Suzanne Elise Assisted Living

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 evaluations accurately described the resident’s physical health status for 1 of 5 sampled residents (# 6) whose evaluations were reviewed. Findings include, but are not limited to: Resident 6 moved into the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease and Parkinson’s. The resident’s medical chart was reviewed, Resident 6’s apartment was observed, and the resident and staff were interviewed. The following was identified: The “AL [Assisted Living] Level of Care and Service Plan” document dated 11/21/24 indicated the following: * Oxygen was not used; * The resident was independent with his/her CPAP (continuous positive airway pressure) machine; * Adaptive devices were needed for eating; * The resident had not “utilized [eight] or more doses of PRN medications for pain in the last 30 days”; * S/he was independent with nebulizer treatments; * Resident 6 did not have a catheter; * The resident slept in a bed; and * A leaf logo was placed outside of Resident 6’s door to let staff know s/he was a fall risk. The resident’s apartment was observed and Resident 6 was interviewed on 12/04/24 at 10:45 am. The following was observed and confirmed by the resident: * There was an oxygen concentrator located to the right of his/her bed and a portable oxygen tank on the floor next to a motorized wheelchair; * A CPAP was observed and the resident verified s/he was unable to wash the tubing and change the filters independently; * Resident 6 stated s/he did not “always” use the CPAP machine and requested staff to help him/her on the nights when the resident did use it; * The resident reported not being able to independently administer a nebulizer treatment; and * “Sometimes” slept in his/her bed and “sometimes” slept in the recliner depending on his/her ability to breath. Observations of Resident 6 and interviews with staff revealed no adaptive devices were needed during meal times and there was no leaf logo observed outside of the resident’s apartment. From 11/01/24 through 11/21/24, the MAR reflected the resident utilizing PRN pain medications 33 times. A progress note, dated 11/04/24, verified the facility was “awaiting new catheter supplies”. On 12/04/24 at 1:55 pm, Staff 3 (Regional Nurse Consultant) verified Resident 6 was self catheterizing. The need to ensure evaluations accurately described the resident’s physical health was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3, Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 2:40 pm. They acknowledged the findings.

1. Resident # 6's evaluation has been reviewed by the IDT Team and updated to be reflective of current status in all required areas. 2. To prevent recurrance, IDT Team was re-educated on regulations related to evaluations and the importance of them being accurate and reflective of current status and all required components. During all resident evaluations, current physicians orders will be reviewed to ensure resident evaluation is reflective of all current orders. Evaluation will also be reviewed and updated as necessary to ensure acuracy of services. A care conference will then be scheduled with the resident and/or family for Care Conference to further ensure accuracy. 3. Evaluations will be reviewed and updated appropriately at move-in, 30-day, quarterly or as necessary due to change in needs. Additionally, the IDT Team will review as part of our monthly CQI meeting. CQI includes rotating audits that include auditing evaluations and service plans to ensure all required components are being maintained and evaluations are reflective. 4. ED, RN & RCC will be responsible for maintaining this system.

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' needs, and provided clear direction to staff including a written description of who would provide the services and what, when, how, and how often the services would be provided for 2 of 6 sampled residents (#s 4 and 6). Findings include, but are not limited to: 1. Resident 4 moved into the facility in 03/2023 with diagnoses including dementia with mood disturbance. The most recent service plan, dated 10/14/24, was reviewed. The resident was observed, and staff were interviewed. The service plan did not reflect the resident's needs and/or did not provide clear direction to staff in the following areas: * Level of assistance with toileting; * Level of assistance with dressing and undressing; * Level of assistance with transfers; * Communication; and * Use of adaptive cups and silverware. The need to ensure service plans reflected the residents' status and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 4:25 pm. They acknowledged the findings. 2. Resident 6 moved into the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease and Parkinson’s. The resident’s service plan, dated 11/22/24, was reviewed. The resident was observed, and staff were interviewed. The service plan did not reflect the resident's needs and/or did not provide clear direction to staff in the following areas: * The use of a “motorized device” for mobility; * Incontinent products used; * The resident’s choice to self-catheter; * Resident 6’s preferences of where s/he sleeps; * Oxygen use; and * Specific instruction for an emergency evacuation. The need to ensure service plans reflected the resident’s current need and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 2:40 pm. They acknowledged the findings.

1. Service plans for resident #4 and #6 have been reviewed by the IDT Team and updated to include all required components and to accurately reflect their current status, needs and preferences. Updated service plans have been printed for staff to review and sign. 2. To prevent recurrance, all staff will be re-educated regarding the importance of thoroughly reviewing service plan before signing and reportimg any inaccuracies on service plan to ED, RN or RCC so that they can be updated timely. Rotating service plan audits will be conducted as part of monthly CQI process. 3. This system will be reviewed five days a week as part of our standup process. ISPs/prog notes will be reviewed during the 24hr/72hr summary review and service plans will be updated as needed. Additionally, this system will be reviewed monthly as part of our CQI process. Service plans will be reviewed and signed off by each department upon admission, at 30 days and quarterly or with change of condition. Each department head is responsible for reviewing the accuracy of the service plan as it relates to their department. 4. ED, RN & RCC will be responsible for maintaining this system.

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 interview and record review, it was determined the facility failed to determine and document actions or interventions, communicate the determined actions or interventions to staff on each shift, and monitor each resident through resolution, for 2 of 6 sampled residents (#s 5 and 6) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 6 moved into the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease and Parkinson’s. The resident's medical chart, including the service plan, Interim Service Plans, progress notes, and MARs, were reviewed. Staff and Resident 6 were interviewed and the following changes of condition were identified: * Resident 6 was not administered Sinemet, a medication to treat Parkinson’s, seven times from 10/02/24 through 11/27/24; * 10/16/24: The resident sustained a rib fracture; * 10/28/24: Staff documented they had to cut off Resident 6’s leg wrap (used for leg wounds) as the resident had rolled it down and the wrap was “cutting off the circulation” to his/her foot; * 11/04/24: The facility identified the resident was self-catheterizing and s/he needed additional supplies; and * 11/11/24: Resident 6 had physician’s orders for two new medications, MiraLax for bowel care and trospium chloride for bladder spasms. There was no documented evidence that actions or interventions were determined, those actions or interventions were communicated to staff on each shift, and/or there was weekly progress noted through resolution for each of the above changes of condition. 2. Resident 5 was admitted to the facility on 11/08/2024 with diagnoses including diabetes and hypertension. The resident's 11/08/24 through 12/02/24 progress notes and resident record were reviewed and revealed the following: On Resident 5’s admission, the facility failed to have interventions or actions developed and communicated to staff on each shift and monitor the resident’s condition with progress noted at least weekly through resolution. During an interview on 12/03/24 with Staff 3 (Regional Nurse Consultant), she reported the facility failed to implement an interim service plan with instructions for staff or monitor Resident 5’s condition after being admitted to the facility. Staff 3 completed a New Admission Follow Up Note on 12/02/24. The need to ensure short-term changes of condition had interventions or actions developed and communicated to staff on each shift and documentation to reflect monitoring at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3, and Staff 4 (Regional Nurse) on 12/04/24. They acknowledged the findings. The need to ensure actions or interventions for short-term changes of condition were determined, those actions or interventions were communicated to staff on each shift, and/or there was weekly progress noted through resolution was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 2:40 pm. They acknowledged the findings.

1. IDT team has been re-educated on regulations related to monitoring of short-term change of condition and the need to monitor until resolution and evaluate interventions for efficacy. HCCs re-educated on process for new admission (resident #5), including putting resident on alert and obtaining weekly weights to establish baseline. For resident #6, focus eval completed regarding all identified changes of condition. 2. To prevent recurrance, Newly hired HCCs will be trained on change of condition process including when to place residents on alert for RN to assess and implement interventions, Training will also include the alert charting process. 24hr/72hr summary will be reviewed daily at standup, as well as alert charting audit form to ensure timely interventions are implemented. If a change of condition is identified as a significant change, resident will be placed on weekly RN assessments for additonal oversight until resolution or a new baseline is established. 3. This system will be reviewed five days a week as part of our standup process and monthly during our CQI process, which includes an audit of all significant changes of condition. 4. ED, RN & RCC will be responsible for maintaining this system.

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 411-054-0055 (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 or other legally recognized practitioner orders were carried out as prescribed for 1 of 5 sampled residents (# 6) whose orders were reviewed. Findings include, but are not limited to: Resident 6 moved into the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease and Parkinson’s. The resident's 10/01/24 through 12/02/24 MARs, progress notes, dated 09/03/24 through 12/02/24, and physician’s orders were reviewed. Resident 6 and staff were interviewed. The following was identified: The following medications and treatments were not administered per physician's orders on multiple occasions: * Daily weights (for hypertensive heart disease); * Donning boots to lower legs for one hour, then doffing the boots once a day (for edema relating to hypertensive heart disease); * The administration of PRN torsemide for weight gain of three pounds in one day or five pounds in one week on 11/09/24 and 11/18/24; and * Sinemet (for Parkinson’s), buspirone (for anxiety), gabapentin (for neuropathic pain), and Blink Tears (for dry eyes). The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 2:40 pm. They acknowledged the findings.

1. Orders for resident #6 have been clarified and updated to match physicians orders. 2. To prevent recurrance, RN, RCC & ED to conduct HCC training to address following physicians orders. 24/72 hour report to be reviewed five days a week and will bring report to standup for further discussion and review with ED & RCC. A weekly audit will be done by the RCC to identify and follow up on any missing documentation as well as any PRN parameters that were not followed. Follow up education will be provided to staff as needed. RN to conduct monthly breakout sessions after All-Staff Meeting and Quarterly HCC Meetings to ensure staff is clear on expectations and proper documentation. 3. This system will be reviewed weekly with RCC audits, as well as monthly as part of CQI process. 4. ED, RN & RCC will be responsible for maintaining this system.

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

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused to consent to an order for 2 of 3 sampled residents (#2 and 6) who had medication and treatment refusals. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 12/2019 with diagnoses including bipolar disorder and emphysema. The resident's current prescriber orders, 11/01/24 to 12/03/24 MAR, and progress notes were reviewed. The following was identified: Staff documented the resident refused the following medications and treatments: * Tums E-X (for osteoporosis) on six occasions; * Urea external cream (for skin) on twenty-four occasions; * Ammonium lactate lotion (for skin) on thirty-one occasions; * Nystatin external powder (for skin infection) on thirty-three occasions; and * "Daily weight" on three occasions. There was no documented evidence staff notified the prescriber of the above medication and treatment refusals. The need to ensure the physician or other practitioner was notified if a resident refused to consent to an order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 1:02pm. They acknowledged the findings. 2. Resident 6 moved into the facility in 10/2022 with diagnoses including chronic obstructive pulmonary disease and Parkinson’s. The resident's physician’s orders, 10/01/24 through 12/02/24 MARs, and progress notes were reviewed. Staff documented the resident refused the following medications and treatments on multiple occasions: * Daily weights (for hypertensive heart disease); * Donning boots to lower legs for one hour, then doffing the boots once a day (for edema relating to hypertensive heart disease); * Questran packet (for diarrhea); * MiraLax packet (for bowel care); and * Torsemide (for edema). There was no documented evidence staff notified the prescriber of the above medication and treatment refusals. The need to ensure the physician or other practitioner was notified if a resident refused to consent to an order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (Regional Nurse Consultant), Staff 4 (Regional Nurse), and Staff 5 (RCC) on 12/04/24 at 2:40 pm. They acknowledged the findings.

1. Physician for resident #2 and #6 were faxed a copy of all refusals for past 30 days. 2. To prevent recurrance, HCCs will be re-educated on regulations surrounding resident right of refusal and requirements to notify the physician unless physician has requested they not be notified. This will also be part of the new hire training for new HCCs. 3. The 24/72 hour report will be reviewed five days a week to identify any residents who refused medications, treatments or tasks, and ensure physician was notified if needed. Notification of refusals are additionally reviewed during weekly RCC audit and monthly during CQI. 4. ED, RN & RCC will be responsible for maintaining this process.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, in good repair, and food was stored appropriately in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility's kitchen was toured on 10/05/23 at 10:15 am. a. An accumulation of food spills, splatters, loose food debris, dirt, and dust was observed on, in and/or underneath the following: * Walls and ceiling in the hot food prep and service area; * Drawer interior to the right of the hot food prep area; * Windowsill in the food service area; * Knife block on the wall near the cold food prep area; * Open laminate shelving under the hot food prep area; * Open metal shelving under the food pass area; * All kitchen drains; * Plastic shelving in the dry food storage area; and * Gray bin with baking supplies in the kitchen storage area. b. Observation of the facility's walk-in refrigerator and freezer revealed the following foods were not covered, dated, and/or labeled appropriately: * Shredded cheese; * Ham; * Various containers of salad dressing; * Pudding; * Walnuts; and * Beets. c. The following items were observed in poor repair: * The ceiling light cover above the food pass area was separated from the base; * The freezer door had ice buildup around the frame and covering the thermometer; * The warewasher rinse thermometer; * The refrigerator to the right of the hot food station was leaking; * The open laminate shelving under the hot food station was cracked exposing bare wood; * The kitchen door frame was worn exposing bare wood; * A laminate seam cover to the right of the kitchen door was cracked exposing a bare seam; and * The wood door to the right of the bulletin board was scuffed exposing bare wood and had black marks. d. The following items were covered in rust: * The open metal shelving above the food prep sink; * The open metal shelving to the right of the dishwashing sinks; and * The metal legs of a plastic food service cart. e. The following items were worn with cut marks and stains: * All cutting boards; and * The plastic hot food prep countertop. f. The following was noted with dead bugs and black debris: * All kitchen ceiling lights. e. One kitchen ceiling light had burned out lightbulbs. The kitchen was toured with Staff 1 (Administrator) 10/05/23. The items that required cleaning, dates, labels, and repairs/replacements were observed and discussed. She acknowledged the findings.

1a. Kitchen will undergo a deep clean.  b. All items that were not properly dated have been discarded. Sign to remind staff to date/label anything they open has been placed on walk in door.  c. All repairs will be completed. New light covers will be ordered and properly attached, freezer door has been repaired, rinse thermometer will be replaced, leaking deli fridge has been repaired, open laminate shelving will be replaced/repaired, kitchen door frame has been repainted, laminate seam covers have been replaced, right wood door will be painted and cleaned.  d. Open metal shelving above food prep area has been removed completely, open metal shelving to right of dishwasher will be replaced, plastic food service cart with metal legs has been thrown away.  e. All cutting boards will be thrown away and replaced. Plastic hot food prep counter will be replaced.  f. New ceiling light covers will be ordered and all burned out lightbulbs have been replaced. 2a. Dietary Manager will create an updated cleaning binder specifically listing problem areas to be cleaned as follows after initial deep clean: Monthly or as needed - walls and ceilings;  Weekly or as needed - drawer to right of hot food prep area, knife block, all kitchen drains, plastic shelving in dry food storage area;  Daily or as needed - window sill in food service area, open laminate shelving under food pass area, open metal shelving under food pass area.  The gray bin with baking supplies has been permanently removed. Staff will refer to binder daily and ensure all tasks are done. Dietary Manager will review during monthly Nutrition Services Quality Improvement Audit.  b. Sign has been placed on the walk-in door reminding staff to cover, date and label all food as appropriate. At the beginning of each shift, cook will tour the walk-in and discard any items that have not been properly covered, dated or labeled and report to Dietary Manager.  This will be discussed monthly during All-Staff Meeting and Dietary Manager will review during monthly Nutrition Services Quality Improvement Audit. c. After all repairs are complete, Dietary Manager will review during monthly Nutrition Services Quality Improvement Audit and will report any areas needing repair to Maintenance Director.  d. Any shelving or food service carts ordered as replacements will be made of plastic, stainless steel, or other material that will not rust.  e. Dietary Manger will evaluate the condition of cutting boards and food prep countertop during monthly Nutrition Services Quality Improvement Audit and replace as necessary.  f. New kitchen ceiling light covers will be ordered to replace current and will be on a Quarterly cleaning schedule. Dietary Manager will review during monthly Nutrition Services Quality Improvement Audit and will report any burned out bulbs to Maintenance Director. 3a. Will be evaluated monthly by Dietary Manager during Nutrition Services Quality Improvement Audit.  b. Will be evaluated daily by Cook.  c. Evaluated monthly during Nutrition Services Quality Improvement Audit.  d. Evaluated monthly during Nutrition Services Quality Improvement Audit.  e. Evaluated monthly during Nutrition Services Quality Improvement Audit.  f. Evaluated monthly during Nutrition Services Quality Improvement Audit. 4. Dietary Manager, Maintenance Director & Executive Director will be responsible for completing and monitoring all necessary corrections and to ensure kitchen is clean, in good repair, and food is stored appropriately.

The findings of the kitchen inspection, conducted 10/05/23, 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 first revisit of the kitchen inspection of 10/05/23, conducted on 01/11/24, 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 has been confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of residents. Findings include: During an unannounced site visit on 08/01/2022; the Compliance Specialist (CS) interviewed Staff #1, Staff #2, Staff #4 and Resident #1-Resident #3, separately. It was stated that in July staffing was a concern. It was stated that there were multiple call outs due to staff illness, which resulted in short staffing and missed needs. CS reviewed Service plans for Resident #1-Resident #3, Staff Schedules for July and August 2022, Acuity Based Staffing Tool and call light logs from 07/05/2022-07/08/2022; which revealed multiple dates where the facility was not staffed to their posted staffing plan. CS revealed 42 instances from 07/05/2022-07/08/2022 where call light response times exceeded 15 minutes, with multiple instances with 30 plus minute wait times. The above information was shared with Staff #1 on 08/01/2022 who was in agreement.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 08/01/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day