Evergreen Senior Living Community

Based on interview and record review, it was determined the facility failed to ensure resident evaluations were performed quarterly for 3 of 5 sampled residents (#s 1, 2, and 4) whose quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the community in 01/2014 with diagnoses including type 2 diabetes, anxiety disorder, and chronic skin ulcer.


On 07/07/25 the resident’s service plan was noted to be dated 01/08/25. In an interview that same day, Staff 5 (LPN) confirmed a quarterly evaluation had not been performed since that date.


The need to ensure evaluations were performed quarterly was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 on 07/10/25. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 10/2021 with diagnoses including vascular dementia.



Observation of the resident, interviews with staff and the resident, and review of the resident's 04/01//25 through 07/08/25 progress notes, physician communications, evaluations, and temporary service plans were completed.



The service plan and evaluation located in the service plan binder for staff was dated 10/06/24 and did not reflect the resident’s current care needs and abilities.



A subsequent evaluation and service plan update were completed during the survey on 07/07/25; the resident's current care needs and abilities were not reflected.



The need to ensure resident evaluations were completed, at least quarterly, and were reflective of the resident's current care needs was discussed with Staff 1 (Administrator), Staff 4 (RN) and Staff 5 (LPN) on 07/10/25. The staff acknowledged the findings.



3. Resident 4 was admitted to the facility in 05/2024 with diagnoses including diabetes.



Observation of the resident, interviews with staff and the resident, and review of the resident's 04/01//25 through 07/08/25 progress notes, physician communications, evaluations, and temporary service plans were completed.



The service plan and evaluation located in the service plan binder for staff was dated 03/21/25 and did not reflect the resident’s current care needs and abilities.


A subsequent evaluation and service plan update were completed during the survey on 07/08/25; however, the resident's current care needs and abilities were not reflected.

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff and were consistently implemented by staff for 4 of 6 sampled residents (#s 1, 2, 4 and 6) whose service plans were reviewed. Findings include, but are not limited to:



1. Resident 2 was admitted to the facility in 10/2021 with diagnoses including vascular dementia.



Observations of the resident, interviews with staff, review of the resident's 10/06/24 service plan, available in the service plan binder for staff and an update to the service plan completed during survey on 07/07/25, 04/01/25 through 07/08/25 temporary service plans and progress notes were completed. Staff indicated the resident was intermittently able to direct his/her own care but frequently refused care and displayed confusion around tasks. The resident could walk and transfer on his/her own but required some assistance with other ADL care. The resident spent most of the day sleeping in bed and rarely left his/her apartment.



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



* Incontinence and toileting assistance;

* Behaviors including leaving the room naked and brief removal;

* Refusals of care;

* Side rail use;

* Hyperglycemia and hypoglycemia;

* Dressing, grooming, hygiene and bathing;

* Wheelchair vs walker use;

* Fall and safety interventions;

* Evacuation ability; and

* Trips to the community unsupervised.



The need to ensure resident service plans were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 4 (RN) and Staff 5 (LPN) on 07/10/25. The staff acknowledged the findings.



2. Resident 4 was admitted to the facility in 05/2024 with diagnoses including diabetes.

Observations of the resident, interviews with staff, review of the resident's 03/21/25 service plan, available in the service plan binder for staff and an update to the service plan completed during survey on 07/08/25, 04/01/25 through 07/08/25 temporary service plans and progress notes were completed. Staff indicated the resident could direct his/her own care. The resident inconsistently called for staff assistance with transfers and ambulation which often resulted in falls. The resident experienced a decline and walked less frequently and required increased assistance with ADLs.



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



* Incontinence and toileting assistance;

* Perineal care and skin rashes;

* Gait belt use;

* ADL assistance from family members;

* Dressing, grooming, hygiene, and bathing;

* Wheelchair vs walker use;

* Fall and safety interventions;

* Self-administration and medication management;

* Evacuation ability; and

* Confusion and anxiousness with ADLs.



The need to ensure resident service plans were reflective of current care needs, were consistently implemented, and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 (LPN) on 07/10/25. The staff acknowledged the findings.

3. Resident 6 was admitted to the facility in 08/2024, with diagnoses including hypothyroidism, atrial fibrillation, and hypertension.

Review of Resident 6’s service plan, dated 06/25/25, progress notes, dated 04/07/25 through 07/07/25, temporary service plans, and interviews with staff revealed the service plan was not reflective of current status or lacked clear instruction to staff in the following areas:

* Activities;

* Nutrition/ hydration;

* Chronic pain;

* Fall history;

* Outside provider services; and

* Cognition/ orientation.



On 07/10/25, the need to ensure service plans were reflective of current care needs and provided clear instructions to staff was discussed with Staff 1 (Administrator). She acknowledged the findings.

3. Resident 1 moved into the community in 01/2025 with diagnoses including type 2 diabetes, anxiety disorder, and chronic skin ulcer.

The resident’s service plan, dated 01/08/25, corresponding TSPs, and Progress Notes dated 04/07/25 through 07/07/25 were reviewed, observations were made, and interviews were conducted.



The resident's service plan was not reflective of the resident’s needs and did not provide clear direction to staff regarding the delivery of services in the area of behaviors and behavioral interventions.



The need to ensure service plans were reflective of the residents’ needs and provided clear instruction to staff was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 (LPN) on 07/10/25. They acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition had resident-specific instructions or interventions developed and communicated to staff and weekly progress documented until resolution for 3 of 6 sampled residents (#s 1, 2, and 4) who experienced changes of condition. Findings include, but are not limited to:



1. Resident 2 was admitted to the facility in 10/2021 with diagnoses including vascular dementia.



Observations of the resident, interviews with staff, review of the resident's 10/06/24 and 07/07/25 service plans, 04/01/25 through 07/08/25 temporary service plans, progress notes, physician communications, and incident investigations were completed.



Multiple observations of the resident were made between 07/07/25 and 07/09/25 while in his/her apartment. The resident did not leave the apartment for meals or activities. The resident inconsistently called staff for assistance, frequently getting up on his/her own. The staff attempted to anticipate the resident’s needs and provide assistance with care before the resident tried to do it on their own.



The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas:



* Hospice admit;

* Medication refusals;

* Swelling to both feet and ankles;

* Medication changes;

* Left eye pain, redness and swelling; and

* Fall with knee pain.



The need to ensure short-term changes of condition had documentation of weekly progress until resolution, and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 4 (RN) and Staff 5 (LPN) on 07/10/25. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in 05/2024 with diagnoses including diabetes.



Observations of the resident, interviews with staff, review of the resident's 03/21/25 and 07/08/25 service plans, 04/01/25 through 07/08/25 temporary service plans, progress notes, physician communications, and incident investigations were completed.



Multiple daily observations were made of the resident between 07/07/25 and 07/09/25 while in his/her apartment and the dining room. The resident attended two meals a day in the dining room, spent a large amount of time visiting with his/her mother in her apartment, as well as spending time in his/her own apartment. The resident was observed to use a wheelchair for all mobility.



The resident experienced multiple short-term changes without noted progress at least weekly until resolved, and/or lacked resident-specific directions to staff in the following areas:



* Hospice admit and subsequent discharge;

* Treatment refusals;

* Injury and non-injury falls;

* Skin injuries and an abscess;

* Medication changes; and

* Oxygen order changes.



The need to ensure short-term changes of condition had documentation of weekly progress until resolution, and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 4 (RN) and Staff 5 (LPN) on 07/10/25. The staff acknowledged the findings.

3. Resident 1 moved into the community in 01/2025 with diagnoses including type 2 diabetes, anxiety disorder, and chronic skin ulcer.



The resident’s progress notes dated 04/07/25 through 07/07/25, and temporary service plans dated 03/20/25 through 07/07/25 were reviewed, and interviews with staff were conducted.



The resident experienced multiple medication changes that were monitored but not resolved, including a seven-day regimen of Doxycycline that had been monitored for 64 days. Staff 4 (LPN) acknowledged in an interview on 07/10/25 that the facility was aware their monitoring system was not working and they were in the process of revamping it.



The need to ensure the facility monitored changes of condition until they resolved was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 on 07/10/25. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure kitchen staff were taking necessary precautions to protect residents health and safety. Findings include, but are not limited to:

On multiple days of the survey, observations were made of staff working in the kitchen and serving residents without exercising proper infection control measures. The following was noted:

* Staff were observed touching their face, residents’ backs, or wheelchair handles, and then putting their thumbs inside individual salad bowls while serving; and

* Staff were observed touching the outside of small dressing cups and then placing the dressing cup inside the individual salad bowls, where it came into contact with the salad, while serving residents.

On 07/10/25, the need to ensure kitchen staff were using appropriate infection control practices, to protect resident health and safety while serving meals was discussed with Staff 1 (Administrator). She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

Resident 1 moved into the community in 01/2014 with diagnoses including type 2 diabetes, anxiety disorder, and chronic skin ulcer.

Resident 1 had the following orders for PRN medications classified as controlled substances:



* Morphine Sulfate 20 mg/ml solution 0.5 dose orally every 1 hour as needed for pain and shortness of breath;

* Lorazepam intensol 2 mg/ml concentrate 0.5 ml by mouth/sublingual every 4 hours as needed for anxiety; and

* Lorazepam 1 mg tab 1 tablet PO/sublingual every 4 hours as needed for anxiety, may give in lieu of liquid lorazepam.



Resident 1's Controlled Substance Disposition Logs and MAR dated 06/01/25 to 07/07/25 were reviewed. The following discrepancies were identified.



a. On 15 occasions in June and two occasions in July, staff signed on the drug disposition log that the morphine was taken out of the locked storage to administer; however, the MAR lacked documentation that the resident received the medication.



b. On six occasions in June and one occasion in July, staff signed on the drug disposition log that the liquid Lorazepam was taken out of the locked storage to administer; however, the MAR lacked documentation that the resident received the medication.



c. The following were entered on the MAR as having been administered but the drug disposition log had no corresponding documentation that the medications had been taken out of locked storage:



* Lorazepam tablet: 06/01/025 at 8:49 pm and 06/04/25 at 3:07 am;

* Lorazepam liquid: 06/04/25 at 3:08 am, 06/07/25 at 8:05 am, 06/15/25 at 2:13 pm, and 06/20/25 and 12:23 am.



d. On 06/15/25 the drug disposition log indicated liquid Lorazepam was removed at 3:45 pm; the MAR for that date documents the medication was administered at 4:14 am.

These findings were discussed with Staff 1 (Administrator) at 12:49 pm on 07/10/25. She acknowledged the findings.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances

(e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer, for 2 of 6 sampled residents (#s 5 and 6) whose MARs and orders were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 08/2024, with diagnoses including hypothyroidism, atrial fibrillation, and hypertension.

Review of Resident 6’s MAR, dated 06/01/25 through 07/07/25, and physician orders, dated 05/23/25, revealed the following:

There was an order for “Oxygen at 2 liters per minute via nasal cannula for desaturations below 90%”.

The oxygen was not included on the MAR.

On 07/10/25, the need to ensure written, signed physician orders were documented in the resident’s facility record for all medications and treatments was discussed with Staff 1 (Administrator). She acknowledged the findings.



2. Resident 5 moved into the community in 04/2025 with diagnoses including cerebral infarction and left hemiplegia.



The residents’ signed physician orders corresponding to the 06/01/25 through 07/07/25 MAR were reviewed. There were no written, signed orders for the following medications in Resident 5’s record:



* L-Arginine 1000mg tab (for nutrients);

* Tolterodine 1mg tab (for bladder spasms);

* Vitamin C 25mg tab (for wound healing);

* Antac+Sim 200-200-200mg/5ml (for GI distress);

* PRN Baclofen 5mg tab (for muscle spasms;

* PRN Diclofenac sodium 1% gel (for pain);

* PRN Loperamide 2mg tab (for loose stools);

* PRN Naloxone 4mg/0.1ml nasal spray (for suspected overdose);

* PRN Ondansetron 4mg tab (for nausea and vomiting); and

* PRN Acetaminophen 325 mg tab (for headache, pain, fever).



The need to ensure the facility had written, signed orders in the resident's record for all medications and treatments being administered was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 (LPN) on 07/10/25. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 4 of 4 sampled residents (#1, 2, 4, and 5) who had documented refusals. This is a repeat citation. Findings include, but are not limited to:



1. Resident 2 was admitted to the facility in 10/2021 with diagnoses including vascular dementia.



A review of the 06/01/25 through 07/08/25 MAR/TAR revealed the following medications and treatments were refused on numerous occasions:



* Aspirin;

* Digoxin (heart medication);

* Jardiance (diabetic medication);

* Genteal eye ointment (dry eyes);

* Isosorbide (blood pressure medication);

* Senna (bowel medication);

* Lisinopril (blood pressure medication);

* Metoprolol (blood pressure medication);

* Methimazole (thyroid medication);

* Hydrocodone (pain medication);

* Refresh eye drops (dry eyes);

* Nystatin (yeast rash treatment);

* Iprat/Albuterol nebulizer (breathing treatment); and

* Spironolactone (blood pressure medication).



The facility failed to ensure the physician was notified when the resident refused to consent to the above orders and failed to ensure subsequent refusals to consent to an order were reported as requested by the prescriber.



The need to ensure the facility notified the physician when a resident refused to consent to orders was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 (LPN) on 07/10/25. The staff acknowledged the findings.



2. Resident 4 was admitted to the facility in 05/2024 with diagnoses including diabetes.



A review of the 06/01/25 through 07/08/25 MAR/TAR revealed the following medications and treatments were refused:



* Triple antibiotic ointment on 16 occasions in June 2025.



The facility failed to ensure the physician was notified when the resident refused to consent to the above orders and failed to ensure subsequent refusals to consent to an order were reported as requested by the prescriber.



The need to ensure the facility notified the physician when a resident refused to consent to orders was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 (LPN) on 07/10/25. The staff acknowledged the findings.

3. Resident 1 moved into the community in 01/2014 with diagnoses including type 2 diabetes, anxiety disorder, and chronic skin ulcer.

Review of the resident’s 06/01/25 through 07/07/25 MAR identified the following medication and treatment refusals:



* Cetirizine 10mg tab for allergies refused on 3 occasions;



* Citalopram 40mg for depression was refused on 3 occasions;



* Clotrimazole 1% cream for gluteal fold rash was refused on 15 occasions;



* Metolazone 2.5mg tab for fluid retention was refused on 1 occasion;



* Senna/docusate 8.6-50mg tab for constipation was refused on 3 occasions;



* Spironolactone 100mg tab for edema was refused on 3 occasions;



* Bupropion hcl sr 200mg tab for depression was refused on 6 occasions;



* Clotrimazole 1% cream for infection was refused on 31 occasions;



* Eliquis 5mg tab for anticoagulant was refused on 6 occasions;



* Furosemide 80mg tab for edema was refused on 2 occasions;



* Haloperidol 2mg/ml conc for major depressive disorder was refused on 70 occasions;



* Buprenor/nalox 8-2mg film for pain was refused on 36 occasions;



* Diclofenac sodium 1% gel (no reason for use) was refused on 45 occasions; and



* Potassium Chloride 20meq for confusion was refused on 10 occasions.



There was no documented evidence the physician was notified of the above medication refusals.



The need to ensure physicians or other practitioners were notified each time a resident refused to consent to an order was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 (LPN) on 07/10/25. They acknowledged the findings.



4. Resident 5 moved into the community in 04/2025 with diagnoses including cerebral infarction and left hemiplegia.

Review of the resident’s 06/01/25 through 07/07/25 MAR identified the following medication and treatment refusals:



* Carboxymethyl for eye health 30x;

* Docusate sodium for constipation 11x ; and

* Arnuity for breathing relief 1x (07/02).

There was no documented evidence the physician was notified of the above medication refusals.



The need to ensure physicians or other practitioners were notified each time a resident refused to consent to an order was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 (LPN) on 07/10/25. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired direct care staff (#16) completed all required pre-service orientation and dementia training within the required timeframes. Findings include, but are not limited to:



Staff training records reviewed on 07/08/25 identified the following:



Staff 16 (CG), hired 03/14/25, lacked documentation of completion of the following pre-service orientation and dementia training:



* Resident rights and values of CBC care;

* Infectious Disease Prevention;

* Home and Community-Based Services (HCBS);

* LGBTQIA2s+ training; and

* Pre-service dementia training.



Staff 28 (Business Office Manager) reported in an interview on 07/08/25 the facility did not have a system to ensure caregivers completed the required pre-service orientation and training before beginning their assigned duties.



The need to ensure all pre-service orientation and dementia training was completed within the required timeframes was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 (LPN), on 07/10/25. They acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service

(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding:

(a) A review of their written position description with their job responsibilities.

(b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings.
(A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities.
(B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of
this rule.

(c) Abuse and reporting requirements.
(d) Fire safety and emergency procedures.

(e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease.

(A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:
(i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease.
(ii) Policy addressing respiratory hygiene and coughing etiquette.
(iii) Standard precautions.
(iv) Hand hygiene.
(v) Use of personal protective equipment.
(vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection.
(vii) Isolating and cohorting of residents during a disease outbreak.
(viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks
under ORS 433.004 and safeguards for employees who report disease outbreaks.

(B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.
(i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.
(ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.

(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below:
(A) Effective March 31, 2024, all staff must have completed the required training.
(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities.
(g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate.

(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.
(a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.
(A) Documentation of dementia training:
(i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training.
Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.
(ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.
(B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training.
(C) A certificate of completion must be made available to the Department upon request.
(D) Pre-service dementia care training must include the following subject areas:
(i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.
(ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.
(iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.
(iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:
(I) Identify and address pain.
(II) Provide food and fluids.
(III) Prevent wandering and elopement.
(IV) Use a person-centered approach.

(b) ORIENTATION TO RESIDENT. Pre-service orientation to resident:
(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan.
(B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 14, 16 and 19) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 07/08/25 at 3:30 pm identified the following:

a. There was no documented evidence Staff 16 (CG), hired 03/14/25, had demonstrated competency in all required areas and job duties performed.

b. There was no documented evidence Staff 14 (CG), hired 03/12/25, had demonstrated competency in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

c. There was no documented evidence Staff 19 (CG), hired 03/17/25, had demonstrated competency in the following areas and in all job duties assigned, including:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal again; and

* General food safety, serving and sanitation.

d. There was no documented evidence Staff 14 and Staff 16 had completed First Aid/Abdominal thrust within 30-days of hire.

The need to ensure newly hired direct care staff demonstrated competencies in all required areas and job duties performed within 30 days of hire was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 (LPN), on 07/10/25. They acknowledged the findings.

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 sampled long-term direct care staff (#s 20, 24, and 29) completed a minimum of 12 hours of annual in-service training, including at least six hours of dementia care. Findings include, but are not limited to:



Staff training records were reviewed on 07/08/25.



There was no documented evidence Staff 20 (CG), hired 04/03/23, Staff 24 (CG), hired 09/08/23, and Staff 29 (CG), hired 02/08/23, completed at least 12 hours of training related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics, based on their anniversary date of hire.



In an interview on 07/09/25, Staff 28 (Business Office Manager) reported that the facility did not have a system in place to monitor the annual training of long-term employees based on their anniversary date of hire.



The need to ensure that long-term direct care staff completed the required number of hours of annual in-service training within the required timeframe was discussed with Staff 1 (Administrator), Staff 4 (RN), and Staff 5 (LPN) on 07/10/25. They acknowledged the findings.

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

(6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF.

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

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure all required components of fire drills were documented. Findings include, but are not limited to:

On 07/08/25, fire drill records were reviewed from January 2025 through June 2025 with Staff 1 (Administrator). Fire drill records revealed the facility failed to consistently document the following required components:

* Location of simulated fire origin;

* Escape route used;

* Problems encountered;

* Evacuation time-period needed; and

* Number of occupants evacuated.

On 07/08/25, the lack of documented components of fire drills was discussed with Staff 1. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to provide fire and life safety procedures for residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

On 07/08/25, fire and life safety records were reviewed with Staff 1 (Administrator).

There was no documented evidence a written record of fire safety training for residents, including content of the training sessions and the residents who were in attendance was completed, at least annually.

On 07/08/25, the need to ensure residents were instructed on fire and life safety procedures at least annually was discussed with Staff 1. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to keep all interior surfaces in good repair. Findings include, but are not limited to:

The interior of the building was toured on 07/07/25. The following areas were in need of cleaning or repair:

* Scuffs and scrapes on multiple wood chairs and tables in dining room and common areas;

* Scratches on front of cabinets in coffee bar area;

* Scratches and damage on wood doors or jams of rooms 119, 120, 121, 124, 130, 132, 204, 207, 208, 217, 220, 221, 222, 226, 230, 234, and also exit doors near rooms 107 and 124;

* Stains on bench cushion near room 229;

* Stains on carpet in hall near room 222;

* Room 102 had extensive dark stains on carpet and an unpleasant odor, which persisted through multiple days of survey; and

* Room 221 had heavy damage to plaster walls near door and in bathroom, damage to laminate counter in kitchen area, and dark stains on carpet.

On 07/10/25, the need to ensure all interior surfaces were kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 8 (Maintenance Assistant). They acknowledged the findings.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable

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

This Rule is not met as evidenced by:

Based on interview and record review, conducted during a site visit on 04/02/25, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1) was substantiated. Findings include, but are not limited to:Compliance Specialist (CS) reviewed Resident 1's June 2024 MAR, progress notes and physician orders which indicated the following:· Order dated 06/09/25 for Carbidopa/Levo 25-250MG tab 1 tablet by mouth 3 times daily before breakfast, lunch and before evening meal for Parkinson's. · MAR indicated resident receive Carbidopa/Levo 25-100 MG 1 tablet by mouth before breakfast and lunch. In an interview, Staff 2 (RCC) was aware of the issues with Resident 1 not getting the correct medication dosage on 06/10/24. She/he stated the MT received one on one coaching at the time and MT no longer works at facility. Findings were reviewed with and acknowledged by Staff 1 (ED) on 04/02/25. The facility's failure to carry out medication and treatment orders as prescribed was substantiated.

The findings of the re-licensure survey, conducted 07/10/23 through 07/13/23, 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the revisit to the re-licensure survey of 07/13/23, conducted 09/11/23 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 Home and Community Based Services Regulations OARs 411 Division 004.

2. On 07/12/23 at 3:24 pm, the acuity-based staffing tool (ABST) was reviewed with Staff 1 (Health and Wellness Director/RN) and Staff 2 (Health and Wellness Coordinator/LPN) and revealed the following:a. Resident 4 was admitted to the facility in 11/2015 and his/her ABST had not been reviewed and updated quarterly since 02/13/23.b. Resident 6 was admitted to the facility in 01/2014 and his/her ABST had not been reviewed and updated quarterly since 02/13/23.The need to ensure the facility's ABST was updated no less than quarterly was reviewed with Staff 1 and Staff 2 on 07/12/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated no less than quarterly and accurately reflected resident care needs for 3 of 6 sampled residents (#s 1, 4, and 6) whose ABST data was reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 12/2020 with diagnoses including anxiety and difficulty walking.Review of the resident's service plan dated 06/08/23, progress notes dated 04/10/23 to 07/10/23, interviews with staff, and interviews and observations of the resident revealed ABST entries were not reflective of the current care needs in the following areas:* Monitoring behavioral conditions or symptoms;* Ensuring non-drug interventions for behaviors; and* Assistance with ambulation, including escorting to and from meals and activities. The ABST data reflected zero minutes when the resident required staff assistance with the above areas.The need to ensure the ABST reflected resident care needs was discussed with Staff 1 (Health and Wellness Director/RN) and Staff 2 (Health and Wellness Coordinator/LPN) on 07/12/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:Observations of resident rooms 221, 223, 227, and 230 identified:* Stained carpets throughout in all apartments;* Damage to entry and bathroom door frames in 221 and 230; * Damage to bathroom walls in 221 and 223; and* Damage to bedroom/living room walls in 230.The areas in need of cleaning and repair were reviewed with Staff 1 (Health and Wellness Director/RN), Staff 2 (Health and Wellness Coordinator/LPN), and Staff 3 (Maintenance Director) on 07/11/23 and 07/12/23. They acknowledged the findings.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 12/07/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and observation, it was confirmed that the facility failed to provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Findings include:In an interview with Staff #1 on 12/07/22, they stated that the heat is turned up, but the facility has high ceilings in the dining room, and it doesn't keep the heat as well. There are 2 units that will be replaced in February that the parts have been on backorder for 5 months now. All the units are functioning; however, this will make them more efficient. The heating in the rooms is working fine and have not been affected.Compliance Specialist (CS) observed thermostats in the building on 12/07/22 and found that the dining room thermostat was set to 77 degrees and the inside temperature was reading 69 degrees. CS tested with a temperature gun and the reading was 68.7 degrees. No issues regarding the heat in the residents' rooms was observed. The 2nd floor hallway was set at 70 degrees and was reading as 67.8 degrees on the monitor.The above information was shared with Staff #1 on 12/07/22 who acknowledged the findings.Plan of Correction: Facility will be getting 2 units replaced in February to make the heating more efficient. Administrator reported that on 12/12/22 a technician was out and able to restore more functioning to the heat units and the dining room is warmer now.

The findings of the kitchen inspection, conducted 11/15/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 11/15/22, conducted 01/13/23, 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 11/15/22, conducted 2/27/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 11/15/22 revealed splatters, spills, drips, and debris noted on: - Can opener blade and casing; - Stand mixer; - Meat slicer; - Interiors of drawers; - Open stainless steel shelving throughout kitchen; - Shelving above the tray line and the range; - Interior, exterior, and beneath ice machine; - Sides of steam table; - Exterior of the range; and - Underneath shelving and equipment. * A box of cans for recycling noted with spilled soda covering the bottom of the box. * A pool of water noted beneath the ice machine.* A reach in refrigerator in the private dining room, storing protein based foods and nutritional supplements for residents, had no thermometer to monitor the internal temperature.* Dish washing racks were stored on the floor. Visible debris was noted on the clean side of the dish machine.* Staff were observed to not change gloves between tasks and handling ready to eat foods.Staff 2 (Dietary Manager) and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings.The areas in need of cleaning and repair were reviewed with Staff 1 (Administrator). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 01/13/23 revealed splatters, spills, drips, dust and debris noted on: - Meat slicer; - Open stainless steel shelving throughout kitchen; - Walls throughout kitchen area; - Interior and exterior of microwave; - Exterior and interior of range/oven; - Stainless steel area directly behind range/grill; - Hood above range/grill; - Underneath shelving and equipment throughout kitchen; - Floors in corners, edges, beside and under equipment; - Ceiling and vents; - Step stool in dry good storage; - Walk in cooler and freezer floors under shelving, corners and thresholds; - Shelving in walk in cooler; - Shelf under coffee station; - Walls and floors behind, under and around dish machine and dish pit; - Shelving where clean cutting boards were stored; - Utility carts; - Portable two burner appliance; - Juice machine; - Water filters by ice machine and juice machine; and - Floor under steam table. * Multiple kitchen staff were observed using latex gloves for food service tasks. Staff 2 (Dietary Manager) was interviewed and acknowledged use of latex gloves. S/he was unaware that latex gloves were prohibited in food service use. When asked if any residents had latex allergy, kitchen staff indicated they had not been notified of any residents with latex allergies. Staff 1 was asked if any residents had latex allergy and s/he reported that two residents had a latex allergy. Staff 1 confirmed that care staff were not using any latex gloves. Staff 1 ensured surveyor that latex gloves would be removed from kitchen and appropriate food service gloves would be used. * A black utility cart was damaged with a cracked handle and visible food debris build up in cracks. Multiple cutting boards had heavy scoring and/or staining.* A dirty rag was observed stored on a wire rack next to clean equipment/dishes.Kitchen sanitation audits were reviewed and multiple audits identified needing kitchen cleaning of walls/floors and shelves. Staff 1 (Administrator) and the surveyor reviewed areas of concern. Staff 1 acknowledged the above findings.