 of 2 sampled residents (#s 3 and 9) who were prescribed PRN medications to address behaviors. Findings include, but are not limited to: 1. Resident 9 was admitted to the facility in 12/2023 with diagnoses including stroke. Review of the resident's 09/01/24 through 10/21/24 MARs, 07/23/24 through 10/12/24 progress notes and 09/05/24 physician orders showed the following: * Lorazepam 0.5 mg tablet, give one tablet every four hours PRN for anxiety. The Lorazepam PRN dose was administered three times in September 2024. No doses were administered between 10/01/24 and 10/03/24, the medication was then placed on hold. * Haloperidol 2 mg/ml, administer 0.50 ml every six hours PRN for agitation, nausea and restlessness. The Haloperidol was administered six times in September 2024. The medication was not administered in between 10/01/24 and 10/23/24. The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety, distress, or agitation. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medication. The need to ensure resident-specific information on how the resident expressed anxiety/agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), Staff 4 (Regional Business Office Manager) and Witness 2 (RN Consultant) on 10/24/24. The staff acknowledged the findings. 2. Resident 3 moved into the facility in 01/2023 with diagnoses including mild cognitive impairment. During the acuity interview on 10/21/24, Resident 3 was identified as being prescribed as needed psychotropic medication. Resident 3’s 10/01/24 through 10/21/24 MAR and signed physician orders were reviewed and identified the following PRN psychotropic medication was prescribed and administered: * Ativan 0.5 mg one tablet by mouth every two hours as needed for anxiety; * The PRN medication was administered on two occasions on 10/17/24 and 10/18/24; * The MAR lacked written instruction of clear parameters of how the resident exhibited anxiety; * Non-drug interventions were not listed on the MAR; and * There was no documented evidence unlicensed staff documented non-pharmacological interventions attempted with ineffective results prior to administering the PRN psychotropic medication. The above findings were discussed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 9:05 am. They acknowledged the findings.

1) Nursing has reviewed all non pharmological interventions for psychotropic medications. Resident #3 & 9 non pharmalogical interventions and perimeters have been added. 2) Quarterly MAR review by RN before sending out 90 day orders. Med Tech training for notification of new psychotropic meds to RN. Mars are reviewed during clinical 5x weekly and will be updated as needed. 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

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.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use and provided instruction to the caregivers on the correct use and precautions for 1 of 1 sampled resident (# 3) who had bilateral half-length side rails on the bed. Findings include, but are not limited to: Resident 3 was observed on 10/22/24 at 9:05 am, to have bilateral half-length side rails on the bed, the left side rail was in the up position, and the right-side rail was in the down position. The side rails were identified to be devices with potentially restraining qualities. Review of the resident's clinical record showed the following: * No documented evidence of an assessment completed by a RN, Physical Therapist or Occupational Therapist for the use of the side rail. Therefore, there was no documented evidence that other less restrictive alternatives had been attempted prior to their use; and * No instruction provided on the service plan for care staff related to use and precaution of the side rails. On 10/24/24 at 9:05 am, the lack of documented assessment and care instructions for the use of the side rail was reviewed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager). They acknowledged the findings.

1) Audit completed to confirm all assistive devices in community. All residents with assistive devices will have assessment completed. Resident #3 no longer has hospital bed with half rails. 2) Walk through completed by care staff to identify any new assitive devices and reported to ED/RCC. ED/RCC will verify proper orders, training for staff, nursing assessment is completed where needed and added to service plan during 5x weeklly clinical meetings. 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

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

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

Based on interview and record review, it was determined the facility failed to ensure they had been consistently staffing to the posted staffing plan. Findings include, but are not limited to: The facility’s ABST entries, staff schedule, calculated staffing hours, and posted staffing plan were reviewed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager). The following was identified: The facility posted staffing plan was as follows: Day Shift: Four Personal Care Assistant and Two Med-Techs; Swing Shift: Four Personal Care Assistant and Two Med-Techs; and Night Shift: Two Personal Care Assistant and One Med-Tech. Staff schedule dated 10/15/24 through 10/21/24 was reviewed. On 10 occasions the number of staff that worked did not meet the posted staffing plan. The need to ensure the facility staffing plan and staff working on the floor exceeded the ABST staffing calculations and that the posted staffing plan matched the current staffing plan was discussed with Staff 1, Staff 2, Staff 3 and Staff 4 on 10/24/24 at 10:20 am. They acknowledged the findings.

1) ABST has been completely reviewed and is current to service plan/assessment. Continuing to interview, hire and train appropriate staff to meet staffing requirements. 2) We will continue to hire and train appropriate staff to meet the needs of our residents in order to meet the needs of the ABST 3) Daily, Weekly, Monthly 4) ED

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

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

Based upon interview and record review it was determined the facility failed to ensure their use of a proprietary Acuity Based Staffing Tool (ABST) had been Department-approved. Findings include, but are not limited to: Records provided by Staff 1 (ED) on 10/23/24 at 8:30 am revealed the facility utilized a proprietary ABST tool called, “AL Advantage”. In an interview with Staff 1 on 10/24/24 at 10:20 am she was unable to provide documented evidence the use of “AL Advantage” had been Department-approved. The need to ensure facilities who utilized proprietary ABST programs had been approved by the Department was discussed with Staff 1, Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 10:20 am. They acknowledged the findings.

1) We will continue to use the State approved ABST portal. 2) ABST has been completed, reviewed and updated in order to meet the needs of our residents. 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

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

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 6 sampled residents (#s 3, 4, and 6) whose ABST were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 01/2023 with diagnoses including mild cognitive impairment. Observations of the resident, interviews with the resident and staff, the 07/01/24 service plan and Interim Service Plan (ISPs), from 07/26/24 thru 10/17/24, and Resident 3’s ABST data was reviewed. The following areas were not reflective of the residents current ADL assistance: * How much time is spent transferring in or out of bed or a chair? * How much time is spent monitoring physical conditions or symptoms? * How much time is spent assisting with communication, assistive devices for hearing, vision, speech? * How much time is spent responding to call lights? * How much time is spent on safety checks, fall preventions? * How much time is spent providing additional care services? The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), Staff 4 (Regional Business Office Manager) on 10/24/24 at 10:20 am. They acknowledged the findings. 2. Resident 4 moved into the facility in 07/2024 with diagnoses including major neurocognitive disorder and bipolar disorder. Observations of the resident, interviews with the resident and staff, the 07/24/24 service plan and Interim Service Plan (ISPs), from 07/29/24 thru 10/19/24, and Resident 4’s ABST data were reviewed. The following areas were not reflective of the residents current ADL assistance: * How much time is spent on personal hygiene such as shaving or mouth care? * How much time is spent on grooming such as nail care or brushing hair? * How much time is spent helping with bowel and bladder management? * How much time is spent with bathing? * How much time is spent transferring in or out of bed or a chair? * How much time is spent on ambulation, escorting to and from meals or activities? * How much time is spent monitoring physical conditions or symptoms? * How much time is spent assisting with communication, assistive devices for hearing, vision, speech? * How much time is spent responding to call lights? * How much time is spent on safety checks, fall preventions? * How much time is spent providing additional care services? The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Vice President of Regional Operations), Staff 4 (Regional Business Office Manager) on 10/24/24 at 10:20 am. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 12/2022 with diagnoses including autism, anxiety, depression, and schizoaffective disorder. The service plan with updates dated 07/22/24, temporary service plans and narrative charting notes dated 08/15/24 through 10/20/24, and Resident 6’s ABST data were reviewed. The following areas were not reflective of the residents current ADL assistance: * How much time is spent ensuring non-drug interventions for behaviors? * How much time is spent monitoring physical conditions or symptoms? * How much time is spent responding to call lights? The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Vice President of Regional Operations), Staff 4 (Regional Business Office Manager) on 10/24/24 at 10:20 am. They acknowledged the findings.

1) ED/RCC will assure ABST tool addresses amount of time staff need to provide care to each resident. The 22 elements required to be reviewed and noted to be in compliance. Residents #3, 4 and 6 have been added and updated in the state approved ABST. 2) All residents in the ABST will be reviewed for accuracy. Ongoing ABST updates will be completed when there is a change in the service plan quarterly, annually and upon any COC. This will be reviewed by the ED/RCC 5x weekly during clinical. 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

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

Based on interview and record review, it was determined the facility failed to ensure the ABST evaluation for each resident was updated with significant changes of condition, and/or quarterly at the same time the resident’s service plan was updated for 6 of 6 sampled residents whose ABST data was reviewed. Findings include, but are not limited to: The facility’s ABST data and posted staffing plan were reviewed on 10/23/24 at 5:09 pm. The following was identified: Review of sampled resident’s ABST data for Resident #1, 2, 3, 4, 5, and 6 revealed there was no documented evidence the ABST had been reviewed and updated quarterly and/or with significant changes of condition. Therefore, the ABST did not generate an accurate staffing plan. The need to ensure the ABST evaluation for each resident was updated with significant changes of condition, and/or quarterly at the same time the resident’s service plan is updated was discussed with Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 10:20 am. They acknowledged the findings.

1) ABST has been updated along with assessments and service plans. Residents #1,2,3,4,5,6 ABST has been completed. Staffing plan has been updated and posted. 2) ED/RCC reviewing 5x weekly during clinical meeting. ABST, assessment's and service plan's will all be completed/updated at the same time. Staffing plan will be updated and posted as needed 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

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

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

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 caregiving staff (#s 5, 8, 10 and 15) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to: Review of the facility's training records was completed on 10/22/24. Staff 20 (Personal Care Assistant), hired 08/22/24, Staff 21 (Personal Care Assistant) hired 07/24/24, Staff 22 (Personal Care Assistant), hired 09/05/24, and Staff 23 (MT), hired 06/10/24, lacked documented evidence they had demonstrated competency in all areas within 30 days of hire, including but not limited to: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; * If the direct care staff person’s duties include the administration of medication or treatments, the facility must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised and Staff 23 (MT), lacked documented medication administration competency; and * First aid and abdominal thrust training for Staff 21 and 22. On 10/22/24 at 1:37 pm, survey requested Staff 23 be removed from administering medications until medication competency could be verified and documented. The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 9:05 am. They acknowledged the findings.

1) Orientation/Onboarding is done the same day every week, with an agenda and a sign off signature page to be singed by managers after they have completed there portion. Compentency Demostration will be completed on 5,8,10,15 by compliance date of 12/23/24. All new hires going forward within 30 days of hire date will have a completed Compentency Demonstration signed by supervisor. Annual in-service training is done during monthly all staff. Staff #20, 21, 22, 23 will have trainings completed by date of compliance 12/23/24. BOM will audit on a weekly basis to confirm maintaining compliance. 2) ED/BOM will review during weekly one on one. Reviewing all new hire and annual/continous education for all staff training to ensure compliance. 3) Weekly, Monthly 4) ED/BOM

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

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

Based on interview and record review, it was determined the facility failed to ensure 1 of 4 long-term direct care staff (# 25) completed 12 hours of annual in-service training, including at least six hours of dementia care topics and annual infectious disease training based on their anniversary date of hire, and failed to ensure 5 of 6 long-term staff (#s 15, 24, 25, 26 and 28) completed approved annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed on 10/22/24 at 1:37 pm and the following was identified: a. There was no documented evidence Staff 25 (MT) hired 11/19/09 completed at least 12 hours of training based on their anniversary date of hire related to the provision of care in CBC, including annual infectious disease prevention training and a minimum of six hours of training on dementia care topics. b. There was no documented evidence Staff 15 (Personal Care Assistant) hired 09/25/19, and Staff 24 (Personal Care Assistant) hired 03/20/22, Staff 26 (Dishwasher), hired 09/16/21, and Staff 28 (MT), hired 06/11/21 completed approved annual training on infectious disease outbreak and control. The need to ensure long-term direct care staff completed and documented the required number of hours of annual in-service training and long-term staff completed approved annual infectious disease training was discussed with Staff 1 (ED) and Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations) and Staff 4 (Regional Business Office Manager) on 10/24/24 at 9:05 am. They acknowledged the findings.

1) Annual training is done during monthly all staff in-service. Staff # 15, 24, 25, 26, and 28 will have trainings completed by date of compliance 12/23/2024. 2) ED/BOM will review during weekly one on one. Reviewing all new hire and annual/continous education for all staff training to ensure compliance. 3) Weekly, Monthly 4) ED/BOM

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff (6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF. (a) Annual infectious disease training requires the following: (A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training. (B) Annual in-service training must be documented in the employee record. (b) Biennial LGBTQIA2S+ training requires the following: (A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff. (i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite. (ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. (vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state. (D) The proposal for training submitted by a facility, entity, or individual shall include: (i) The regulatory criteria described in paragraph (C) of this section as part of the proposal. (ii) The following elements must be included in the proposal: (I) A statement of the qualifications and training experience of the facility, individual or entity providing the training; (II) The proposed methodology for providing the training either online or in person. (III) An outline of the training. (IV) Copies of the materials to be used in the training. (iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision. (c) Annual Home and Community-Based Services (HCBS) training requires the following: (A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations. (B) Annual in-service training must be documented in the employee record. (C) These annual trainings will be required as of April 1, 2025. (7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF. (a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire. (b) Requirements for annual in-service dementia training: (A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care. (B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter. (C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above. (D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia. (E) The facility shall determine the competency of direct care staff in dementia care in the following ways: (i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19). (ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff. (iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency. (8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.

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

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months and to conduct unannounced fire drills according to the Oregon Fire Code. Findings include, but are not limited to: On 10/21/24, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed: 1. There was no documented evidence the facility provided fire and life safety training on alternating months for staff; and 2. Staff relocated second-floor residents during the fire drills using the facility elevator; therefore, the facility's fire drill documentation did not include information on potential problems encountered when the facility elevator was not operational. The need to provide fire and life safety instruction to staff on alternate months and the requirements regarding fire drills were discussed with Staff 6 (Maintenance Director) on 10/23/24 and Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), and Staff 4 (Regional Business Office Manager) on 10/24/24. They acknowledged the findings. No further information was provided.

1) Monthly fire drills; fluctuating shifts. Documentation completed and showing what went right and what potential problems were encountered. 2) ED/MD will be discussing and scheduling during one on one 3) Weekly, Monthly 4) ED/MD

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

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed, at least annually, on fire and life safety procedures according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 10/23/24. There was no documented evidence residents were 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. The need for residents to be re-instructed about fire and life safety procedures at least annually per the OFC was discussed with Staff 6 (Maintenance Director) on 10/23/24 and Staff 1 (ED), Staff 2 (Operations Specialist), Staff 3 (Regional Vice President of Operations), and Staff 4 (Regional Business Office Manager) on 10/24/24. They acknowledged the findings. No further information was provided.

1) Townhall scheduled for 11/20 with residents. Each resident will sign a Resident Fire and Life Safety training form while MD does the training. We will go room to room and provide training for the residents that do not come to townhall 2) Annual townhall in-service with residents. We will go room to room with training for the ones who do not come to townhall. 3) Upon M/I and Annually 4) ED/MD

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.

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.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces and surrounding pathways were maintained in good repair. Findings include, but are not limited to: a. Observations of facility pathways, patio, and seating areas on 10/21/24 and 10/22/24 identified the following: * Multiple drop-offs of two to six inches were noted along pathway edges around the perimeter of the facility, along the back patio and along resident individual patios; * Cracked concrete with missing pieces and raised edges was noted in the front of the facility as well as along the back patio; * Multiple areas of uneven concrete slabs were noted along the back pathways and patio outside the dining room. The concrete slabs were lifting and created one- to two-inch gaps and/or raised areas which created potential tripping hazards; and * Multiple paver pathways through the borders were lifting and/or uneven, which created uneven surfaces. b. Observations of the facility grounds on 10/21/24 and 10/22/24 showed the following: * Ripped, stained patio furniture was noted in the smoking area along with a broken table; * Broken doors, boxes, closet doors and furniture were stored along the back of the facility and in the grass area; and * A mattress, broken kitchen equipment, window screens and other damaged items were noted around the perimeter of the facility. The need to ensure pathways around the facility were in good repair with no potential tripping hazards and that the facility grounds were free of discarded items was discussed with Staff 1 (ED) and Staff 6 (Maintenance Director) on 10/22/24. The staff acknowledged the findings.

1) Submitted quote for top soil to raise ground level to sidewalk height. Submitted quote for contractor to professionally grind sidewalk to eliminate any trip hazards. Patio furniture and cluttered items around the community grounds have been cleared and discarded. 2) MD/ED will do community walk throughs weekly during one on one meeting. Making sure pathways are clear of trip hazards and cluttered items. 3) Daily, Weekly, Monthly 4) ED/MD

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.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility on 10/21/24 and 10/22/24 showed the following areas in need of cleaning or repair: * Multiple walls, doors, and door frames in the facility had scrapes, dings, chips, missing pieces of wood or spills; * Room 121’s bathroom had strong, pervasive urine odors throughout the room. The caulking around the toilet was discolored or missing in various sections. A window screen in the living room and in the bedroom were torn with large holes; * The floor in the laundry room had large pieces of the upper layer torn away from the area located between the stackable unit and the other unit; * Cupboards and drawers in the activity room had spills and drips, as well as stains and debris in the interiors; * Tile flooring in the front of the facility had sections of missing grout, and large gaps were noted to the laminate flooring near the fire doors by the front desk; * Multiple dark black/brown stains were noted to the hallway carpets on the main floor. A large red/orange carpet stain was noted near the west end hall exit; * Room 103 had large scrapes, dings and chunks missing from the door frame, along the wall and the corner of the wall at the doorway, and inside the apartment; * The exterior exit door to the smoking area had large chunks of the door frame missing, and long scrapes across the interior wall and chips/dings to the door itself; * A bucket with multiple cigarette butts and trash was located in the smoking area. A post in the area had multiple dark black/gray discoloration that appeared like ash; * Room 104, 119 and 221 had carpet stains outside the apartment doors; * Dead insects and debris were noted in multiple ceiling lights on the first and second floor hallways as well as in the staff laundry room; * Room 207 had a strong pervasive urine odor; * Upstairs laundry room had chips to the flooring with small pieces missing. The carpet at the transition to the door was pulling up; * Dead insects noted in the windowsill near the west exit door; * Washing machine interiors and lids in the staff laundry room had black/brown debris and stains. Storage shelves in the laundry room had dark stains and spills on multiple shelves; * Room 231 had strong urine odors throughout the apartment. Multiple walls, doors and door frames were dinged, chipped or missing large pieces; * Multiple pieces of siding in the back of the building were hanging from the side of the facility on the upper floor; * Damaged window screens were noted in several windows on the ground floor and vent covers were pulling away from the walls; and * Public bathroom near Room 127 had missing and discolored caulking around the toilet. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) and Staff 6 (Maintenance Director) on 10/22/24 and 10/23/24. The staff acknowledged the findings.

1) MD repairing wall damage, completing daily maintenance projects, deep cleanings throughout the community. AD completing deep clean of activity room including cabinets and drawers. MD collecting bids for flooring replaced in multiple areas. 2) ED/MD/AD will review during one on one meetings. walk the apartments and common areas and ensure there is no foul smell, clutter accumulated or maintenance issues not acknowledged. 3) Daily, Weekly, Monthly 4) ED/MD/AD

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.

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting.

Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the right to freedom from restraints. Findings include, but are not limited to the following: Refer to C330 and C340.

1) Nursing has reviewed all pharmological interventions for psychotropic medications. We will continue to use the State approved ABST portal. 2) ED/RCC completing 5x weekly clinical meetings. 3) Daily, Weekly, Monthly 4) ED/RCC/Nursing

OAR411-004-0020(1)(d) Individual Rights Settings Right to Freedom (1) Residential and non-residential HCB settings must have all of the following qualities: (d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS 443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting.

Based on observation and interview, it was determined the facility failed to ensure food was stored, and the kitchen was maintained, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen, food storage areas, food preparation, and food service on 10/03/23 revealed splatters, spills, drips, and debris noted on:   - Hand washing sink and supplies; - Stand mixer; - Spice self; - Bakers racks; - Exterior sides and interior of the gas range and oven; - The stove hood had a build up of grease and debris; - Walls throughout the kitchen; - Flooring throughout the kitchen; - Floor drains; - Door, flooring, fan, and shelving of walk-in refrigerator - Flooring, walls, and shelving of walk in freezer; - Dry storage area flooring, shelving, and food containers; - Interior of the microwave; - Dishes and cookware stored on open shelving and racks; - Open stainless steel shelving and metal rack shelving throughout the kitchen; - Underneath shelving and equipment throughout the kitchen; - Dishwashing area including walls, shelving, and equipment; and - The janitorial closet/area.   * There were undated and unlabeled foods in the walk in refrigerators. * Packaged foods were not dated when opened. * Scoops were left in bulk food bins with the handles in the food. * Boxes were stored on the floor in the walk in freezer. * There were no test strips available to ensure the low temperature dishwasher was reaching the required level of chemical sanitizer. * There was no evidence the temperatures of the dish sanitizer, refrigerators, or foods were monitored. * Staff were using a Quaternary solution for sanitizing towels. There was no evidence of testing the solution to ensure it was between 150 and 200 parts per million. * The laminate shelving across from the tray line was damaged creating an un-cleanable surface. * There was not an operable probe thermometer to monitor the temperature of foods. Staff immediately went to purchase a thermometer. The areas in need of cleaning and food storage concerns were reviewed with Staff 1 (Executive Director) and Staff 2 (Assistant Dietary Manager).  They acknowledged the findings.

1. Dietary Services Director (DSD) will schedule a deep clean for the kitchen to take care of any and all splatters, spills, drips, and debris. *DSD will do an audit of all items in food storage areas and ensure that all items are labeled and properly dated. *Scoops will be removed from dry bins. *Boxes will be properly stored on shelves, and/or items will be removed from boxes and properly stored on shelves. *Test strips will be ordered to ensure the low temperature dishwasher was reaching the required level of chemical sanitizer. *The DSD will provide proper logs to monitor the dish sanitizer and refrigerators. *Test strips will be ordered to test the Quaternary solution for sanitizing towels. *The laminate shelving will be repaired so it is free from un-cleanable surfaces. *New thermometers will be ordered. 2. The DSD has a scheduled in-service for staff on proper policies and procedures. Logs and task sheets with cleaning schedules will be provided to kitchen staff. 3. DSD and Executive Director will meet on a monthly basis to go over audits, logs and task sheets. DSD will audit logs and task sheets weekly. DSD will have a monthly in-service with kitchen staff to insure policies are understood and followed. 4. The DSD and/or the executive director will ensure the corrections are completed and monitored.

The findings of the kitchen inspection, conducted 10/03/23, 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 10/03/23, conducted on 01/30/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review, it was determined the facility failed to ensure resident incidents were immediately reported to the local Seniors and People with Disability (SPD) office for 1 of 1 sampled residents (#2) who were reviewed. Findings include, but are not limited to: A review of Resident 2's service plan, dated 12/14/22 and 03/23/23, indicated s/he requires the assistance of two staff members for transfers and ambulation, regular assistance with toileting, and total assistance with bathing. A review of Resident 2's progress notes, dated 04/03/23 through 02/16/23, revealed an entry categorized as a "non-injury fall" on 03/29/23 (a CG) was assisting (Resident 2) with transferring without the assistance of a second staff member when the resident fell to the ground, hitting his/her head on the shower. CG called for a MT and the emergency medical technicians (EMTs) were "called to check the Resident 2 out. Resident refused to be sent out. No apparent injuries at this time. Resident requested something for [his/her] head pain." A review of the facility's investigation, dated 03/30/23, indicated "abuse and neglect ruled out - resident was not alone_staff was there, resident's foot turned and caused resident to fall." There was no evidence to indicate this incident was reported to local Adult Protective Services (APS) or local SPD. In an interview on 05/05/23, Staff 1 and Staff 6 stated this incident was not reported to APS. Staff 1 stated the reason for not reporting was because of a "gray area". It was determined the facility failed to ensure resident incidents were immediately reproted to the local SPD office for 1 of 1 sampled resident incidents. On 05/05/23, these findings were reviewed with and acknowledged by Staff 1 and Staff 6. Plan of Correction: Effective immediately, the Administrator will resume daily clinical meetings to review incident reports, determine what actions are required, and to review service plan updates and status.

a.

Based on interview and record review, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (#2). Findings include, but are not limited to: A review of Resident 2's service plan, dated 12/14/22 and 03/23/23, indicated s/he required the assistance of two staff members for transfers and ambulation, regular assistance with toileting, and total assistance with bathing. A review of Resident 2's progress notes, dated 04/03/23 through 02/16/23, indicated that on 03/29/23 (a CG) was assisting (Resident 2) with transferring without the assistance of a second staff member when the resident fell to the ground, hitting his/her head on the shower. CG called for an MT, and the emergency medical technicians (EMTs) were "called to check Resident 2 out. Resident refused to be sent out. No apparent injuries at this time. Resident requested something for [his/her] head pain." In an interview on 05/04/23, Staff 1 (Administrator) stated s/he had transferred Resident 2 alone, the last time was approximately 3 months ago, and some day shift staff "may do so" alone. The facility failed to ensure the implementation of resident's service plans for 1 of 1 sample resident when staff members transferred the resident without the assistance of a second staff member. On 05/05/23, these findings were reviewed with and acknowledged by Staff 1 and Staff 6. Plan of Correction: Effective immediately, the Administrator and Resident Care Coordinator will orient all direct care staff to the residents' service plan and implement a signature sheet to ensure review and accountability.

Based on interview and record review, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: In an interview on 05/04/2023 at 6:10 pm, Resident 1 stated "medications has been an ongoing issue" and there had been issues with his/her [mood stabilizing medication]. Resident 1 stated the powder treatment was believed to be discontinued but it wasn't and was approved to be self-administered. A review of Resident 1's progress notes, dated December 2022 through April 2023, and  Medication Administration Records, dated January through April 2023, indicated there was no evidence the following medications had been administered: *Medications used to treat mood, depression, migraines, and hypothyroidism were  missed 12 times in January. *Medications used to treat mood and migraines were missed six times in February. *Medications used to mood and migraines were missed seven times in March; and *Medications used to treat mood and migraines were missed two times in April before Resident 1 left on vacation. On 05/05/2023, Resident 1's physicians orders were reviewed and signed by his/her physician on 01/17/23 and 04/19/2023 which revealed the missed medications were ordered. In an interview on 05/04/2023 at 7:17 pm, Staff  5 (MT) stated after reviewing Resident 1's medication history and cards was unable to explain why they would not have been administered. In an interview on 05/05/2023 at 1:07 pm, Staff 1 (Administrator) and Staff 6 (RCC) were unable to explain why Resident 1's medication had not been administered. It was confirmed the facility failed to carry out medication orders as prescribed. On 05/05/2023 at 12:30 pm these findings were reviewed with and acknowledged by Staff 1 and Staff 6. Plan of Correction: Effective 05/06/2023, Staff 6 will require all MTs to generate daily missed medication reports before the end of shift and submit them to RCC to be reviewed daily with Staff 1 and RN at clinical huddles.

Based on interview and record review, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: In an interview on 05/04/23, Staff 1 (Administrator) stated the facility's ABST updated automatically when resident service plans were updated and confirmed multiple residents' service plans were overdue. In an interview on 05/05/23, Staff 6 (RCC) stated service plans were updated before/upon move in, quarterly, and with a significant changes of condition. S/He had been working on updating 11 resident service plans that were overdue, but one had been updated on 05/04/23. A review of the "Service Plans Due within 90 Days" report, dated 05/04/23, provided by Staff 1 indicated there were 11 residents' service plans that were overdue. It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST) for 11 identified residents whose service plans were overdue for their quarterly review. On 05/05/23, these findings were reviewed with and acknowledged by Staff 1 and Staff 6. Plan of Correction: Within one week, the Resident Care Coordinator will ensure all out-of-date serivce plans will be updated adn entered into the facility's Service Planning/ABST system.

The findings of the on-site investigation, conducted 05/04/2023 and 05/05/2023 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the re-licensure survey, conducted 05/02/22 through 05/04/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to deficiencies in report.

OR-411-0025 C-150 Facility Operation 1. Please see Plan of Correction in its completeness. 2. Executive Director will meet with each Department on a scheduled weekly meeting with an agenda to review all of the areas of the community. 3. This will be evaluated weekly. 4. Executive Director and Department Heads will meet weekly and discuss QA.

Based on observation, interview and record review it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: 1. Witness 1 (Ombudsman) shared concerns that residents were dissatisfied with the facility meals and food. Staff 4 (Dietary Services Manager) documented the following resident comments after meeting with residents about the meals: * "Meat is tough..."; * "Braised beef tough."; * "...soups not enough flavor, food not hot.."; * "Beef a little tough."; * "Beef is tough...no soups have flavor."; * "A lot of repetition."; * "Chicken dry...potatoes too hard...hamburger steak no flavor."; * "...meat is a little tough. Pork and chicken tough...not a fan of the soup." * "Meats tough or cold, potatoes are tough."; * "...beef is a little tough...food is a little cold..."; * "...meat is dry..."; * "Some meat is raw and food is cold. Potatoes and vegetables are hard."; and * "...Pork thin and dry..." There was no documented follow up to the concerns expressed by the residents. A test tray of the lunch meal on 05/02/22 was requested and tasted by the Surveyor. The meal was Swiss Steak, cheddar mashed potatoes, and green beans. The steak was covered with a layer of grease, very difficult to cut, tough to chew, and lacked flavor. The potatoes were under cooked with hard chunks of potatoes and lacked flavor. The green beans lacked flavor. They were very soft and fell apart when the surveyor tried to eat them with a fork. Interviews with residents were conducted on 05/02/22 during the lunch meal. They said: * "Food sucks."; * "Doesn't taste good."; * "Meat is tough."; * "Swiss steak is tough to eat."; * "I can't stand to eat it."; * "Food is OK. We don't have much choice."; * "The meat was dry. I couldn't cut it."; * "I couldn't eat meat."; * "Food is so-so."; * "The meat is too tough to cut."; and * "The potatoes have no flavor and are supposed to have cheese. Where is the cheese?" Interviews with residents were conducted on 05/03/22 during the lunch meal. The meal was BBQ Baby Back ribs, twice baked potatoes, and cream style corn. They said: * "The food today is not handicap appropriate." The resident requested a staff member cut the rib meat off the bone.; * "I get the meat pureed but it is still too tough for me to eat."; * "The baked potato is cold and the meat is hard to chew. This is normal for the meat."; and * "The meat is cold and the potatoes are dry." In an interview with Staff 1 (ED) on 05/03/22, she acknowledged she was aware residents had complaints about the food. 2. Witness 1 (Ombudsman) informed the survey team of resident complaints of extended call light response times. Review of the call light response times between 04/01/22 and 04/30/22 revealed numerous occasions when response times to call lights were greater than 20 minutes, up to over an hour. During an interview with Staff 1 (ED) she stated residents reported long call light response times to her. The documented complaints of residents were discussed with Staff 1 (ED) on 05/03/22. She acknowledged there was no documentation regarding follow-up to residents' concerns.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure 1. ED or designee will meet with dietary services director weekly to discuss food quality. ED or designee will do random test trays before meal service begins. Staff Inserviced on 5/12/22 for proper call times and answering them in a timley manner. 2. ED will meet with DSD weekly as part of QI. ED or designee will review call light times weekly to ensure timely call times. DSD or designee will hold a monthly food committee meeting with the residents to discuss food likes, dislikes, changes, and special requests. ED or designee will hold a monthly town hall meeting with the residents to discuss any comments, or concerns. 3. ED will meet with DSD weekly to discuss QA for food quaility and any concerns. Food quality will be reviewed randomly by different managers throught the month with test trays. ED and/or RN/RCC will review call light times weekly and will be discussed at weekly QA meeting with ED and RN/RCC. Town hall and Food Committee meetings with residents scheduled monthly. 4. ED and DSD will review food quality and concerns weekly during Kitchen QA meeting. ED and RN/RCC will review call light times weekly during Health Servies QA meeting

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to: During the survey, conducted 05/02/22 through 05/04/22, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective. Refer to the deficiencies in the report.

OR-411-0025 C-156 Facility Quality Improvement 1. Re-establishing the Pacifica Quality Assurance program that was not in use at time of survey. 2.All areas identified in QA Audit will be corrected in a timely manner and/or documentation will be evident of efforts put into place to correct immediately. 3.Audits will be performed according to QA scheduled weekly and discussed with Departent Manager: * DSD/Kitchen - Diet boards, snack program, cleaning, equipment, food quality, food storage, menu and food ordering, temp logs, ect. Audit sheet will be in completed POC binder. * RN/RCC Health Services - resident files, assessments/evaluations, PCP reports, Service Plans, COC, outside provider documentation, 24 hr communication binder, Medtech/PCA training, MAR, med cart audit, supplies, shower/laundry schedules, ect. Audit sheet will be in completed POC binder. * MD/Fire and life safety -building and grounds appearance, housekeeping, fire drills, emergency evacuations, fire extinguishers, ect. Audit sheet will be in completed POC binder. * BOM/HR - workers comp, personnel files, employee orientation, employee training, background checks, time tender, montly employee safety meetings, dress code, ect. Audit sheet will be in completed POC binder. 4. Executive Director will be reviewing audit sheets with Dept. Managers weekly. If ED see there are areas of immediate concern while completing audit, department manger will be notified right away.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to: During the survey, conducted 05/02/22 through 05/04/22, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. From 05/02/22 through 05/04/22, numerous facility staff were observed wearing face masks below their noses or chins on multiple occasions. The failure to ensure facility staff consistently utilized COVID-19 protocols was discussed with Staff 1 (ED) on 05/02/22 and 05/04/22. She acknowledged the findings.

OAR  411-054-0025 (4) Reasonable Precautions 1. Staff were in-serviced on 5/12/22 about mask use in the community. 2. ED and/or Department Managers, and/ or designee will do daily walks and will check staff to ensure their masks are being worn properly. 3. Daily reminders will be given to all staff who are not wearing their masks properly. 4. ED and/or department managers and/or designee will remind staff to wear their masks properly if staff are not doing so.

Based on observation, interview and record review, it was determined the facility failed to ensure resident evaluations addressed all required elements, were relevant to the needs and current conditions of the resident, and indicated who was involved in the evaluation process for 4 of 5 sampled residents (#s 2, 3, 4 and 5) whose new move-in and quarterly evaluations were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 04/2022. The new move-in evaluation did not indicate who was involved in the evaluation process, and failed to address the following elements: * List of current diagnoses; * List of medications and PRN use; * Visits to health practitioner(s), ER, hospital or NF in the past year; * Ability to use call system; * Transportation; * Skin condition; * Nutritional habits; * List of treatments: type, frequency and level of assistance needed; * Indicators of nursing needs including potential for delegated nursing tasks; * Fall risk or history; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Elopement risk or history; * Smoking, ability to smoke safely; and * Alcohol and drug use. The need to ensure move-in evaluations indicated who was involved in the evaluation process and addressed all required elements was discussed with Staff 1 (ED) on 05/03/22. The findings were acknowledged. 2. Resident 3 was admitted to the facility in 2020 with diagnoses including diabetes and a history of skin breakdown. Observations and interview with the resident, and review of his/her clinical record revealed the quarterly evaluation did not indicate who was involved in the evaluation process, and did not address or was not relevant to the needs/current condition of the resident in the following areas: * Customary routines: sleeping and bathing; * Spiritual, cultural preferences and traditions; * List of current diagnoses; * List of medications and PRN use; * Visits to health practitioner(s), ER, hospital or NF in the past year; * Mental Health issues including: Presence of depression, thought disorders or behavioral or mood problems; * Cognition, including: Memory, orientation, confusion and decision making abilities; * Personality including: how the person copes with change or challenging situations; * Transportation; * Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Skin condition; * Nutritional habits; * List of treatments: type, frequency and level of assistance needed; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Elopement risk or history; * Smoking, ability to smoke safely; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. The need to ensure the quarterly evaluation indicated who was involved in the evaluation process and addressed the needs and current condition of Resident 3 was discussed with Staff 1 (ED) on 05/03/22. The findings were acknowledged. 3. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Parkinson's and COVID-19 prolonged. Observations and interview with the resident, and review of his/her clinical record revealed the quarterly evaluation did not indicate who was involved in the evaluation process, and did not address or was not relevant to the needs/current condition of the resident in the following areas: * Personality including: how the person copes with change or challenging situations; * Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Skin condition; * Nutritional habits; * List of treatments: type, frequency and level of assistance needed; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Recent losses; * Elopement risk or history; * Smoking, ability to smoke safely; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. The need to ensure the quarterly evaluation indicated who was involved in the evaluation process and addressed the needs and current condition of Resident 2 was discussed with Staff 1 (ED) on 05/03/22. She acknowledged the findings. 4. Resident 5 was admitted to the facility in 01/2021 with diagnoses including heart failure and Resident 1 was receiving hospice services. Observations and interview with the resident, and review of his/her clinical record revealed the quarterly evaluation did not indicate who was involved in the evaluation process, and did not address or was not relevant to the needs/current condition of the resident in the following areas: * Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; * Skin condition; * Nutritional habits; and * List of treatments: type, frequency and level of assistance needed; The need to ensure the quarterly evaluation indicated who was involved in the evaluation process and addressed the needs and current condition of Resident 5 was discussed with Staff 1 (ED) on 05/03/22. She acknowledged the findings.

OR-411-0054-0034 C-252 Resident Move-in and Evalutation General 1. Residents #2,3,4,and 5 will be brought into compliance 2. All service plans and new admit evaluations will be reviewed by the resident, the service plan team and/or family to assure that all of the new residents needs are met as well as the service plan is resident specific and person centered. Service plan will be signed by all involved once completed. All Service plans and new admits will be completed upon move in and reevaluated after 30 days, then every 90 days after move in. Any change of condition will have interventions updated as needed by the RN. 3. 30/90 day and change of conditions will be reviewed daily/weekly during clinic meetings. 4.ED/RN/RCC will assure service plans are completed, and current with any changes warranted.

3. Resident 4 was admitted to the facility in 04/2022 with diagnoses including insulin dependent diabetes, skin breakdown, a urinary catheter, and a biliary drainage bag. Observations and interviews with Resident 4 during the survey, and review of the clinical record including the initial service plan, dated 04/05/22, was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas: * Where the resident preferred to eat his/her meals; * Foley catheter; * Biliary draining bag; * Use of a commode; * Use of incontinence products; * Mobility devices; * Hospital bed; * Staff assistance to make bed; * Edema to bilateral lower legs; * Glasses; * Dressing assistance; and * PT services. The need to ensure the service plan was reflective of Resident 4's current care needs and provided clear direction to staff was discussed with Staff 1 (ED) on 05/03/22. She acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were followed, reflective of residents' needs, provided clear direction to staff, and were updated with resident changes for 3 of 5 sampled residents (#s 2, 4 and 5). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including heart failure and was receiving hospice services. Observations of the resident, interviews with staff from 05/02/22 to 05/04/22, and review of the service plan, dated 03/02/22, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and did not provide clear direction to staff in the following areas: * Meal assistance, cueing and positioning; * Skin at risk and interventions; * Falls and safety interventions; and * Pain. The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 11/2022 with diagnoses including Parkinson's and COVID-19 prolonged. Observations of the resident, interviews with Resident 5 and staff from 05/02/22 to 05/04/22, and review of the service plan, dated 03/03/22, showed the service plan was not reflective of the resident's current care needs, had not been updated, and did not provide clear direction to staff in the following areas: * Transfer assistance of up to two staff; * Mobility assistance including wheelchair and walker use; * Toileting assistance; * Bathing and grooming assistance; and * Hospice services being discontinued; The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were updated with changes, was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General 1. Residents #2, 4, and 5 will be brought into compliance 2. All service plans and new admit evaluations will be reviewed by the resident, the service plan team and/or family to assure that all of the new residents needs are met as well as the service plan is resident specific and person centered. Service plan will be signed by all involved once completed. All Service plans and new admits will be completed upon move in and reevaluated after 30 days, then every 90 days after move in. Any change of condition will have interventions updated as needed. 3. 30/90 day and change of conditions will be reviewed daily/weekly during clinic meetings. 4.ED/RN/RCC will assure these are completed, current with any changes warranted.

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, and were updated with resident changes for 1 of 3 sampled residents (#9). This is a repeat citation. Findings include, but are not limited to: Resident 9 was admitted to the facility in 2002, was receiving hospice services, and had diagnoses including a decubitis ulcer and edema. Resident 9 was identified to have had a significant decline in condition and went from being independent with care to requiring full assistance with all activities of daily living. Resident 9 was observed seated in a recliner with his/her legs elevated. Resident 9 reported s/he had recently become increasingly weak and was no longer able to walk. In an interview with Staff 14 (MT) on 11/09/22, she reported Resident 9 had declined significantly after a fall and now required full assistance with all care. Staff 14 explained Resident 9 preferred to sleep in his/her recliner, had edema and needed his/her legs elevated, and had a bed-side commode available for use. Staff 14 reported Resident 9 was checked on hourly and assisted and encouraged to change positions. Staff 14 said Resident 9's pressure ulcer was not currently open. Resident 9's service plan was not reflective of: * Sleeping preferences; * Elevation of legs; * Position changes; and * Hospice services. The need to ensure service plans provided clear direction to staff, were reflective of resident needs, and updated with changes, was reviewed with Staff 1 (ED) on 11/08/22 and 11/09/22. She acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General 1. Resident #9 - service plan will be brought into compliance by updating sleeping preferences, elevation of legs, position changes, and hospice services. 2. 30/90 day service plans and change of conditions will be reviewed daily/weekly during QA meetings. 3.ED/RN/RCC will assure these are completed, current with any changes warranted.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5). Findings include, but are not limited to: Resident 1, 2, 3, 4 and 5's most recent service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plan. The need to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

OR-411-0054-0036 C-262 Service Planning Team 1. All direct care staff will be inserviced on Service Planning and Procedures. Service Planning Team will consist of the RN/RCC/ED, resident/family/POA, and whomever resident chooses to be involved. 2. Part or all of the Service Planning Team will meet weekly/daily to review upcoming Service Plans that are coming due and discuss any changes or updates to be added. 3. These Service Plans once updated will be reviewed with resident and/or residents choice/family/POA when possible and changes implemented as needed. 4.ED and or Designee, RCC, or RN will audit servic plan during daily clinical and/or weekly QI

Based on observation, interview and record review, it was determined the facility failed to monitor and document on the progress of short-term changes in condition at least weekly until resolved, and monitor the resident consistent with his/her evaluated need for 4 of 6 sampled residents (#s 1, 3, 5 and 6). Findings include, but are not limited to: 1. Resident 3 was admitted in 2020 and had diagnoses which included diabetes. Resident 3's clinical record and charting notes, reviewed from 04/01/22 through 05/02/22, revealed the following: a. On 02/01/22, staff reported the resident had a bruise on his/her right thumb. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition. b. A narrative charting note written by Staff 2 (RN) on 02/02/22, indicated the resident was "going to be put on insulin, and CBGs four times a day with sliding scale." Alert monitoring was initiated the same day. However, there was no on-going monitoring of the resident's significant change in condition consistent with his/her evaluated needs or until it was determined that monitoring was no longer needed. Additional information was requested on 05/03/22. On 05/04/22, Staff 1 (ED) reported she reviewed the resident's record and concluded the short-term change in condition had not been monitored until resolved, and the resident's significant change in condition had not been monitored consistent with his/her evaluated needs. No further information was provided. 2. Resident 6 was admitted in 2016 with diagnoses which included hypertension and COPD. Resident 6's clinical record and narrative charting notes, reviewed from 02/20/22 through 05/01/22, revealed the following short-term changes in condition: a. On 02/20/22, the resident was placed on alert monitoring for a medication error. Review of the record revealed no documentation on the progress of the resident's condition at least weekly until resolved. b. The resident was seen in the hospital on 03/21/22 and was diagnosed with a UTI. S/he returned to the facility the same day. Documentation indicated the facility initiated short-term change monitoring. However, no monitoring until resolution was documented for the change in condition. Additional documentation was requested on 05/03/22. In an interview on 05/03/22 at 3:00 pm, Staff 2 (RN) stated she was unable to find documentation that the short-term changes in condition were monitored until resolved. The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (ED) on 05/03/22 at 1:30 pm. She acknowledged the findings. 4. Resident 5 was admitted to the facility in 01/2022 with diagnoses including heart failure and was receiving hospice services. Resident 5 was observed to be in bed and receive all care in bed on all days of the survey. Staff reported Resident 5 was bed bound and all care, including incontinent care, was provided in bed. Staff explained hospice provided bed baths and nursing oversight. Hospice communication was reviewed and revealed Resident 5 was identified to be impacted or constipated on: * 02/07/22 - "...last BM [bowel movement] was 3-4 days ago..."; * 02/14/22 - "Manually disimpacted for very large hard stool...severe constipation."; and * 4/18/22 - "...last BM reportedly 2 days ago...". Resident 5 was at risk for constipation. There was no documented evidence of monitoring of Resident 5's bowel movements. The need to monitor residents per their evaluated needs was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged Resident 5 was not monitored for constipation. 3. Resident 1 was admitted to the facility in 06/2019. Resident 1's narrative chart notes dated 02/07/22 through 05/02/22 were reviewed and revealed there was no documented evidence the facility monitored the following changes of condition until resolution: * 02/05/22 Blood in urine; * 02/07/22 Fall; * 02/09/22 Bleeding around nephrostomy tube; * 02/12/22 Went to hospital and received IV antibiotics; * 02/15/22 Started antibiotics and blood in nephrostomy bag; * 02/15/22 New antibiotic doxycycline; * 03/23/22 Flu like symptoms; * 04/01/22 Non-injury fall; * 04/09/22 Sent to ER for frank bleeding in nephrostomy bag; * 04/09/22 Started new antibiotics; * 04/14/22 Admitted to the hospital for displaced nephrostomy tube; * 04/18/22 Complaint of right side pain; * 04/19/22 New confusion; * 04/27/22 Sent to ER for thick red fluid in nephrostomy bag; and * 04/28/22 Return from hospital and new prescription. The need to ensure the facility documented monitoring of short-term changes of condition until resolution was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring 1. RN and RN Consultant will review all residents in the community to ensure all change of conditions are noted and Service Plans updated to reflect changes. All direct care staff will be in-serviced on change of condition and monitoring as well as how and who to report to once identified. 2. Daily/Weekly clinical meeting will take place with the RN/RCC/ED to discuss next steps, review service plan and make any further changes such as interventions when needed. They will also review chart notes and confirm alert charting is completed daily. 3. ED/RN/RCC will review COC and monitoring daily. 4. ED or Designee, RCC, or RN will review COC and monitoring during daily clinical and weekly QA.

Based on observation, interview, and record review, it was determined the facility failed to monitor and document on the progress of short-term changes in condition at least weekly until resolved, and failed monitor residents consistent with their evaluated needs for 3 of 3 sampled residents (#s 7, 8, and 9). This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 02/2019 with diagnoses including insulin dependent diabetes and was evaluated to be at risk for falls. Review of the resident's evaluation, service plan, temporary service plans, Narrative Charting, Outside Agency/Services Documentation, and facility Unusual Incident/Injury report indicated: * Resident 7 fell on 08/16/22 with bruising to lower back; and * Resident 7 was identified with a new treatment to the left heel on 08/24/22. There was no documented evidence Resident 7's fall interventions were evaluated for effectiveness. There was no documented evidence of monitoring of the bruise from the fall or monitoring of the heel until the condition resolved. 2. Resident 8 was admitted to the facility in 09/2022 and was evaluated to be at risk for falls. Review of the resident's evaluation, service plan, temporary service plans, Narrative Charting, Outside Agency/Services Documentation, and facility Unusual Incident/Injury report indicated: * Resident 8 fell on 10/03/22, 10/28/22, and 11/04/22; and * Injuries resulted from the fall on 10/28/22. There was no documented evidence Resident 8's fall interventions were evaluated with each instance and monitored for effectiveness. There was no documented evidence of monitoring of the skin tears from the fall on 10/28/22 until they resolved. 3. Resident 9 was admitted to the facility in 06/2002, was receiving hospice services, and was identified as requiring full assistance with all care needs. On 10/27/22 it was documented in facility Narrative Charting "...scratches on [Resident 9] left leg were discovered today." There was no documented evidence the scratches were monitored until resolved. The need to monitor interventions related to falls and to monitor changes in residents' condition at least weekly until resolved was reviewed with Staff 1 (ED) and Staff 2 (RN) on 11/08/22 and 11/09/22. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring 1. RN/RCC and/or ED will review all residents in the community with a change of condition and any falls to ensure proper noting and updates are in the service plans. 2. Daily/Weekly clinical meeting will take place with the RN/RCC/ED to discuss next steps, review service plan and make any further changes as needed. Fall interventions and monitoring of effectivness will be reviewed as well as any related injuries are monitored properly until resolved. 3. ED/RN/RCC will review COC and fall monitoring during working days. 4. ED or Designee, RCC, or RN will review COC and fall monitoring during daily clinical and weekly QA.

Based on interview and record review, it was determined the facility failed to monitor and document on the progress of short-term changes in condition at least weekly until resolved, and failed monitor residents consistent with their evaluated needs for 2 of 4 sampled residents (#s 11 and 13). This is a repeat citation. Findings include, but are not limited to: 1. Resident 11 was admitted to the facility in 08/2019 with diagnoses including age related cognitive decline and was evaluated to be at risk for falls. Review of the resident's evaluation, service plan, temporary service plans, Narrative Charting, and facility Unusual Incident/Injury report indicated Resident 11 fell on: * 01/10/23 and had a swollen left wrist; * 01/26/23 with no noted injury; and * 03/17/23 and had "discoloration" to the right arm, "...scrape to left side of chin.." , and "...apparent skin abrasions..." On 3/22/23 Resident 11 was identified with discoloration on the right hip, attributed to the 03/17/23 fall. There was no documented evidence Resident 11's fall interventions were evaluated with each instance and monitored consistent with their evaluated needs. There was no documented evidence of monitoring of the injuries from the falls until they resolved. 2. Resident 13 was admitted to the facility in 07/2018 with diagnoses including cerebral palsy and was evaluated to be at risk for falls. Review of the resident's evaluation, service plan, temporary service plans, Narrative Charting, and facility Unusual Incident/Injury report indicated: * Resident 13 was identified with rashes: -  Underneath both breasts, and left and right hips on 01/08/23; -  Left armpit/beneath breast on 03/19/23; and * Resident 13 fell on 03/05/23 resulting in a knee strain and hematoma to the left leg. There was no documented evidence Resident 13's fall interventions were evaluated and monitored consistent with evaluated needs. There was no documented evidence of monitoring of the rashes until they resolved. The need to monitor interventions related to falls and to monitor changes in residents' conditions at least weekly until resolution was reviewed with Staff 1 (ED) on 03/29/23 and 03/30/23. She acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring 1. Daily/Weekly clinical meeting will take place with the RN/RCC/ED to review: -Incident report packets. -fall monitoring and updates to TSPs/care plans with any needed addditional fall interventions. -Alert charting for consistency of charting. The medtechs will be using a "V&A-alert charting log and audit tool". -Skin logs for as needed assessments by the RN and weekly monitoring from the RN.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by a facility RN for 3 of 3 sampled residents (#s 1, 2 and 3) reviewed for significant changes of condition. Findings include, but are not limited to: 1. Resident 3 was admitted in 2020 and had diagnoses which included diabetes and a history of skin breakdown. During the entrance conference on 05/02/22, Staff 2 (RN) stated the resident had a history of skin breakdown and was a diabetic. Review of the resident's clinical record revealed the following: a. On 02/01/22, staff documented in narrative charting notes the resident had open wounds on his/her right leg. Home health, initiated 02/08/22, indicated the resident "needs care for 4 venous stasis ulcers to left lower extremity." The leg ulcers constituted a significant change in condition for which an assessment by the facility RN was required. There was no documented evidence the facility RN conducted an assessment. During an interview on 05/03/22 at 9:25 am, Staff 2 (RN) reviewed the record and acknowledged she did not document an assessment of the wounds. b. A narrative charting note written by Staff 2 (RN) on 02/02/22, indicated the resident was "going to be put on insulin, and CBGs four times a day with sliding scale." This was considered a significant change of condition and required a facility RN assessment. There was no documented evidence the facility RN conducted an assessment. During an interview on 05/03/22, Staff 2 (RN) acknowledged the initiation of insulin constituted a change in condition requiring RN assessment. She reviewed the record and acknowledged she had not completed an RN assessment. 3. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Parkinson's and COVID-19 prolonged. Interviews with Resident 2 and staff revealed Resident 2 required assistance with all care including two staff for transfers at times. Resident 2 reported s/he had been independent with with most activities but now required assistance. Staff reported Resident 2 had declined and now required full assistance with all care and at times two staff were needed for transfers. Resident 2's service plan indicated s/he was independent with care. Resident 2 experienced a decline in condition in multiple areas constituting a significant change in condition. There was no documented evidence the facility RN had completed an assessment of Resident 2's decline. Resident 2's change in condition was reviewed with Staff 2 (RN) on 05/03/22. She acknowledged the decline and reported she had not documented an assessment. The lack of an RN assessment of Resident 2's decline in condition was reviewed with Staff 1 (ED) on 05/03/22. She acknowledged the findings. 2. Resident 1 was admitted to the facility in 06/2019 with a diagnosis of hypertension. Resident 1's narrative chart notes dated 02/07/22 through 05/02/22 and Home Health notes revealed the following significant changes of condition: a. On 02/07/22, Resident 1 fell in his/her room and fractured two ribs on the left side. An interview with Staff 2 (RN) on 05/03/22 revealed she did not think the fall with fracture constituted a significant change of condition and did not do an RN assessment or update the service plan for Resident 1. b. On 03/31/22, a Home Health LPN left a note documenting a new wound lateral to the Nephrostomy tube measuring 1.2 cm by 1.4 cm on Resident 1's left side. The note stated the LPN notified Staff 2 (RN) of the new wound. In an interview with Staff 2 on 05/03/22, she said she knew about the wound and stated Home Health provided the wound care. Home Health services were discontinued for Resident 1 and the last note was left on 03/31/22. Staff 2 revealed she did not provide wound care, conduct an RN assessment for the new wound, or update the service plan. The need to ensure the facility RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan was discussed with Staff 1 (ED) and Staff 2 on 05/03/22.  They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services 1. RN completed assessment on Resident 1 and addressed dressing changes and updated service plan. RN completed assessment on Resident 2 and addressed decline, weakness, and needing more assistance. RN completed assessment on Resident 3 and addressed insulin, blood sugar, and skin assessment. 2. RN and RN Consultant will review all residents in the community to ensure all change of conditions are noted and Service Plans updated to reflect changes. 3. Change of condition and weight monitoring will be added to the clinical meeting held weekly by the RN and the RCC. 4. ED and/or designee will complete monthly QA audits and review change of conditions, service plans, and end of shift reports, medication reviews, and high risk concerns. If any areas of concern are found the RN will provide assessments and proper monitoring.

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 3 and 4) 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 05/02/22, Residents 3 and 4 were identified to be administered insulin injections by non-licensed staff. a. Resident 3's MARs, reviewed from 04/01/22- 05/02/22, revealed insulin had been given by Staff 5, Staff 13 and Staff 14 (MTs) on multiple occasions. Delegation documentation, reviewed on 05/02/22 revealed no documentation had been completed for Staff 5, 13 and 14. b. Resident 4's MARs, reviewed from 04/01/22 through 05/02/22, revealed insulin had been given by Staff 7, 14 and 15 (MTs) on multiple occasions. Delegation documentation, reviewed on 05/02/22 revealed no documentation had been completed for Staff 7, 14 and 15. In an interview on 05/02/22 at 4:20 pm, Staff 2 (RN) acknowledged she had not performed delegations for Staff 5, 7, 13, 14 and 15. The RN Surveyor informed Staff 2 that unlicensed staff could not give insulin to Residents 3 and 4 without current delegation. She acknowledged and stated that either she or delegated staff would give insulin injections moving forward. On 05/03/22 at 9:40 am, the RN Surveyor asked Staff 2 who gave insulin to Resident's 3 and 4 that morning. She acknowledged that non-delegated staff performed the injections. The surveyor informed her that unlicensed staff could not perform insulin injections without being delegated. She agreed to immediately delegate unlicensed staff. Failure to ensure delegation was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules was reviewed with Staff 1 (ED) on 05/03/22 at 1:20 pm. She acknowledged the findings.

OAR 411-054-0045(1)(f)(B) RN Delegation and Teaching 1. All delegations will be updated. All medtech's will be delegated on Residents 3 & 4. 2. RN will teach and delegate all new med techs on each resident that have blood sugars and insulin. All delegated med techs will have documentation on each residents. 3. All delegations will be updated if needed with change of order. After initial delegation, Medtechs will be reviewed after 60 days then every 180 days. 4. ED and/or designee will audit delegation records to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to: During the relicensure survey, conducted 05/02/22 through 05/04/22, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas: C 282: RN Delegation and Teaching; C 303: Systems: Medication and Treatment Orders; C 304: Systems: Medication and Treatment Review; C 305: Systems: Resident Right to Refuse; C 310: Systems: Medication Administration; and C 372: Training within 30 days: Direct Care Staff. Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 05/04/22.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments 1. Re-establishing the Pacifica Quality Assurance program that was not in use at time of survey. QMAR system was updated to show all correct information on the MAR. All medtechs will be inserviced on Systems: Medication and treatment orders, treatment review, resident right to refuse, medication administration and 90 day orders. 2.All areas identified in QA Audit will be corrected in a timely manner and/or documentation will be evident of efforts put into place to correct immediately. 3.Audits will be performed according to QA scheduled as follows: * Health Services will be audited weekly, daily clinical * Staff Training will be reviewed weekly during BOM/HR QA 4. Executive Director will be reviewing with Dept. Managers daily/weekly

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed, and signed provider orders were documented in the resident's record for all medications and treatments the facility was responsible to administer, for 3 of 6 sampled residents (#s 1, 3 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted in 2020 with diagnoses which included diabetes. Resident 3's physician orders and MARs, reviewed from 04/01/22 through 05/01/22, revealed the following orders were not followed: a. Resident 3 had an order for Admelog sliding scale insulin to be given before breakfast, lunch, dinner and bedtime in varied amounts based on results of the CBGs. From 04/01/22 - 05/01/22, there were 63 occasions when the resident should have received the Admelog sliding scale insulin based on CBG results, but none was documented as given. In an interview on 05/03/22 at 9:00 am, Staff 2 (RN) reviewed the MAR. She was unable to verify if staff had administered the insulin as ordered. b. The resident had an order for Steglatro (medication for glucose control) 5 mg one tablet once a day. According to the MAR, the resident did not receive the medication from 04/01/22 through 04/05/22 because it was unavailable. Additionally, the PCP had not been notified that the resident did not receive the medication as ordered. In an interview on 05/03/22, Staff 2 (RN) reviewed the MAR. She acknowledged the medication had not been given as ordered. She also stated staff should have notified the PCP. The need to ensure orders were followed was reviewed with Staff 1 (ED) on 05/03/22 at 1:30 pm. The findings were acknowledged. 2. Resident 4 was admitted in 04/2022 and had diagnoses which included diabetes, depression, and hypertension. Resident 4's physician orders and MARs, reviewed from 04/01/22 through 05/01/22, revealed the following orders were not followed: a. The resident had an order for Lispro sliding scale insulin to be given before meals and bedtime in varied amounts based on results of the CBGs. From 04/06/22 - 05/02/22, there were numerous occasions that staff gave sliding scale insulin without documentation that CBGs were obtained to determine the required amount of insulin to administer. b. Resident 4 had an order for Bupropion HCL 75 mg 1 tablet every eight hours for depression. According to the MAR, staff failed to administer the medication on two occasions because it was unavailable. c. The resident had an order for Metoprolol 50 mg two tablets daily at bedtime. Staff were instructed to hold the medication if the BP was less than 100/60 or pulse was less than 60. According to the MAR, staff administered the medication without obtaining the BP or pulse to determine if the medication should have been held. The need to ensure orders were followed was reviewed with Staff 1 (ED) on 05/03/22 at 1:30 pm. She reviewed the MAR and acknowledged the findings. 3. Resident 1 was admitted to the facility in 06/2019 with a diagnosis of hypertension. Resident 1's 04/01/22 through 04/30/22 MAR was reviewed, and the following deficiencies were identified: There were no written, signed orders in the facility for any medications or treatments the facility was responsible for administering. Signed physician's orders for Resident 1 were received from the pharmacy on 05/04/22. The need to ensure signed physician's orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

OAR 411-054-0055(1)(f-h) Systems: Treatment Orders NOTES: 1. Residents #3 and 4 - QMar has been updated to show proper information. PCP was notified of missed medications. Resident #1 - signed 90 day orders were completed and in the community by 5/6/2022. 2. Medtechs will be in-serviced on proper QMAR documentation and PCP notification protocols. All 90 Day orders will be completed and signed and in the community. RCC has sent out requests to all residents PCP to ask if we can notify PCP monthly instead of daily for missed and/or refused medications. 3. MARs will be audited weekly by RN and/or RCC 4. ED will audit weekly with QA audit and discuss with RN/RCC during Health Services weekly QA meeting.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment recommendations made by the registered pharmacist were reviewed or implemented. Findings include, but are not limited to: On 05/03/22, the facility provided copies of pharmacist medication reviews completed on 03/28/22 for numerous residents. The pharmacist requested further clarifications and/or made recommendations. As of the survey, there was no documented evidence the facility had reviewed and/or notified the residents' prescriber of the pharmacist recommendations. The failure to follow up on pharmacy recommendations was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. During the interview they acknowledged the facility failed to submit the recommendations to the prescriber for clarification and/or implementation. No further information was provided.

OAR 411-054-0055 (1)(i) Systems: Medication and Treatment Review 1. Pharmacy review on March 28, 2022 - All recommendations sent to MD's for clarification and/or implementation. All reviews for the RN have been addressed. 2. Pharmacy reviews are completed every 90 days and will have all recommendations sent to MD's for clarification and/or implementation. All reviews for the RN will be addressed in a timely manner. 3. Pharmacy reviews are received by OMNI Pharmacy every 90 days and will be reviewed/completed in a timely manner. 4. ED and/or designee, RN will ensure audits are completed /reviewed monthly to ensure compliance.

2. Resident 3 was admitted in 2020. Resident 3's MARs were reviewed for the time period of 04/01/22 through 05/02/22. Staff documented Resident 3 refused: * Ketoconazole 2% Cream (treats fungal infections) on 14 occasions. There was no documented evidence the facility notified Resident 3's physician of the refusals. In an interview on 05/03/22 at 9:40 am, Staff 2 (RN) acknowledged there was no documented evidence the facility had notified the physician of the refusals. No further information was provided. 3. Resident 4 was admitted in 04/2022. Resident 4's MARs were reviewed for the time period of 04/01/22 through 05/02/22. Staff documented Resident 4 refused the following medications: * Clearlax powder (for bowel care) on 17 occasions. There was no documented evidence the facility notified Resident 4's physician of the refusals. In an interview on 05/03/22 at 9:40 am, Staff 2 (RN) acknowledged there was no documented evidence the facility had notified the physician of the refusals. No further information was provided.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 3 of 4 sampled residents (#s 1, 3 and 4) who had documented medication refusals. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2019 with a diagnosis of hypertension. Resident 1's April 2022 MARs were reviewed. Staff documented Resident 1 refused the following medications: * Amiodarone CHL 100 mg (for heart rate); * Atorvastatin 10 mg (for cholesterol); * Doxycycline hyclate 100 mg (for UTI); * Ferrous sulfate 325 mg (supplement); * Levothyroxine 50 mcg (for hypothyroidism); * Lidocaine 5% patch (for pain); * Methanamine Hipp 1 mg (for UTI prevention); * Metoprolol succ er 25 mg (for high blood pressure); * Sensi-care protect oint 113 gm (skin integrity); * Vitamin C 500 mg to improve effectiveness of methanamine; * Xarelto 20 mg (for blood clot prevention); and * Zeasorb prevention powder. In an interview with Staff 2 (RN) she revealed there was no documented evidence the facility notified Resident 1's physician of the medication refusals for the month of April. The need to ensure the facility notify the physician/practitioner when a resident refused to consent to orders was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse 1. PCPs for residents #1,3,and 4 were notified of medication refusals. 2.Faxes were sent to all resident MDs to ask about frequency of notifications for medications. Once monthly notifications or continue with notifications for every missed/refused medication. Responses from MD's will be documented and filed in a quick refrence binder. 3. When a new resident moves into the community their MD will be asked for frequency notifications. MDs will be notified if there is a significant change in a residents medications. 4. ED or designee, RN and/or RCC will review every 90 days in corrolation with 90 day physicians orders.

3. Resident 3 was admitted in 2020 with diagnoses which included diabetes and hypertension. Residents 3's MARs were reviewed from 04/01/22 through 05/02/22 and the following was noted: * Reasons for use was not indicated for all medications. On 05/04/22, the need for the facility to ensure MARs were accurate was discussed with Staff 1 (ED). She acknowledged the findings. No further information was provided. 4. Resident 4 was admitted to the facility in 04/2022 with diagnoses which included diabetes. Residents 4's MARs were reviewed from 04/01/22 through 05/02/22 and the following was noted: * Reasons for use was not indicated for all medications. In an interview on 05/03/22 Staff 1 (ED) reviewed the resident's MAR. She acknowledged several medications were lacking reasons for use. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure residents' MARs were complete, accurate, and provided clear instruction and parameters for administration of PRN medications for 4 of 5 sampled residents (#s 1, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 01/2021 with diagnoses including heart failure, was bed bound, and was receiving hospice services. The resident's 03/01/22 through 05/02/22 MARs and physician's orders were reviewed. a. Resident 5 had a prescription for Magnesium Citrate oral solution 5 oz by mouth if fleet suppository was ineffective after 24 hours. The Magnesium Citrate solution was entered on the MAR as a daily routine medication to be administered at 8:00 am. The medication was documented as refused daily in March 2022. Resident 5 was noted "physically unable to take" the medication on 04/01/22. The medication was documented as administered on 04/02 through 04/04/22, and as refused on 04/05 and 04/06/22. The medication was discontinued on 04/06/22. The physician's order and MARs were reviewed with Staff 2 (RN) on 05/03/22. She acknowledged the medication was inaccurately entered on the MAR as a routine medication and the documentation of administration was inaccurate. b. Resident 5 had physician's orders for: *Fleet glycerin suppository once daily as needed for constipation; and *Milk of Magnesia as needed for constipation if no BM in three days. The were no resident specific parameters directing non-licensed or certified staff on the order of administration of the PRN bowel medications. The need to ensure MARs were accurate, complete, and included clear direction to staff for medication administration was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 06/2019 with a diagnosis of Hypertension. Resident 1's 04/01/22 through 05/02/22 MARs were reviewed and revealed the following medication did not have reasons for use: * Zeasorb powder; * Sensi-care protect ointment; and * Metoprolol succ ER 25 mg tab. The following PRN bowel medications lacked parameters as to which medication to try first and second: * Senna 8.6 mg tablet; and * Polyethylene Glycol 3350 powder. The need to ensure the facility's MAR has reasons for use for all medications and had parameters for PRN medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/04/22. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration 1. RN updated and/or corrected MARS for residents #1,3,4, and 5. 2. RN and/or RCC will review all MARs to ensure they are accurate, complete, and include clear direction to unlicensed staff. RN will also ensure that all PRN medications will have resident specific reason for use and parameters. 3.MARs will be reviewed every 90 days in correlation with 90 day pharmacy reviews as well as when new prescription orders are received. 4. ED will review MARs weekly with RN/RCC during QA meeting.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' MARs were accurate, and provided clear instruction and parameters for administration of PRN medications for 2 of 3 sampled residents (#s 7 and 8) whose MARs were reviewed. This is a repeat ciatation. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 02/2019 with diagnoses including insulin dependent diabetes. Resident 7 had physician's orders for: * 5 units of Novolog insulin before breakfast and lunch; and * Novolog insulin on a sliding scale determined by blood sugars before every meal. Resident 7's 10/01-11/07/22 MARs were reviewed. The units of insulin administered prior to breakfast and lunch was documented inaccurately on 39 occasions. Staff documented the units given added together for both the routine and the sliding scale orders. The inaccurate MAR was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 13 (RCC). They acknowledged the documentation was inaccurate. 2. Resident 8 was admitted to the facility in 09/2022 and was receiving hospice services. Residents 8's 10/01-11/07/22 MARs were reviewed. Resident 8 had physician's orders for: * Acetaminophen 325 mg as needed for pain; * Hydrocodone Acetaminophen 5-325 as needed for pain; and * Morphine Sulfate 5 mg as needed for pain. There were no resident specific parameters to guide non-licensed staff which medication to administer and in which order. The need to provide clear parameters to guide non-licensed staff in the administration of PRN medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 11/08/22 and 11/09/22. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration 1. RN updated and/or corrected MARS for residents #7 and 8. 2. RN and/or RCC will review all MARs to ensure they are accurate, complete, and include clear direction to unlicensed staff. RN will also ensure that all PRN medications will have resident specific reason for use and parameters. 3.MARs will be reviewed every 90 days in correlation with 90 day pharmacy reviews as well as when new prescription orders are received. 4. ED will review MARs weekly with RN/RCC during QA meeting.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia training was completed prior to providing services to residents for 3 of 3 newly hired staff (#s 8, 9 and 10) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 05/03/22. Staff 8 (MT), hired 02/08/22, Staff 9 (CG), hired 03/31/22, and Staff 10 (CG), hired 03/17/22, lacked documented evidence of having completed pre-service dementia training prior to beginning job responsibilities. Pre-service orientation training documentation provided consisted of completed quizzes with staff names written across the top of the page. There was no documentation of when the quizzes had been completed or staff signatures acknowledging the completion of the pre-service orientation. The need for staff to complete all required pre-service orientation and dementia training before working with residents was reviewed with Staff 1 (ED) on 05/03/22. She acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts 1. All staff who need training will be completing training immediately either through Relias or inservicing. 2. ED or designee, and/or BOM will assure that all required trainings are completed within 30 days of hire. Pre-service orientation and pre-service dementia training will be completed before direct care staff begin their job duties. BOM will work with RCC/RN to assure all aspects of training is completed 3. ED or designee and/or BOM will audit training monthly to assure all training is completed and in compliance. 4. ED and BOM will review weekly during QA meeting

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 caregiving staff (#s 8, 9 and 10) demonstrated satisfactory performance in all required areas within 30 days of hire and were trained in First Aid and abdominal thrust. Findings include, but are not limited to: Training records were reviewed on 05/03/22. 1. There was no documented evidence Staff 8 (MT), Staff 9 (CG), and 10 (CG), hired 02/08/22, 03/31/22, and 03/17/22 respectively, had demonstrated competency in all required areas within 30 days of hire including, but not limited to: * Role of service plans in providing individualized care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. 2. There was no documented evidence Staff 8 had demonstrated competence with the administration of medications. Staff 8's competence with medication pass was observed and documented on 05/03/22. 3. There was no documented evidence Staff 8 had been trained in First Aid. There was no documented evidence Staff 10 had been trained in First Aid or abdominal thrust. The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (ED) on 05/03/22. She acknowledged the findings.

OAR 411-054-0070 C-372 Training within 30 days: Direct Care Staff 1. All staff who need training will be completing training immediately either through Relias and/or inservicing. All required staff will also be completing online courses for Food Handlers Certification, and CPR/First Aid Certifications. 2. ED or designee, and/or BOM will assure that all required trainings are completed within 30 days of hire. 3. ED or designee and/or BOM will audit training monthly to assure all training is completed and in compliance. 4. ED and BOM will review weekly during QA meeting

Based on interview and record review, it was determined the facility failed to have documented evidence the 12 hours of annual in-service training included six hours related to the care of residents with dementia, for 2 of 2 long-term staff (#s 5 and 11) whose training records were reviewed. Findings include, but are not limited to: The annual in-service training records for the Year 2021 were reviewed on 05/03/22. Staff 5 (MT), hired 11/19/09, and Staff 11 (MT), hired 09/25/19, failed to have documented evidence of completing six hours of annual in-service training on dementia care in 2021. There need to ensure staff completed 12 hours of on-going training, including six hours related to dementia, was reviewed with Staff 1 (ED) on 05/03/22. She acknowledged the findings.

OAR 411-054-0070 (5-7) Annual Training and Other Requirements 1. All staff who need training will be completing training immediately either through Relias or inservicing. 2. ED or designee, and/or BOM will assure that all required trainings are completed within 30 days of hire. BOM will work with RCC/RN to assure all aspects are completed.There will be 12 hours of annual training for staff. Twelve hours in total. Six of the twelve hours will be Dementia training for the direct care staff through Relias. BOM will work with RCC/RN to assure all aspects of training is completed. 3. ED or designee and/or BOM will audit training monthly to assure all training is completed and in compliance. 4. ED and BOM will review weekly during QA meeting

Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months, conduct fire drill every other month, and document all required components on fire drill records. Findings include, but are not limited to: Fire drill and fire safety instruction records were requested for 11/2021 through 05/2022. Review of the records revealed: * Fire and life safety instruction was not provided to staff on alternating months; and * Fire drills were not conducted every other month and records lacked the following components: - Location of simulated fire origin; - The 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. Fire and life safety training and fire drill documentation requirements was discussed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 05/03/22. They acknowledged the findings.

OAR 411-054-0090 C-420 Fire and Life Safety 1. Fire and Life Safety Training will be completed at all staff meeting and/or through Relias online training program. 2. Alternating months will have fire drills with the location,scenario and exits from the fire being different each time. Months between the fire drills will have specific training for fire and life safety through either all staff inservicing, or Relias training. 3. Documentation will be reviewed with the ED after every fire drill. 4. ED/MD will review weekly to assure compliance at QA meeting.

Based on interview and record review, it was determined the facility failed to document all required components on fire drill records. This is a repeat citation. Findings include, but are not limited to: Fire drill records were requested for 07/2022 through 11/2022. Review of the records revealed: Fire drills records lacked documentation of the following required information: * The escape route used; * Evacuation time period needed; and * Number of occupants evacuated. Fire drill documentation requirements were discussed with Staff 1 (ED) on 11/09/22. She acknowledged the findings.

OAR 411-054-0090 C-420 Fire and Life Safety 1. Documentation will be reviewed with the ED and MD after every fire drill to ensure all details are properly documented. Including but not limited to the escape route used, evacuation time period needed, and number of occupants evacuated 4. ED/MD will review weekly to assure compliance at QA meeting.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to: Fire and life safety records for 03/2022 through 04/2022 were provided. Review of the records revealed a lack of documented evidence related to the following required elements: * Alternate evacuation routes used during fire drills; and * Documentation of interventions and/or resolution for resident evacuation concerns identified during fire drills. There was no evidence of instruction, at least annually, in general safety procedures, evacuation methods, and responsibilities during fire drills to residents. The need to have all components of fire drill and life safety training documented and to provide annual fire and life safety training to residents was discussed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 05/03/22. They acknowledged the findings.

OAR 411-054-0090 C-422 Fire and Life Safety 1. All staff training will be completed at all staff meeting and/or through Relias. Resident training will be completed to ensure that all residents are able to evacuate safely and are aware of what to do in the event of a fire or other emergency. Scheduling a resident meeting for fire and life safety training for the first week of June 2022. MD and/or desingee will meet with residents that do not attend the meeting on a one on one basis and complete the training with them. 2.Resident training and assessment for fire and life safety will be completed at move in, and updated as needed during service plan meetings. Documention of interventions and/or resolution for resident evacuation concerns identified during fire drills will be completed and kept in a specific Fire and Life Safety Binder. 3. Documentation will be reviewed with ED each month 4. ED/MD will review monthly for compliance during QA

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 05/02/22. The following issue was identified as needing repaired: * Exterior sidewalks around the facility had multiple drop offs up to five inches, measured from the concrete to the ground. These drop-offs created potential hazards for residents. On 05/02/22, the building's exterior was toured with Staff 1 (ED). She acknowledged the findings.

OAR 411-054-0200 General Building Exterior 1. MD did a walk and inspection of sidewalks with landscaping contractor. Contractor will be sending a bid to ED and MD. Completion of repairs and supplies will be pending availability of contractor. 2. MD will complete a weekly walk through and then will review with ED findings from his walk through during weekly QA meeting 3. ED will review findings of QA walk through with the MD weekly. 4. ED will review with MD during weekly QA meeting.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept in good repair. Findings include, but are not limited to: Observations of the facility on 05/02/22 revealed the following: * Elevator doors had scratched and chipped paint; * Room 104 and 205 door and door frames were damaged exposing bare wood; * Hand rails were scratched and scuffed; and * Scratches in the paint throughout the hallways and common areas of the facility. The need to ensure the facility environment was kept in good repair was discussed with Staff 1 (ED) on 05/02/22. She acknowledged the findings.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable 1. MD will be painting and ordering supplies needed to repair elevator doors, room 104 and 105 doors/frames, repairing handrails, and walking around the community to paint/repair any findings throught the hallways and common areas. 2. MD will complete a weekly walk through and then will review with ED findings from his walk through during weekly QA meeting 3. ED will review findings of QA walk through with the MD weekly. 4. ED will review with MD during weekly QA meeting.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or surfaces of baseboard heaters did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to: During an environmental walk-through on 05/02/22, the metal surface on the baseboard heaters located in apartments with one or two bedrooms exceeded 120 degrees F when turned on. The need to ensure residents could not come into incidental contact with baseboard heating elements that exceeded 120 degrees F was discussed with Staff 1 (ED). She acknowledged the findings.

OAR 411-054-0300 (8) Heating and Ventilation 1. MD will inspect the wall heaters and will temporarily disconnect the heaters that are not able to stay under 120 degrees. 2. ED and MD will evaluate if the heaters will be disconnected and removed, or if they are able to stay under 120 degrees and will need protective covers. 3. Once the heaters are in proper working condition the MD will inspect the heaters monthly and as needed. 4. ED and MD will discuss at weekly QA meeting

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 260, C 270, C 310, and C 420.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval 1. The facility will ensure complete compliance of C 260, C 270, C 310, and C 420 by December 24, 2022. 2.  Refer to the POC in its completeness for compliance. 3.ED/MD/RN/RCC will review compliance process weekly during QA meeting.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 270.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval 1. The facility will ensure complete compliance of C 270 by April 29, 2023. 2.  Refer to the POC in its completeness for compliance. 3.ED/RN/RCC will review compliance process weekly during QA meeting.

The findings of the re-licensure survey, conducted 05/02/22 through 05/04/22, are documented in this report. The survey was conducted to determine compliance with 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 05/04/22, conducted 11/07/22 through 11/09/22, are documented in this report. The survey was conducted to determine compliance with 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 05/04/22, conducted 03/29/23 through 03/30/23, are documented in this report. The survey was conducted to determine compliance with 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 living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 05/05/22, conducted 07/21/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.