Cedar Village Assisted Living Community

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

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 4 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 04/2025 with diagnoses including diastolic congestive heart failure, tremors and chronic obstructive pulmonary disease (COPD). During the acuity interview on 06/16/26, Resident 4 was identified as receiving hospice services at the time of admission. Observations were made of the resident's care on 06/17/26 and 06/18/26. Interviews with the resident, hospice providers and facility staff were conducted, and the service plan, dated 05/06/26, was reviewed. Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Number of staff needed to assist with activities of daily living; * Instructions on signs and symptoms of depression and anxiety to report while on anti-depressant therapy; * Instructions for staff as to how the side rails were to be used, monitored for safety, and to whom to report any malfunctions; * Oxygen equipment precautions, instructions for proper maintenance, including when to add distilled water, how to charge a portable oxygen tank, and how to monitor for safety; * Instructions on what types of skin impairments to report and to whom; and * Incorrect reference to the resident as using a bilevel positive airway pressure (BiPAP) ventilation device or continuous positive airway pressure (CPAP) therapy device. Staff 9 (Care Partner) was interviewed on 06/17/26 at 2:19 pm and stated Resident 4 spent most of the time in bed and “when [Resident 4]’s hand tremors get worse, [s/he] needs help with everything around the room.” Staff 9 added, “I always check side rails while changing bedding because they [side rails] get loose often.” The need to ensure service plans reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED) and Staff 4 (Regional Director of Operations) on 06/18/26 at 1:57 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 05/2025 with diagnoses including chronic kidney disease and hypertension. The resident’s 03/08/26 to 06/16/26 clinical record was reviewed, interviews with staff and resident were conducted, and observations were made. The service plan, dated 05/27/26, was not reflective of the resident’s current care needs or lacked clear instructions to staff in the following areas: * Instructions regarding how the side rails were to be used, monitored for safety, and to whom to report any malfunctions; * Instructions regarding level of assistance needed for management of oxygen; * Incorrect reference to the resident as using a bilevel positive airway pressure (BiPAP) ventilation device or continuous positive airway pressure (CPAP) therapy device; * Instructions regarding bowel movements including supplies needed, bowel status and modifications of the briefs; * Preferences regarding where to eat meals; * Skin conditions including what to apply following brief changes; * Frequency of providing safety checks; * Ability to reposition in bed; * PRN psychotropic medication including reason for use and what to do when exhibiting; * Frequency of taking weight and which wheelchair to use; and * Diabetic status. During an observation on 06/16/26 at 1:45 pm, Resident 2 had two quarter length side rails on the hospital bed, preferred the side straps of briefs removed prior to use, and relied on staff to assist with his/her oxygen needs. Resident 2 indicated s/he used a BiPAP, not CPAP, machine at night and was not diabetic. During an interview on 06/18/26 at 12:55 pm, Staff 6 (Care Partner) indicated Resident 2 was continent of his/her bowels, was unsure if the resident had a PRN medication for anxiety or which wheelchair the resident used to obtain his/her weight and had two types of ointment to apply following a brief change and believed the “thicker one” was applied at night. The need to ensure residents’ service plans were reflective of their needs and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 4 (Regional Director of Operations) on 06/18/26 at 2:30 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) Resident #4's service plan were immediately reviewed and revised to reflect the number of staff needed to provide assistance, safety interventions for depression medication, equipment, and reporting instructions for staff. b) Resident #2's service plan were immediately reviewed and revised to reflect equipment instructions, level of assistance, resident preferences, safety interventions, and physician orders. 2. The system will be corrected so that the violation will not occur by: a) The community will implement a service plan review process requiring service plans to be reviewed and updated upon admission, within 30 days, quarterly, and with a significant change of condition followed by a service plan audit checklist to verify all required care instructions, equipment, interventions, resident preferences, and safety measures are accurately documented. 3. The area needing correction will be evaluated by the Licensed Nurse and/or Administrator by completing weekly service plan audits to ensure compliance. Any areas of non-compliance will be addressed immediately. 4. The Administrator, Resident Care Coordinator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

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 medication and treatment orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible for administering for 2 of 4 sampled residents (#2 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2025 with diagnoses including chronic kidney disease and hypertension. The resident's 03/08/26 to 06/16/26 clinical record and 06/01/26 through 06/16/26 MAR were reviewed and noted the following: a. On 06/04/26 Novolog 100 U/ml insulin sliding scale for hyperglycemia was ordered for administration before each meal three times daily based on Resident 2's blood glucose level while taking prednisone. Based on review of the MAR, an incorrect dose of insulin was administered on two occasions. Additionally, there was no documented evidence how many units of insulin had been administered based on the resident’s blood glucose level on three occasions. The administration of incorrect dose had no negative outcome to Resident 2. b. A physician’s order on 05/14/26 instructed staff to obtain weights twice weekly on Tuesday and Friday and notify the PCP for a weight gain of five pounds or more. Based on review of the MAR, the resident was not weighed on 06/04/26, 06/09/26 and 06/12/26. c. The following orders were not transcribed to the 06/01/26 through 06/16/26 MAR: * Pantoprazole (for acid reflux) 40 mg daily; and * Glucose (for low blood sugar) 15 grams as needed for blood sugar less than 70. The need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed was discussed Staff 1 (ED) and Staff 4 (Regional Director of Operations) on 06/18/26 at 2:30 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 04/2025 with diagnoses including diastolic congestive heart failure, tremors and chronic obstructive pulmonary disease (COPD). During the acuity interview on 06/16/26, Resident 4 was identified receiving hospice services at the time of admission. Resident 4's MARs from 06/01/26 through 06/16/26 were reviewed. Interviews with facility staff were conducted. During the review of the resident’s chart on 06/16/26 at approximately 2:30 pm, it was noted there was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the medications and treatments that the facility was responsible to administer. Signed physician orders dated 06/16/26 were received by the survey team on 06/17/26 at 11:03 am. During an interview on 06/17/26 at 9:45 am, Witness 1 (Hospice RN) confirmed the facility asked for a copy of the hospice orders on 06/16/26 and they were faxed as requested. The need to ensure written, signed or other legally recognized practitioner orders were documented in the resident’s facility record for all medications and treatments that the facility was responsible to administer was reviewed with Staff 1 (ED) and Staff 4 (Regional Director of Operations) on 06/18/26 at 1:57 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) Resident #2's physician orders and medication records were immediately audited. All medications and treatments were verified to accurately reflect current physician orders. b) Resident #4's physician orders were immediately obtained. A facility-wide audit of active physician orders was completed to ensure all medications and treatments have corresponding signed practitioner orders within the resident record. 2. The system will be corrected so that the violation will not occur by: a) The community implemented a Physician Order Reconciliation Process requiring all new physician orders to be reviewed for completeness, entered into the electronic record, and verified against the MAR/TAR prior to implementation by the Med Tech's, Care Coordinator and RN. 3. The area needing correction will be evaluated by the Licensed Nurse weekly. Any areas out of compliance will be addressed immediately. 4. The Administrator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

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

Based on interview and record review, it was determined the facility failed to complete, update and review the Acuity Based Staffing Tool (ABST) evaluation for each resident before a resident moved in and no less than quarterly and corresponding with resident service plan updates for 3 of 4 sampled residents (#s 2, 3 and 4). Findings include, but are not limited to: The ABST data was captured on 06/16/26 at 10:41 am. a. On 06/18/26 at 12:30 pm, Staff 1 (ED) confirmed Resident 3 moved into the facility on 04/30/26. The resident’s ABST evaluation was not created until 05/26/26. b. Resident 2’s most recent service plan was dated 05/27/26. The resident’s ABST evaluation was last reviewed on 02/13/26. c. Resident 4’s most recent service plan was dated 05/06/26. The resident’s ABST evaluation was last reviewed on 02/12/26. The need to ensure resident ABST evaluations were completed prior to move-in and no less than quarterly and corresponding with resident service plan updates, was reviewed with Staff 1 and Staff 3 (RCC) on 06/18/26 at 12:30 pm and with Staff 1 and Staff 4 (Regional Director of Operations) on 06/18/26 at 3:05 pm. They acknowledged the ABST evaluations had not been created or reviewed as required.

1. The actions that will be taken to correct the rule are: a) Resident #'s 2, 3 and 4 had their ABST evaluations updated to actively reflect current service plan needs. 2. The system will be corrected so that the violation will not occur by: a) The community will implement an ABST Review Process audit requiring completion upon admission, 30 days, quarterly and significant changes of condition. A monthly evaluations log is created to monitor for upcoming due dates and completed reviews. 3. The area needing correction will be evaluated by the Administrator weekly for four weeks and then monthly therafter to ensure evaluations remain current. 4. The Administrator and Resident Care Coordinator will be responsible to ensure that corrections are completed and monitored.

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

Based on interview and record review, it was determined the facility failed to conduct and document fire drills per Oregon Fire Code (OFC). Findings include, but are not limited to: Fire drill records were reviewed on 06/17/26. The following was identified: a. The facility was not conducting fire drills at different times of the day, evening and night shifts. The facility conducted drills on day, and evening shifts every other month, but the last drill conducted on night shift was 09/30/25. b. The facility had one first floor wing of resident rooms, and two second floor wings of resident rooms: rooms 201 – 221 and 222 – 238. Fire drills conducted between 07/18/25 and 05/31/26 indicated fires were simulated on the first floor and on the second-floor wing for rooms 222 – 238. No drills were conducted for the residents in the 201 – 221 wing. c. The facility did not document any follow up regarding the residents who resisted or failed to participate in the fire drills in order to ensure the facility was capable of evacuating the building in an emergency. The need to ensure fire drills were conducted and documented per the OFC was reviewed with Staff 1 (ED) and Staff 4 (Regional Director of Operations) on 06/18/26 at 3:05 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) Leadership responsible for conducting fire drills received re-education regarding required drill frequency, documentation elements, staff participation, resident participation and evacuation expectations. 2. The system will be corrected so that the violation will not occur by: a) A Fire Drill Documentation Checklist has been implemented to ensure all required Oregon Fire Code elements are documented for each drill. Fire drills will be scheduled throughout varying shifts to ensure staff participation across all work hours. Completed documentation will be reviewed by the Executive Director prior to filing to ensure compliance with regulatory requirements. 3. The area needing correction will be evaluated by the Administrator following each fire drill and monitored monthly. 4. The Administrator and Maintenance Director will be responsible to ensure that corrections are completed and monitored.

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

Based on interview and record review, it was determined the facility failed to complete quarterly evaluations for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose records were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, 4, 5, 6 and 7’s records were reviewed during the survey and identified the following: There was no documented evidence that quarterly evaluations were completed for Residents 1, 2, 3, 4, 5, 6, and 7. In an interview on 06/04/25, Staff 1 (ED) acknowledged that quarterly evaluations had not been completed. On 06/04/25, the need to ensure evaluations were completed quarterly, as required, was discussed with Staff 1. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The residents quarterly evaluations for residents 1, 2, 3, 4, 5, 6, and 7 will be completed to accurately reflect the residents current needs and preferences. 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse or designee will ensure that resident evaluations are are conducted at the time of move in, within 15-30 days of move in, with any change in condition, and quarterly to accurately reflect the residents needs and preferences. b) The Administrator or designee will maintain a monthly schedule of upcoming evaluations to ensure timely completion. 3. The area needing correction will be evaluated by the Licensed Nurse or Administrator by completing weekly audits to ensure compliance. Areas of non-compliance will be addressed immediately. 4. The Administrator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services, and/or were implemented for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia, traumatic brain injury, and hypotension (low blood pressure). During the survey, Resident 2 was observed to use a wheelchair with assistance for all mobility. Staff interviewed on 06/03/25 reported the resident was a full assist with transfers using a gait belt to the wheelchair. Staff reported the resident was not able to walk and was full assist of one person for all ADL cares to include meal assistance at times. Review of Resident 2’s service plans available for staff, dated 09/03/24 and 05/13/25, interim service plans, interviews with staff and resident, and observations during the survey revealed the service plan was not reflective of current care needs, and/or did not provide clear instructions to staff in the following areas: * Ambulation/mobility status; * Communication deficits; * Fall history with interventions; and * Meal assistance. On 06/04/25, the need to ensure service plans were reflective of current resident care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 3 (RCC) and Staff 10 (MT). They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2025 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and hypertension. During survey, Resident 3 was observed to wear glasses and hearing aids. The resident and staff reported that s/he was independent with transfers and ambulation, used a walker independently and was independent with ADLs except bathing. Review of Resident 3’s service plans available for staff, dated 04/15/25 and 05/28/25, interim service plans, interviews with staff and resident, and observations during the survey revealed the service plan was not reflective of current care needs, and/or did not provide clear instructions to staff in the following areas: * Shower assist; * Hospice services; * Side rail use; * Tremors to upper extremities; * Specialized utensils and glass/cup/straw for meals; * Oxygen, to include direction for staff; * Eyeglasses; and * Hearing aids. On 06/04/25, the need to ensure service plans were reflective of current resident care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 3 (RCC) and Staff 10 (MT). They acknowledged the findings. 3. Resident 4 was admitted to the facility in 12/2018 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 05/06/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * Evacuation assistance; * Behaviors, hallucinations and dementia; * Toileting, significant output, incontinent care and brief changes; * Dressing, transfers and mobility assistance; * Vision impairment, orientation to food on the plate, and cut up food items; * One-person vs. two-person assistance; * Fall risk and safety interventions; * Fluid intake and placement of fluids; and * Wheelchair, walker and electric scooter use. 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 (ED) and Staff 3 (RCC) on 06/04/25. They acknowledged the findings. 4. Resident 5 was readmitted to the facility in 11/2022 with diagnoses including pain. Observations of the resident, interviews with staff and review of the service plan, dated 02/12/25, showed the service plan was not reflective of the resident's current care needs, was not consistently implemented and/or did not provide clear direction to staff in the following areas: * Evacuation assistance; * Wheelchair, walker and electric scooter use; * Transfers, standby assist, mobility/ambulation; * Escorting resident to meals and activities; * Toileting, incontinent care and brief changes; * Dental status; * Diabetes, hypo/hyperglycemia and insulin use; * Dressing assistance related to lower body and walking boot; The need to ensure resident service plans were reflective of current care needs, was consistently implemented and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (RCC) on 06/04/25. They acknowledged the findings. 5. Resident 1 was admitted to the facility in 10/2022 with diagnoses including myocardial infarction (heart attack) and type 2 diabetes. The resident’s record including the current service plan and progress notes dated 03/04/25 through 06/02/25 were reviewed. Observations were made, and staff were interviewed. The following was identified: a. The service plan available at the time of the survey was dated 02/12/25 and had not been updated quarterly, as required. b. The service plan was not reflective and/or did not provide clear direction to staff in the following areas: * Symptoms of high and low blood sugar; * Home health services and responsibilities; * Current skin condition and treatment; * Family member providing wound care; * Use of wheelchair; * Use of four-wheel walker; * Staff to encourage the resident to ambulate after meals; and * Resident-specific needs during evacuation. On 06/04/25, the need to ensure resident service plans were reviewed quarterly, were reflective of resident needs and provided clear direction to staff was discussed with Staff 1 (ED). He acknowledged the findings. 6. A review of Resident 6 and 7's service plans, interim service plans and interviews with care staff identified the following: Resident 6 and 7’s most current service plans were dated 02/12/25. In an interview on 06/04/25, Staff 1 (ED) confirmed Resident 6 and 7’s service plans had not been reviewed quarterly as required. The need to ensure resident service plans were reviewed quarterly was discussed with Staff 1 on 06/04/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The Licensed Nurse and/or designee will complete a comprehensive review and update of the service plans for all seven residents identified in the survey to ensure current ADL needs are accurately reflected and interventions are clearly documented and implemented. 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse or designee will conduct a full audit of all current residents service plans to identify any additional discrepancies or updates needed. This will ensure that all service plans accurately reflect the resident’s current care needs and that staff have clear direction for implementation. 3. The area needing correction will be evaluated by the Licensed Nurse and/or Administrator by completing weekly audits to ensure compliance. Any areas of non-compliance will be addressed immediately. 4. The Administrator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

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 the resident’s care needs, and provided clear instructions to staff for 1 of 3 sampled residents (#10) whose service plan was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 10 moved into the assisted living community in 03/2025 with diagnoses including hypertension, chronic pain, and history of falls. Review of the resident’s clinical record, including observations made during an interview with the resident, identified the service plan was not reflective of his/her care needs and failed to provide clear direction to staff in the following areas: * One-person transfer with a gait belt versus a stand pivot transfer with reminders to use grab bars; * Assistance to keep glasses clean versus independent with vision care; * Assistance with oral care and grooming versus independent; * One-person assistance with dressing versus independent; * One-person assistance with toileting versus independent; * Preference of where s/he liked to eat meals; * Refusals for bed making and laundry assistance; * Use of a walking boot; * Home exercise program to promote strength and gait; and * Fall interventions. The need to ensure the service plan was reflective of care needs and provided clear instructions to staff was reviewed with Staff 1 (ED) and Staff 15 (RN) on 10/01/25 at 1:32 pm. They acknowledged the findings.

1. The actions that will be taken to correct the rule are: Resident 10's service plan will be updated to reflect his/her care needs and clear direction to staff. 2. The system will be corrected so that the violation will not occur by: All resident service plans have been reviewed and updated to accurately reflect the services being provided by staff. The Resident Care Coordinator has been re-educated on timely updates to the service plans to be reflective of care needs. 3. The area needing correction will be evaluated by the administrator and licensed nurse by reviewing a sample of 5 service plans monthly for accuracy and any discrepancies will be corrected immediately. 4. The Administrator and Licensed nurse will be responsible that corrections are completed and monitored.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose records were reviewed. Findings include, but are not limited to: Resident 1, 2, 3, 4, 5, 6 and 7's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. During interview on 06/03/25 with Staff 3 (RCC), she reported no documented or organized Service Planning Team was completed when service plans were updated. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) on 06/04/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The service plans for residents 1, 2, 3, 4, 5, 6, and 7 will be updated to reflect evidence as applicable that a service planning team participated in the development of the service plans. 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse or designee will review all current residents evaluations and conduct service plans reviews including all applicable parties such as: Resident, Resident Legal Representative, any person of Resident's choice, Administrator, Licensed Nurse, and at least one other person who is familiar with the resident such as dietary team, and Life Enrichment team 3. The area needing correction will be evaluated by the Licensed Nurse and the Administrator by completing weekly audits to ensure compliance. Areas of non compliance will be addressed immediately. 4. The Administrator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, the condition was monitored at least weekly to resolution and that interventions were re-evaluated to determine effectiveness for 3 of 5 sampled residents (#s 1, 2 and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 11/2022 with diagnoses including pain. The resident's 02/12/25 service plan, 03/03/25 through 06/01/25 progress notes, incident investigation notes and physician communications were reviewed. 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: * Foot swelling; * Toe bruising and pain; and * Skin Tear. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 3 (RCC) on 06/04/25. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia, traumatic brain injury and hypotension (low blood pressure). The resident's service plans, progress notes and incident reports dated 03/02/25 through 06/02/25, and MARs dated 05/01/25 to 05/31/25 were reviewed, observations were made, and interviews with staff were conducted. The following short-term changes of condition, documented in the progress notes, lacked actions or interventions determined and communicated to staff on all shifts, and were not monitored at least weekly to resolution: * 04/17/25 – Medication changes; * 04/18/25 – Fall; * 04/22/25 – New medication (Metamucil for constipation), and discontinuation of Melatonin (for sleep); * 04/29/25 – Fall with head strike; and * 05/13/25 – Fall. The need to ensure all changes of condition had actions or interventions determined and communicated to staff on all shifts, and/or were monitored at least weekly to resolution was discussed with Staff 1 (ED), Staff 3 (RCC) and Staff 10 (MT) on 06/04/25, and Staff 2 (RN) on 06/03/25. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 10/2022 with diagnoses including myocardial infarction (heart attack) and type 2 diabetes. The resident's 03/04/25 through 06/02/25 progress notes, service plan dated 02/12/25 and interim service plans were reviewed, and interviews with staff and the resident were conducted. The following was identified: A progress note indicated Resident 1 had a chronic wound to his/her lower back. “Pinhole size draining wound.” There was no documented evidence the facility communicated actions or interventions to staff on each shift or monitored the condition at least weekly to resolution. The need to ensure actions or interventions for changes of condition were communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 1 (ED) on 06/04/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The service plans for sample residents 1,2, and 5 will be updated to ensure that all short term changes of condition were documented and communicated to staff. The resident's progress will be evaluated at least weekly until resolution. 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse or designee will review all current resident service plans to ensure service plans are descriptive of the residents current health and functional status. The Licensed Nurse or designee will ensure that all significant and short-term changes of condition are reflected in an updated service plan or temporary service plan respectively. The Licensed Nurse will document instructions and interventions that are specific to each change of condition. b) Any change will be monitored at least weekly with a minimum of a progress note and communicated to staff. 3. The area needing correction will be evaluated by the Licensed Nurse and the Administrator by completing weekly audits to ensure compliance. Areas of non compliance will be addressed immediately. 4. The Administrator and Licensed Nurse will be responsible to ensure that corrections are completed and monitored.

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed to include documented findings, resident status, and interventions made as a result of the assessment for 1 of 3 sampled residents (# 2) who experienced a significant change of condition. Findings include, but are not limited to: Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia, traumatic brain injury and hypotension (low blood pressure). Observations of Resident 2 during survey revealed s/he used a wheelchair with assist for mobility and had word finding difficulties during conversation. On 06/03/25 during an interview, Witness 1 (Family member) reported that Resident 2 was no longer able to ambulate and had declined in her speech, cognition and mobility due to “a lot of falls with brain injuries”. Interviews with staff and review of the resident's 09/03/24 and 05/13/25 service plans, and 03/02/25 through 06/02/25 progress notes, and incident investigations were completed. The service plan indicated the resident used a walker for mobility with a gait belt and one staff assistance and was independent with meals after set-up. Staff 8 (CG) reported that Resident 2 had declined since a fall on 04/29/25, needing meal assistance at times, was more confused, and was unable to ambulate any longer due to knees buckling. The declines in mobility, cognition and ability to consistently eat and drink without assistance constituted a significant change of condition for Resident 2. Staff 2 (RN) and Staff 3 (RCC) reported on 06/03/25 there was no documented RN assessment completed for the significant change of condition. The need to ensure an RN assessment was completed for significant changes of condition which included findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 3, and Staff 10 (MT) on 06/04/25. Staff acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The Licensed Nurse will complete a change of condition note/RN assessment for the change in condition on resident #2 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse will complete the "Role of the RN" training course scheduled for August of 2025. 3. The area of correction will need to be monitored by the Licensed Nurse or designee and will conduct weekly audits of required clinical documentation and service plans of residents who experienced a change of condition. Areas of non compliance will be addressed immediately. 4. The Registered Nurse and The Administrator will be responsible for ensuring the corrections are completed and monitored.

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

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation and interview, it was determined the facility failed to ensure staff utilized proper infection control while serving in the dining room. Findings include, but are not limited to: Observations of the dining room during breakfast and lunch meal on 06/03/25 showed the following: * Four care staff were delivering meals and fluids to residents in the dining room. The staff were not wearing aprons or other clothing covers when serving food. * Staff were observed with gloves on. Multiple staff were touching other surfaces including the kitchen doors, wheelchair handles, and dirty dishes without a change of gloves. * Staff were exiting and entering the dining room without consistently changing gloves or washing hands. * Two staff were stopped and asked to change gloves and clean hands before beginning to serve in the dining room again. The need to ensure staff consistently used proper infection control, hand hygiene and glove use was discussed with Staff 1 (ED) and Staff 3 (RCC) on 06/04/25. The staff acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) All staff involved in meal service on 06/03/25 were immediately re-educated on proper infection control protocols, including glove use, hand hygiene, and the requirement to wear aprons or clean clothing covers while serving food. b) all care and dietary staff will be provided aprons and will be required to wear aprons while serving food. 2. The system will be corrected so that the violation will not occur by: a) All direct care staff and dietary staff will be required to complete the "about infection control and prevention" training from Oregon Care Partners by 7/4/2025. b) Clear visual reminders (posters/signs) will be placed in the food service area to reinforce glove, apron and hand hygiene protocols. 3. The area needing correction will be evaluated by the Executive Chef or designee by observation at least 3 times per week. Observations will be documented and any areas of non compliance will be addressed on the spot. 4. The Administrator and Executive Chef will be responsible to ensure all corrections are completed and monitored.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 2 sampled residents (#7) who were prescribed and administered PRN medications to treat behaviors. Findings include, but are not limited to: Resident 7 was admitted to the facility in 07/2024 with diagnoses including anxiety disorder and obsessive-compulsive behavior. Resident 7 had a physician's order for lorazepam 0.5 mg as needed for anxiety. Resident 7's 05/01/25 – 05/31/25 MAR was reviewed. The resident was administered the psychotropic medication on 05/11/25, 05/13/25, 05/27/25, and 05/28/25 with no documented evidence staff had first attempted non-drug interventions with ineffective results. The need to attempt non-drug interventions prior to administering PRN psychotropic medications was reviewed with Staff 1 (ED) on 06/04/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The Licensed Nurse will update resident 7's record to accurately reflect non-drug interventions with effective/ineffective documentation. 2. The system will be corrected so that the violation will not occur by: a) The Administrator, Licensed Nurse, Resident Care Coordinator, and Med Techs will receive additional training by the community consultant on regulatory expectations regarding PRN psychotropic medication use, appropriate non-pharmacological interventions for behavior and anxiety, documentation standards and including when interventions are ineffective. b) The Licensed nurse will review all PRN psychotropic medication administrations weekly to ensure appropriate documentation of prior non-drug interventions. 3. The area needing correction will be evaluated by the Licensed Nurse or designee weekly and any areas of non compliance will be addressed immediately. 4. The Licensed Nurse and Administrator will be responsible to ensure all areas are completed and monitored.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was assessed by an RN, PT or OT prior to use, and instruction was provided to caregivers on precautions and correct use of the device, for 3 of 3 sampled residents (#s 2, 3, and 4) who had a supportive device with restraining qualities. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including dementia, traumatic brain injury, and hypotension (low blood pressure). During observation and interview, completed with Resident 2 and Witness 1 (Family member) on 06/03/25 it was reported and observed that the resident had a half side rail on his/her exiting side of the bed. On 06/03/25 Staff 8 (CG) reported the half side rail was put in the up position any time the resident was in bed to prevent him/her from getting out of the bed. There was no documented evidence the side rail had been assessed by an RN, PT or OT, or that caregivers had been instructed on precautions and the correct use of the device. On 06/04/25, the need to ensure an assessment was completed by an RN, PT, or OT prior to use of any supportive device with restraining qualities, including precautions and instructions to staff was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 10 (MT), and on 06/03/25 with Staff 2 (RN). They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2025 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease and hypertension (high blood pressure). During an interview on 06/03/25 with Resident 3 it was observed that the resident had half side rails on each side of the bed. The right one was in the up position and the left side rail was down. There was no documented evidence the side rail had been assessed by an RN, PT or OT, or that caregivers had been instructed on precautions and the correct use of the device. On 06/04/25, the need to ensure an assessment was completed by an RN, PT, or OT prior to use of any supportive device with restraining qualities, including precautions and instructions to staff was discussed with Staff 1 (ED), Staff 3 (RCC), Staff 10 (MT), and on 06/03/25 with Staff 2 (RN). They acknowledged the findings. 3. Resident 4 was admitted to the facility in 12/2018 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan dated 09/10/24 showed the resident had a half side rail on the left side of the bed. The rail was in the center of the bed. The service plan did not reflect a side rail was in use. The resident rarely got up out of bed. S/he was able to direct his/her own care and indicated the side rail helped him/her in bed. Review of the resident's record showed no assessment, or evaluation was completed of the device. The device was not evaluated at least quarterly to determine safety and appropriateness for the resident. The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed with Staff 1 (ED) and Staff 3 (RCC) on 06/04/25. The staff acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The Licensed Nurse will be assessing residents 1, 2, and 4 including evaluation of medical necessity, risks, and resident preferences. 2. The system will be corrected so that the violation will not occur by: a) The Licensed Nurse or designee will complete a facility-wide audit of all residents using or potentially needing assistive devices to ensure complete assessments and proper documentation. 3. The area needing correction will be evaluated by the Resident Care Coordinator monthly to ensure all assistive devices assessments are completed, documented and care plans accurately reflect device use. 4. The Administrator will be responsible to ensure that all areas are completed and monitored.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

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

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 long-term direct care staff (#s 12, 13 and 14) completed 12 hours of annual in-service training, including at least six hours of dementia care based on their anniversary date of hire. Findings include, but are not limited to: Staff training records were reviewed on 06/03/25 and the following was identified: There was no documented evidence Staff 12 (MT), Staff 13 (MT), and Staff 14 (CG), hired 01/30/2018, 10/29/2020, and 08/24/2021 respectively, completed at least 12 hours of training based on their anniversary date of hire related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics. The need to ensure and document that long-term direct care staff completed the required number of hours of annual in-service training was discussed with Staff 1 (ED) on 06/04/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The facility will complete an audit to bring all remaining staff up to compliance. 2. The system will be corrected so that the violation will not occur by: a) A tracking system will be created to ensure and monitor annual training compliance. 3. The area needing correction will be evaluated by the Administrator, Business Office Director or designee to ensure compliance quarterly to ensure all direct care staff remain in compliance. 4. The Administrator will be responsible to ensure that all areas are completed and monitored.

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

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

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include but are not limited to: Fire drill records for 01/01/2025 through 06/02/2025 were reviewed on 06/02/25, and revealed the following: a. Fire drills lacked documentation of one or more of the following components: * The escape route used; * Evacuation time-period needed; and * Evidence alternate routes were used during fire drills. In an interview on 06/03/25, Staff 1 (ED) acknowledged the documentation lacked one or more of the required components. b. The facility failed to provide fire and life safety instruction to staff on alternate months. In an interview on 06/03/25, Staff 1 confirmed staff were not provided fire and life safety instruction. The need to ensure fire drills were conducted according to Oregon Fire Code with all required components documented and fire and life safety instruction to staff was provided on alternating months was discussed with Staff 1 on 06/04/25. He acknowledged these findings.

1. The actions that will be taken to correct the rule are: a) The facility will be conducting fire drills moving forward to include complete documentation of the specific escape route used, the total evacuation time, verification that alternate routes are rotated and used as part of drill scenarios. b) The facility will create a fire and life safety instruction schedule to ensure education is provided to staff at minimum on alternating months throughout the calendar year. 2. The system will be corrected so that the violation will not occur by: a) The administrator or designee will review all fire logs within 48 hours to ensure all required elements are included. b) A tracking system will be created to ensure and monitor training compliance. 3. The area needing correction will be evaluated by the Administrator, Business Office Director or designee to ensure compliance quarterly to ensure all direct care staff remain in compliance. 4. The Administrator will be responsible to ensure that all areas are completed and monitored.

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

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

Based on interview and record review, it was determined the facility failed to ensure residents were provided fire and life safety training within 24 hours of admission and annually according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Facility Fire and Life Safety records from 01/01/2025 to 06/02/2025 were reviewed on 06/03/25. The following was identified: * The facility fire and life safety records lacked documented evidence residents were provided training and instruction on fire and life safety within 24 hours of admission to the facility; and * There was no documented evidence the residents were re-instructed on fire and life safety procedures at least annually. The need to ensure residents were instructed on fire and life safety procedures within 24 hours of admission to the facility and re-instructed at least annually was discussed with Staff 1 (ED) and Staff 4 (Environmental Service Director) on 06/04/25. They both acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The facility will audit all current residents records to include documentation of fire and life safety training. Any areas of non compliance will be addressed immediately by providing the required instruction. 2. The system will be corrected so that the violation will not occur by the administrator or designee will schedule annual re-instruction tied during the month of admission or done community-wide. 3. The area needing correction will need to be monitored quarterly through service plan meetings. 4. The Maintenace Director and The Administrator will be responsible for ensuring all areas are completed and monitored.

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

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces and surrounding pathways were maintained in good repair. Findings include, but are not limited to: Observations of facility pathways and patio areas on 06/02/25 and 06/03/25 identified the following: * Multiple drop-offs of 2-5 inches were noted in the along pathways around the perimeter of the facility and outside exterior doorways; and * Cracked, lifting and/or broken sidewalk pieces near the patio areas and the exterior pathways at the back of the facility. The need to ensure pathways around the facility were in good repair with no potential tripping hazards were shown to and discussed with Staff 1 (ED) and Staff 4 (Environmental Services Director) on 06/03/25. The staff acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The facility will be filling and leveling drop offs to return to immediate compliance. b) The facility has marked with a yellow visible spray any areas of uneven surface to inform staff, residents, and visitors until permanent repair is completed. 2. The system will be corrected so that the violation will not occur by: a) The community will conduct monthly perimiter walks to identify any areas of non compliance. Any areas of non compliance will be addressed immediately. 3. The area needing correction will be evaluated by the Administrator and Maintenance Director weekly through weekly perimeter walks. 4. The Administrator and Maintenance Director will be responsible for ensuring all areas are completed and monitored.

OAR 411-054-0300 (3)(a-h) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the ALF's common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) An ALF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) ALF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR chapter 411, division 057, memory care communities licensed as an ALF must be located on the ground floor.(e) An ALF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by third party contract.(f) An ALF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory care communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 57.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the ALF has received written approval from the Department or the ALF is in compliance with OAR chapter 411, division 57 (Memory Care Communities) or OAR 309-032-1500 through 309-032-1565(Enhanced Care Services).(h) An ALF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces and surrounding pathways were smooth and maintained in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of facility pathways and patio areas on 09/30/25 through 10/01/25 identified the following: * Multiple areas of concrete were lifting up approximately one to three inches and were uneven in the patio areas and along the exterior pathways at the back of the facility and around the perimeter of the building. Observations during the survey identified the patio and walking path were used by several residents. The need to ensure exterior pathways around the facility were smooth and in good repair, with no potential tripping hazards, was discussed with Staff 1 (ED) on 09/30/25 at 3:52 pm. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: The facility had concrete replacement scheduled for 10/21/2025 to ensure all areas are smooth and in good repair. 2. The system will be corrected so that the violation will not occur by: The Administrator and Maintenance Director will walk the community perimiter once a week to ensure the community is in good repair with no potential triping hazards. 3. The area needing correction will be evaluated by the Administrator and the Maintenance Director weekly and address any areas of non compliance immediately. 4. The Administrator and Maintenance Director will be responsible that corrections are completed and monitored.

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

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility between 06/02/25 and 06/03/25 showed the following areas in need of cleaning or repair: * Laundry rooms on both floors had scrapes to the walls, spills, stains and chips to the interior and exterior cabinet doors and drawers. Linoleum flooring was ripped, dinged and/or had large pieces missing between the washers and dryers. The first-floor laundry room had two windowsills with chipped paint and surfaces were spongy and soft to the touch; * Furniture in seating areas of the upstairs hallway had spills and splatters on the arms, seats and/or the outer surfaces; * Four light fixtures in the dining room had debris inside the fixtures; * Room 213 had numerous spills, stains to kitchenette shelves, cupboards and drawers. Shelves had large dark stains with chipped and/or missing pieces of paint, and a large piece of counter laminate was pulled away. Bathroom flooring was cracked and had dark brown stains around the base of the toilet, red splatters to the wall and brown substance on the floor of the shower; * Room 226 had spills and stains on the kitchenette counter tops and inside cupboards. The bathroom floor was cracked, and brown stains and debris were near the base of the toilet; * Second floor common bathroom had a large crack in the wall, laminate floorboards were pulling apart at the edges, creating gaps that allowed dirt and debris to accumulate; * Windowsills throughout the dining room and hallways had dirt, debris, dead insects and/or dust. Multiple blinds located in the dining room were dusty with dark stains; * Activity room kitchen had multiple spills, stains and debris to both the interiors and exteriors of the cupboards and drawers. Large yellow spills/stains were noted in the upper cupboards and two drawers. Clean dish items were stored in both areas. Spills and splatters were noted on the floor; a counter mixer was covered with white substance on the bowl and the upper mixer. Large dark stains and debris were noted in the cabinet under the sink and thick white accumulation was noted to be stuck to the drawer fronts near the sink. A long untreated/unsealed wood shelf had multiple food and non-food items stored on it; and * Vents along the lower part of the wall in the hallways, on both floors, had substantial dust accumulation. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) and Staff 4 (Environmental Services Director) on 06/02/25 and 06/03/25. The staff acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) All stained, dirty furniture was cleaned. b) High traffic areas including laundry rooms, dining room fixtures, hallway vents, activity room were deep cleaned and sanitized. c) Rooms 213, 226 will be scheduled for repair work including bathroom repair and counter/cabinet touch ups. d) Second floor common bathroom wall was scheduled for repair. 2. The system will be corrected so that the violation will not occur by: a) All housekeeping staff will be trained on infection control and sanitation protocols, routine and deep-cleaning procedures, proper documentation and reporting of deficiencies. 3. The area needing correction will be evaluated by the Administrator and Maintenance Director through weekly and monthly community walks. Any areas of non-compliance will be addressed immediately. 4. The Administrator and Maintenance Director will be responsible for ensuring all areas are completed and monitored.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure the interior environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to: Observations of the facility between 09/30/25 and 10/01/25 showed the following areas were in need of cleaning or repair: a. Laundry room on the first floor- * Multiple areas had gouges in the drywall and areas of wall were damaged behind the washing machines; * Spills, stains, and chipped shelving to the interior of the cabinet below the sink; * Linoleum flooring was torn between the washers and dryers, rendering the surface uncleanable; * The windowsills had been exposed to water which caused the paint to peel and the surfaces were spongy and soft to the touch; and * A dryer had a broken knob and was not functioning properly. b. Second floor laundry room- * There were multiple holes in the wall approximately six inches in circular shape behind the dryers; * Approximately one inch by two foot cut in the drywall to the right of the dryers; * The wall behind the washing machines had multiple areas of water damage causing the paint to bubble and peel in some areas; * The linoleum floor covering was torn in multiple areas between the washer and dryers; * A folding table had four broken corners that exposed sharp edges; and * The dryer labeled “4” was not operational. c. Bathrooms - * The bathroom floor in room 226 was cracked and had brown stains and debris near the base of the toilet; and * The second-floor common bathroom had a large crack in the wall. The areas in need of cleaning and/or repair were discussed with Staff 1 (ED) on 10/01/25 at 10:38 am. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) Laundry Room areas will be repaired and maintained. b) Second Floor Laundry Room areas will be repaired and maintained. c) Bathroom floor in room 226 will be scheduled for repair. Second Floor bathroom crack on the wall will be repaired and maintained. 2. The system will be corrected so that the violation will not occur by: a/b) The Maintenance Director and the Administrator will complete once a week interior audits to identify any areas in need of correction and complete immediatley. c)The resident care coordinator or designee will complete a 3 room audit weekly to ensure all items are clean and in good repair. 3. The area needing correction will be evaluated by the Administrator and Maintenance Director through weekly and monthly community walks. Any areas of non-compliance will be addressed immediately. 4. The Administrator and Maintenance Director will be responsible for ensuring all areas are completed and monitored.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: Observations on 06/02/25 and 06/03/25 showed exit doors to the resident patio and at the end of hallways, did not have an operational alarm or other acceptable system to alert staff when residents exited the building. The need to ensure exit doors were equipped with a functional alarming device or other acceptable system was discussed with Staff 1 (ED) on 06/03/25. He acknowledged the findings.

1. The actions that will be taken to correct the rule are: a) The facility will be placing an audible alarm to exit doors leading to the outdoor areas of the facility. 2. The system will be corrected so that the violation will not occur by: a) All direct care staff will be re-educated on what to do when an exit door alarm malfunctions. b) The Maintenance Director will perform weekly inspections of all exit doors to verify functionality. 3. The area needing correction will be evaluated by the Maintenance Director or designee weekly through weekly community walks. 4. The Administrator and Maintenance Director will be responsible for ensuring all areas are completed and monitored.

OAR 411-054-0300 (11-13) Call System (11) CALL SYSTEM. An ALF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided at each resident bathroom, central bathing rooms, and public-use restrooms.(b) EXIT DOOR ALARMS. Exit door alarms or other acceptable systems must be provided for security purposes and to alert staff when residents exit the ALF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES.(a) RESIDENT PHONES. Each unit must have at least one telephone jack to allow for individual phone service.(b) PUBLIC TELEPHONE. There must be an accessible local access public telephone in a private area that allows a resident or another individual to conduct a private conversation.(13) TELEVISION ANTENNA OR CABLE SYSTEM. An ALF must provide a television antenna or cable system with an outlet in each resident unit.

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

Based on observation and interview, it was determined the facility failed to ensure the individual the right to freedom from restraints for 1 of 1 sampled Resident (#2) who had a side rail restraint device. Refer to C340.

Refer to C340 for Plan of Correction

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

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C260, C610, and C613.

See POC for all Citations

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

Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen was reviewed on 04/07/25 from 10:15 am through 2:00 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Movable metal racks storing bread * Wall under staff coats * Wall behind industrial mixer * Industrial mixer * Light fixtures * Metal racks storing clean pots/pans/dishes * Sprinkler heads * Top of ice machine storing binders * Bottom of dry erase white board * Exterior of bulk dry food bins and lids * Interior of ice machine * Knobs of steam table * Threshold and flooring of walk in cooler entry/door * Walk in cooler door/seal * Light switch in walk in cooler * Exterior of black insulated food cart * White towel on top of plastic drawer storing cooking utensils * Interior and exterior of cabinets/cupboards in dining room b. The following areas were in need of repair: * Sections of caulking in ware washing area with buildup of black debris * Area of wall near white board with large crack/damage near floor. * Dishwasher rinse temperature gauge not working c. Industrial mixer and bowl stored uncovered and exposed to potential contamination when not in use d. Multiple cleaning rags were observed stored on counter tops and other areas in the kitchen. No sanitizer bucket was observed. e. Two drinks for staff were stored in the walk in cooler where food for residents was stored. f. Multiple potential hazardous foods were found stored in the walk in cooler and freezer open/not covered and exposed to potential contamination. g. Multiple plastic bags storing cooked or open potentially hazardous foods were observed not dated when opened or prepared as required. h. Multiple boxes of food were observed stored on the freezer floor. Staff 2 (Executive Chef) acknowledged that it was from stock delivery from 04/05/25. Staff 2 acknowledged it should have been put away the day of delivery and no food items should be stored on the floor. i. Kitchen staff members were noted handling clean dishes and/or serving residents food without hair or facial hair restraints as required per rule. j. A scoop was observed stored in an ice bin in the dining room with the handle touching the ice, potentially contaminating the food product. k. Tables in in dinging room had preset silverware that was not covered per requirement. Staff 2 (Executive Chef) toured kitchen areas with surveyor and acknowledged the areas of concern. At approximately 1:45pm, surveyor reviewed above areas with staff 1 (Facility representative/Memory Care Administrator) who acknowledged the identified areas.

1) The actions that will be taken to correct the rule violation include: a) The facility will ensure enhanced cleaning practices by including the following on daily, weekly, and monthly cleaning task lists (Movable metal racks storing bread; Wall under staff coats; Wall behind industrial mixer; Industrial mixer; Light fixtures; Metal racks storing clean pots/pans/dishes; Sprinkler heads; Top of ice machine storing binders; Bottom of dry erase white board; Exterior of bulk dry food bins and lids; Interior of ice machine; Knobs of steam table; Threshold and flooring of walk-in cooler entry/door; Walk-in cooler door/seal; Light switch in walk-in cooler; Exterior of black insulated food cart; White towel on top of plastic drawer storing cooking utensils; and Interior and exterior of cabinets/cupboards in dining room). b) The facility will ensure repair/replace: sections of caulking in the ware washing area; crack/damage near floor; and dishwasher temperature gauge. c) The facility will cover the industrial mixer and bowl while not in use with an industrial mixer cloth cover. d) The facility will ensure cleaning santizing buckets are available to hold cleaning/sanitizing rags. e) The employees were in-serviced to not place employee beverages in the walk-in cooler. f) All items in the refridgerator are covered, dated, and properly labeled. g) All bags storing food are dated and covered once opened. h) Executive Chef/Cooks will be re-stocking boxes of food upon delivery. i) All employees who are involved in the preparation of food will be required to wear a beard/hair restraint. j) The facility will be designating an ice scoop handle location near the ice bin. k) The facility will be rolling/covering silverware when preset in the dining room. 2) They system will be corrected so that this violation does not occur again by: a) Daily, Weekly, and Monthly cleaning task lists. b) Monthly Facility Maintenance Log to address items in need of repair/replace. c) Purchase and retain industrial mixer and bowl cover. d) Executive Chef or designee will ensure sanitizing buckets are available upon kitchen opening e) Executive Chef or designee will inspect walk in cooler and remove any employee items daily. f) Executive Chef or designee will inspect walk in cooler daily and audit for proper storage, cover, and date. g) Executive Chef or designee will inspect for uncovered, undated items daily. h) Executive Chef or designee will be properly re-stocking food upon delivery. i) Executive Chef or designee will ensure there are hair and beard restraints available prior to entry of the kitchen. j) Purchase and retain ice scoop holder k) Executive Chef, Dietary aide, or designee will be in-serviced on rolling/covering silverwear prior to resetting. 3) The areas needing correction will need to be monitored daily, weekly, and monthly through task lists. All employees who are involved in the preparation of food will be trianed through the "food safety fundamentals" course on proper food storage, holding temperatures, personal hygiene and practice, serving and cleaning. 4) The Executive Chef and Administrator will be responsible for ensuring corrections are completed/monitored.

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

Based on interview and record review, conducted during a site visit on 03/25/24, it was confirmed the facility failed to update an acuity-based staffing tool (ABST). Findings include, but are not limited to: During an interview on 03/25/24, Staff 1 (ED) indicated the facility currently staffed the following; ·Day: one MT, one treatment aid, and three CG's. ·Swing: one MT, one treatment aid, and three CG's. ·Night: one MT and two CG's. During an email correspondence on 03/25/24, Staff 1 indicated the breakdown of the facility's ABST had 5893 minutes, divided by 60 minutes, divided by 7.5 working hours. Equaling 13.09. The facility scheduled 13 care staff a day. The facility's ABST was reviewed on 03/25/24, the tool had total minutes needed: 5893 minutes, divided by 60 minutes, divided by 7.5 working hours, which equaled 13.09 care staff needed for the day. There were 5 of 45 residents' profiles that had not been updated quarterly. The posted staffing plan indicated on day and swing shift the facility had one MT, four CG's, and one treatment aide, on night shift there is one MT and two CG's. It was confirmed the facility failed to update an acuity-based staffing tool. On 03/25/24, the findings were reviewed with and acknowledged by Staff 1.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main kitchen and memory care kitchenette were conducted on 11/06/23 from 9:45 am through 2:40 pm and the following was identified:   a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:   * Walls throughout kitchen; * Walk-in cooler metal racks; * Walk-in cooler fan and ceiling; * Open stainless steel shelving; * Ceiling with dust accumulation; * Fire sprinklers with dust accumulation; * Inside server station drawers; * Industrial can opener and casing; * Industrial mixer; * Wall behind industrial mixer; * Window frame; * Interior of oven; * Exterior of stove; * Stove knobs and handles; * Removable hood vents; * Stainless steel wall behind stove/grill; * Drain under steam table; * Interior of ice machine; and * Interior and exterior of microwave. b. The following areas were in need of repair: * Broken tile on floor to the left of stove; * Stove knobs and handles; * Several cooking utensils were observed to have integrity concerns (example: parts of utensils melted); * Oven (left side inoperable); and * Caulking behind dish pit area with dark mold-like substance. c. Poor infection control practices observed, but not limited to: * Ice machine had pink and black mold-like residue on inside of machine; * Dented containers storing food in walk-in refrigerator; * Dining room had cutlery pre-set and not protected from potential contamination; * Test strips to test sanitizer solution were not accurately reading chemical used in buckets; * Cook used dry towel to wipe thermometer in-between checking food temps; * Dishwasher racks found on floor; * Bins containing food had scoops stored inside of bins; and * A kitchen staff did not have facial hair restrained as required. At approximately 2:40 pm, surveyors reviewed above areas with Staff 1 (Executive Director) and Staff 2 (Executive Chef), who acknowledged the identified areas.

A updated cleaning check list is now in place for daily, weekly, monthly cleanings. Ice Machine on a regular cleaning schedule New utensils ordered for the kitchen Setting cutlery out only 30 minutes or less prior to the meal Sanitizer strips have been ordered and are working. Staff to go through a training with Executive Chef on how they work and when to use them. Bins with scoops in them have been removed and we are switching storage bins to a system where scoops will not be placed in them at all Hair nets and beard nets were ordered for kitchen staff Racks on the floor were removed and will not be placed on the floor and are off the floor on the shelf. Sanitation of thermometors training will be held for kitchen staff. Executive Chef to oversee cleanings are being completed and to hold trainings for staff on kitchen related topics. System to prevent re-occurance: ED to meet with Executive Chef bi weekly for check in's and walk through.

The findings of the kitchen inspection, conducted 11/06/23, 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 11/06/23, conducted 04/16/24, 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.

Based on interview and record review, conducted during a site visit on 10/06/23, it was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. Findings include, but are not limited to: During interviews on 10/06/23, Staff 1 (ED) and Staff 2 (MC ED) stated the facility had an ongoing issue with bed bugs that started around January 2023. Staff 1 identified a group of apartments that continued to be infested with the bed bugs, including apartments 201-202, 204, 207, and 216-220. Staff 1 stated, "Treatments the facility has used to control the bed bugs included, a bed bug sniffing dog, heat treatments in the affected rooms and the removal and replacement of infested furniture." Staff 2 stated, "The bed bugs have only been on the second floor and had not extended to other areas of the facility." A review of the pest control company invoices indicated the last time a pest control company had been to the facility to treat for bed bugs was 09/28/23. The invoice indicated the facility still had bed bugs in rooms 207, 216, and 217. It was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. On 10/06/23, the findings were reviewed with and acknowledged by Staff 1 and Staff 2. Verbal plan of correction: Staff 1 stated the facility will continue to treat the rooms until eradicated.

The findings of the on-site investigation, conducted on 10/06/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse Notes on Abbreviations: " The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. " Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate. " Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. " If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on observation, interview, and record review, during a site visit conducted on 07/10/23 and 07/17/23, it was confirmed the facility failed to implement and update an acuity-based staffing tool (ABST). Findings include, but are not limited to: During an interview on 07/10/23, Staff 1 (RN) and Staff 2 (RCC) stated they were unable to access the facility's ABST tool. Both stated Staff 3 (Administrator) and Staff 4 (Business Office Manager) were both out of the facility and would be the two who could access the ABST. During an email correspondence on 07/17/23, Staff 4 explained the tool the facility used is Frontier. Staff 4 stated to get the staffing numbers they take the total minutes and divide that by 60 (60 minutes in an hour), then divide that total number by 7.5 (amount of working hours in a shift) and that gave them the number of staff needed for the building per day. Staff 4 was unable to explain how the tool determined individual staffing numbers for each shift. The facility's ABST was reviewed on 07/17/23, the tool had total minutes needed: 10367. Based on the calculation provided above, CS took 10367 divided by 60= 172.783 then divided that by 7.5= 23.03 care staff needed for the day. The posted staffing plan indicated on day and swing shift the facility scheduled one MT, three CG, and one treatment aide, on NOC shift there is one MT and two CG. The tool did not address all 22 ADLs for each resident and the amount of staff time needed to provide care. The tool addressed 15 of the required 22 ADLs. The facility failed to implement and update an acuity-based staffing tool that addressed all the 22 activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care and, as a result, the facility's acuity-based staffing tool does not reflect the correct care time for each resident. On 07/17/23, the findings were reviewed with and acknowledged by Staff 2. Verbal plan of correction: Not provided.

Based on observation, interview, and record review, conducted during a site visit on 07/10/2023, it was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. Findings include, but are not limited to: During interviews on 07/10/23, Staff 1 (RN) and Staff 2 (RCC) stated the facility had an ongoing issue with bed bugs that started around January 2023. Staff 1 identified a group of apartments that continued to be infested with the bed bugs, including apartments 220, 219, 201, 202, 131, and 204. S/he also stated they had reduced the bed bugs to only three rooms, 220, 219 and 202. Staff 2 stated the bed bugs were currently only on the second floor and had not extended to other areas of the facility. Staff 2 stated treatments used to control the bed bugs included, a bed bug sniffing dog, heat treatments in the affected rooms, and had suggested residents move to a vacant room while their rooms were treated for bed bugs. Resident 2 declined moving to another room. Resident 1 stated Resident 2 had bites from the bed bugs all over his/her body for months when the bed bug infestation started. A review of the pest control company invoices indicated two different past control companies had been out to the facility multiple times since 12/30/22. The last time a pest control company had been in the facility to treat for bed bugs was 05/18/23, reporting the facility still had bed bugs. It was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. On 07/10/23, the findings were reviewed with and acknowledged by Staff 1 and Staff 2. Verbal plan of correction: Staff 3 (Administrator) stated to the policy analyst had been notified on 07/25/23, all the bed bugs have now been eradicated from the facility and they have replaced the furniture in the rooms that had the infestations.

Based on observation, interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: During interviews with sampled and un-sampled residents on 11/14/22, 11/15/22 and 11/16/22, residents reported the following concerns had not been resolved: * Meal service- Menus were frequently not followed, the kitchen frequently ran out of menu items and nutritionally adequate substitutes were consistently not provided; * The facility's activity van was no longer available; and * The facility's elevator was frequently out of order. Observations of lunch meal services on 11/14/22 and 11/16/22, revealed the menu was not followed and nutritionally adequate substitutes were not provided. * On 11/14/22, salad and baked squash was not served per the November menu, and no nutritionally adequate substitute was provided; and * On 11/15/22, the lunch menu for beef enchilada casserole and Spanish rice was changed to pineapple chicken and white rice. Additionally, green salad per the menu was not served. During an interview on 11/16/22, Staff 1 (Executive Director) and Staff 3 (Business Office Manager) stated the facility was in the processes of implementing a new resident grievance process but did not have documentation of recent grievances reported by residents. The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1 and Staff 3 on 11/16/22. They acknowledged the findings.

Cedar Village/Frontier has a grievance policy that will be reviewed by ED and BOM and a new binder will be put into place to house written and typed grievances and resolutions in them. System to prevent re-occurance, ED to follow through with each grievance and do a monthly audit as part of the QA process.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to: During the survey, conducted 11/14/22 through 11/17/22, quality improvement oversight to ensure adequate resident care, services, satisfaction and staff performance was found to be ineffective. Refer to the deficiencies in the report.

Cedar Village/Frontier has a QA policy that will be implemented and followed. It will be 15 minutes of compliance audits daily. System to prevent re-occurance, ED to ensure all audits are done and returned weekly.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main kitchen in the Assisted Living on 11/14/22 at 9:30 am revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Pipes, walls, gauges, disposal, drain and flooring behind/underneath the dish machine; * Flour, powdered sugar and cornstarch bins; * Spice shelves; * Juice dispenser; * Kitchen drains; * Electrical outlets and light switches; * Trash cans; * Pipes and flooring underneath the three compartment sink; * Interior and exterior of cabinets and drawers; * Ceiling fire sprinklers; * Walls above/adjacent to stove/grill and steamer; * Cabinets under the steamtable; * Stainless steel cart with plastic drawers with utensils; * Toaster; * Walk-in refrigerator door and shelves: * Freezer floor; * Interior and exterior of microwave; * Walls throughout kitchen area; * Stove/grill knobs, doors, interior, exposed piping and vents; * Wall behind hand wash sink and the sink; * Rolling carts; * Two radios; * Bugs in the light fixtures; * Open shelving throughout kitchen; * Interior and exterior of walk-in refrigerator and freezer; * Industrial mixer and slicer; * The top of the dish machine; and * Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges. b. The following areas were in need of repair: * Several cabinet doors had exposed wood corners and edges; * The hand washing sink had black matter in the caulking; and * Entry doors and jambs were scraped, gouged and had peeling paint. c. Staff 7 (Cook) was asked about chemical sanitizer test strips. She was unable to locate test strips and could not explain how to use them. d. Staff 10 (Dietary Aid) was observed cleaning off dirty dishes and touching clean dishes without washing her hands. e. A non kitchen staff person was observed to enter the kitchen without a hair restraint and did not wash her hands. She proceed to grab a cart and exited out the side door while food was being prepared. f. The kitchen did not have pasteurized eggs available for the residents who received soft-cooked eggs. g. The walk-in refrigerator had a half cut tomato, onion and jello uncovered. h. There was a dented can in the dry storage, cup in the rice bin, and a spoon in the bag of brown sugar. i. Clean glassware were stored on towels that were visibly dirty. At 10:24 am, the surveyors and Staff 1 (Executive Director) toured the kitchen. Staff 1 acknowledged the above areas needed to be cleaned and repaired. Staff 1 further indicated she would have staff clean the kitchen right away.

A zone cleaning check list is now in place. Zones will be cleaned twice weekly. There was a kitchen staff training on 12/5/22 on test strips and how to use them along with the CBC training on kitchen readiness. Executive Chef to oversee zone cleaning. System to prevent re-occurance: Quarterly QA meetings to include walk-through inspection, with Executive Chef, ED and ESD monthly.

Based on observation, interview and record review, it was determined the facility failed to ensure quarterly evaluations were reflective of the residents' current health status for 1 of 4 sampled residents (#3) whose evaluations were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 04/2021, with diagnoses including congestive heart failure, bilateral hearing loss and kidney disease. Observations, interviews, and review of Resident 3's clinical records dated 07/25/22 - 11/14/22, revealed the quarterly evaluation, dated 09/12/22, was not reflective of Resident 3's health status including: * Order for the use of continuous oxygen; * History of leg edema; * Hearing loss and use of hearing aids; and * Use of a motorized scooter. During an interview on 11/14/22, Resident 3 reported s/he used supplemental oxygen, hearing aids and a motorized scooter and had a history of leg edema. During the interview an oxygen concentrator, motorized scooter and hearing aids were observed in Resident 3's apartment. The need to ensure quarterly evaluations were reflective of residents' health status was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

Resident #3 service plan to be updated to include comprehenisve elements listed in OAR 411-054-0034. Ongoing auditing of initial, quarterly service plans, change of condition service plans to make sure they are comprehensive and completed timely to be done by ED, VPO and/or Regional Nurse Consultant at least quarterly.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and provided clear direction to staff regarding the delivery of services for 2 of 4 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 06/2021, with diagnoses including diabetes and hypertension. Interviews with staff and review of Resident 2's clinical records dated 07/30/22 - 11/14/22,  revealed the following: Resident 2 returned to the facility on 11/09/22, following a hospitalization and rehabilitation stay related to hemorrhagic shock due to GI bleed, acute gastric ulcer and repeated falls. During an interview on 11/15/22, Staff 2 (RN) stated she evaluated Resident 2 prior to his/her readmission to the facility and was aware Resident 2's transfer and mobility status had changed from independent to a one-person assist with transfers and use of a wheelchair for mobility. An interim service plan dated 11/09/22, related to "return from rehabilitation" did not provide clear direction to staff related to Resident 2's following care needs: * One person assist with transfers; * Use of a wheel chair for mobility; and * Fall risk and fall interventions. The need to ensure the service plan provided clear direction to staff was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2021, with diagnoses including congestive heart failure, bilateral hearing loss and kidney disease. Observations, interviews and review of Resident 3's clinical records revealed the resident's service plan dated 09/12/22, was not reflective of Resident 3's current status and care needs and/or did not provide clear direction to staff in the following areas: * Assistance with dressing; * Use of continuous oxygen; * History leg edema; * Hearing loss and use of hearing aids; and * Use of a motorized scooter. During an interview on 11/14/22, Resident 3 reported s/he used supplemental oxygen, hearing aids, a motorized scooter and had a history of leg edema. During the interview an oxygen concentrator, motorized scooter and hearing aids were observed in Resident 3's apartment. The need to ensure service plans were reflective of residents' care needs and provided clear direction to staff was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

ISP's for all changes will be implamented before a resident comes back from the hospital with information for care staff regarding transfer status, mobility status and will have fall risk interventions in place prior to readmission. RN/RCC to oversee to completion for each resident on readmission. Weekly high risk meeting to discuss readmissions

Based on interview and record review, it was determined the facility failed to monitor and document on the progress of short-term changes in condition at least weekly until resolved for 3 of 4 sampled residents (#s 1, 3 and 4). Findings include, but are not limited to: 1. Resident 1 was admitted in 06/2020. Resident 1's clinical record and charting notes, reviewed from 08/15/22 through 11/14/22, revealed the following: * On 10/05/22, Resident 1 fell and sustained a skin tear. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term changes in condition. During an interview on 11/16/22, Staff 2 (RN) reviewed the resident's record and acknowledged the lack of documented resolution for the fall and skin injury. The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Executive Director) and Staff 3 (Business Office Manager) on 11/16/22 at 2:30 pm. They acknowledged the findings. 2. Resident 4 was admitted in 08/2019 with diagnoses which included edema. Resident 4's clinical record and narrative charting notes, reviewed from 07/08/22 through 11/14/22, revealed the facility initiated alert monitoring on 10/18/22 for a medication change. However, no monitoring until resolution was documented for the change in condition.   In an interview on 11/15/22 at 3:30 pm, Staff 2 (RN) stated she failed to document a resolution for the short-term change in condition. The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Executive Director) and Staff 3 (Business Office Manager) on 11/16/22 at 11:15 am. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 04/2021 with diagnoses including congestive heart failure, bilateral hearing loss and kidney disease. Interviews with staff and review of Resident 3's clinical records dated 07/25/22 - 11/14/22, revealed the following: A progress note dated 09/09/22, documented Resident 3 reported s/he thought s/he had thrush. During an interview on 11/15/22, Staff 2 (RN) stated Resident 3 was started on antibiotics for thrush on 09/10/22 and alert charting was implemented related to starting a new medication and potential adverse reactions. There was no documented evidence the facility monitored the thrush infection through resolution. The need to ensure short term changes of condition were monitored through resolution was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

RN enrolled for the role of the RN class Dec 6-8, 2022. RN to review policy about COC and when/how to do these. ED/RN to audit COC on weekly basis.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN or the assessment included documentation of findings, the resident's status and interventions made as a result of the assessment for 2 of 4 sampled residents (#s 1 and 2) reviewed for significant changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted in 06/2020 and had diagnoses which included skin breakdown. During the entrance conference on 11/14/22, staff stated the resident had a pressure injury on his/her bottom that was being treated by home health. Review of the resident's clinical record revealed s/he was discharged from the hospital on 10/25/22 with a pressure injury on his/her left buttock. The wound constituted a significant change in condition for which an assessment by the facility RN was required. There was no documented evidence the facility RN conducted an assessment. During an interview on 11/16/22 at 10:50 am, Staff 2 (RN) reviewed the record and acknowledged she did not document an assessment of the wound. 2. Resident 2 was admitted to the facility in 06/2021 with diagnoses including diabetes and hypertension. Interviews with staff and review of Resident 2's clinical records revealed the following: Resident 2 returned to the facility on 11/09/22, following a hospitalization and rehab stay related to hemorrhagic shock due to GI bleed, acute gastric ulcer and repeated falls. A change of condition evaluation completed by the facility RN on 11/11/22 lacked information related to the following significant changes in the resident status and/or care needs: History of recent falls, fall risk and interventions; and Numerous medication/treatment order changes upon readmission. The need to ensure the RN's assessment for significant changes in condition included the residents' current status and interventions made as a result of the assessment was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

See C270

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task. During the acuity interview on 11/14/22, Resident 4 was identified to be administered insulin injections by non-licensed staff. Resident 4's MARs, reviewed from 08/01/22 - 11/14/22, revealed insulin had been given by Staff 12, 14 and 16 (MTs) on several occasions. Review of delegation documentation on 11/15/22 revealed the following: a. The initial delegation for Staff 12 dated 09/06/22, and re-delegation dated 11/05/22, revealed no RN assessment of the condition of the resident had been completed when the initial and re-delegation occurred. b. The initial delegation for Staff 14, completed on 08/27/22, lacked documentation in the following areas: * Nursing assessment of the client;   * How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs; * Frequency and rationale for how often the unlicensed person(s) should be supervised and reevaluated based on the competency of the caregiver; and * Re-delegation completed within 60 days of the initial delegation. c. The initial delegation for Staff 16, completed on 08/05/22, lacked documentation in the following areas: * Nursing assessment of the client;   * How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs; * Frequency and rationale for how often the unlicensed person(s) should be supervised and reevaluated based on the competency of the caregiver; * Re-delegation completed within 60 days of the initial delegation; and * None of the delegation documentation had been signed by Staff 16. The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (RN) on 11/15/22 at 1:30 pm. She acknowledged the findings. Delegation documentation was reviewed with Staff 1 (Executive Director) on 11/16/22 at 11:15 am. She acknowledged the findings.

On 12-2-22 RN reviewed Oregon Division 047 - Community Based RN Delegation Process. RN took the self evaluation at the end of reviewing Oregon Division 047 - Community Based RN Delegation Process and scored 100% RN also enrolled in the Roles of the RN class for December 6-8, 2022 RN to audit delegations quarterly

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 5) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task. During the acuity interview on 04/12/23, Resident 5 was identified to be administered insulin injections by non-licensed staff. Resident 5's insulin administration record and MARs, reviewed from 03/01/23 through 04/12/23, revealed insulin had been administered by Staff 12 (MT), Staff 18 (MT) and Staff 20 (MT) on multiple occasions. a. The most recent periodic inspection, supervision and re-evaluation of the delegation for Staff 12, completed 02/15/23, lacked documentation in the following areas: * Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable; and * The initial re-evaluation was not completed within 60 days of the initial delegation. b.  Staff 18 was delegated to administer insulin to Resident 5 until she took a leave of absence from 12/02/21 until 03/25/23. There was no documented evidence that Staff 18 was delegated to administer insulin to the resident after her return to work on 03/25/23. c.  Staff 20's initial delegation to administer insulin to Resident 5 was completed on 02/10/23 and lacked documentation in the following area: * Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable. d. The most recent periodic inspection, supervision and re-evaluation of the delegation for Staff 20, completed on 03/06/23, lacked documentation in the following area: * Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable. The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 17 (Regional RN) on 04/13/23. They acknowledged the findings. Staff  2 completed the delegation process for Resident 5 with Staff 18 on 04/13/23.

RN completed Roles of the RN class December 8, 2022. RN will do her diabetic assessment on residents monthly. Form for Justification for Delegation edited to add information missing to meet regulations. Justification for Delegation to be done quarterly or PRN by RN

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 2 was admitted in 06/2021 and had diagnoses which included pain. On 11/09/22, Resident 2 returned to the facility following a hospitalization and rehabilitation stay and was readmitted to the facility with an order for hydrocodone-acetaminophen (narcotic analgesic) 5-325 mg, one tablet every six hours PRN for pain. Resident 2's Controlled Substance Disposition Logs and MARs, dated 11/09/22 - 11/14/22, revealed two occasions when staff signed on the drug disposition log that the hydrocodone was given. However, the MAR lacked documentation that the resident received the medication. Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 11/16/22. Staff 2 reviewed the documentation and acknowledged the discrepancies.

A narcotic audit will be done weekly by RN. We will be going over our Narc policy and retraining staff at the med tech meeting on 12/9/22.

Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the residents' facility records for all medications and treatments that the facility is responsible to administer for 3 of 4 sampled residents (#s 2, 3 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted in 08/2019 with diagnoses which included insulin dependent diabetes. S/he had orders for Humulin 70 units of insulin to be given before breakfast. Additionally, staff were to administer an additional 2 units if the CBG (blood sugar) was between 300 and 600. Resident 4's TARs, reviewed from 10/01/22 - 11/15/22, revealed five occasions when the resident should have received the additional 2 units of Humulin insulin based on CBG results, but none had been documented as given. Staff 4 (RCC) and Staff 12 (MT) were interviewed on 11/15/22. They reviewed the TARs and confirmed staff had not documented if the resident received the insulin as ordered. The need to ensure orders were followed was discussed with Staff 1 (Executive Director) on 11/16/22. She acknowledged the findings. 2. Resident 2 was admitted to the facility in 06/21, with diagnoses including diabetes and hypertension. Interviews with staff and review of Resident 2's clinical records revealed the following: Resident 2 returned to the facility on 11/09/22, following a hospitalization and rehabilitation stay related to hemorrhagic shock due to GI bleed, acute gastric ulcer and repeated falls. Review of Resident 2's rehabilitation discharge orders dated 11/07/22 and MAR dated 11/09/22 - 11/14/22, revealed the facility failed to implement new medication and treatment orders upon the resident's re-admission to the facility. The new orders were not updated on the MAR and the facility continued to administer the resident's previous medications/treatments. a. The following medication/treatments were continued on the MAR but were not included on the re-admission orders and were administered to the resident without current signed physician orders: * Diclofenac sodium 75 mg tab BID, for pain; * Doxepin 25 mg, take two capsules nightly, for major depressive disorder; * Gabapentin 300 mg, 2 capsules daily, for nerve pain; * Hydrochlorothiazide 25 mg daily, for blood pressure; * Melatonin 10 mg at bedtime, for insomnia; * Metoprolol 100 mg, take 1.5 tablet daily, for high blood pressure; * Jublia 10% solution daily, for pain; * Lidocaine 5% ointment, TID, for pain; * Trulicity 4.5 mg injection weekly, for diabetes; and * Capsaicin cream, apply to legs BID, for pain. b. The following medication/treatment orders were not added to the MAR and there was no documented evidence the medications/treatments had been administered as prescribed: * Pantoprazole 40 mg daily, for GERD (gastroesophageal reflux disease). * Monitor for increased BP (blood pressure) every shift. "Special instructions:     Hydrochlorothiazide dc'd [discontinued] due to low potassium." The need to ensure the facility had signed physician orders for all medications administered by the facility and orders were carried out as prescribed was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22 and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 04/2021 with diagnoses including congestive heart failure, bilateral hearing loss and kidney disease. Observations, interview, and review of Resident 3's clinical records revealed the following: Resident 3's service plan dated 09/12/22, stated the resident had a diagnosis of dementia and the facility was responsible for administering the resident's medications. a. On 10/24/22, Resident 3 was ordered Midodrine 5 mg three times daily, for blood pressure. The orders included parameters for the medication to be held if the resident's SBP (systolic blood pressure) was greater than 140/90. Review of Resident 3's MARs dated 10/01/22 - 11/13/22, revealed the medication was not held when the resident's SBP pressure was documented as greater than 140/90 on six occasions from 10/24/22 through 11/13/22. b. On 08/16/22, Resident 3 was ordered continuous oxygen at 1 LPM (liter per minute), increase to 2 LPM with sleep, related to congestive heart failure. The order was not included on the October or November 2022 MAR. During an interview on 11/14/22,  Resident 3 was observed without oxygen in use and stated s/he only needed to use the oxygen every now and then. During an interview on 11/16/22, Staff 15 (MT) stated the resident managed his/her oxygen and it seemed as though the resident didn't need it as much lately. The need to ensure physician orders were carried out as prescribed was discussed with Staff 2 (RN) and Staff 4 (RCC) on 11/15/22, and Staff 1 (Executive Director) on 11/16/22. They acknowledged the findings.

We will be holding a med tech meeting 12/9/22 on following orders and reviewing MAR closely for details/changes and parameters. ED/RCC/RN will hold trainings monthly at med tech meetings

2. Resident 7 was admitted to the facility in 04/2023 with diagnoses including atrial fibrillation and COPD. Resident 7's MAR, dated 04/04/23 through 04/12/23, and prescriber orders were reviewed and revealed the following: * The resident had an order for Lidocaine Patch 4%, apply two patches to skin daily. The MAR was blank on eight occasions between 04/04 and 04/12/23. On 04/13/23, the lack of documentation on the MAR was discussed with Staff 15 (MT) who stated when the resident was admitted on 04/04/23 the patches they received were 5% not 4% as ordered. They didn't have an order for 5%, so no patches were used between 04/04 and 04/12/23. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Executive Director) and Staff 17 (Regional RN) on 04/13/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 5 and 7) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 10/2021 with diagnoses including hypertension, polymyalgia rheumatic and diabetes. Facility staff administered insulin to the resident multiple times daily. Review of Resident 5's current physician orders and MARs/TARs from 03/01/23-04/13/23 revealed the following: * Humalog 100 U/ml insulin sliding scale for diabetes was ordered for administration with each meal based on Resident 5's blood glucose level. There was no documented evidence the correct dose of insulin was administered on six occasions; * Blood sugar checks (CBG's) were ordered before every meal and at bedtime (for diabetes). The physician was to be notified of any CBG below 70 or above 350. There was no documented evidence the facility notified the physician of blood sugars above 350 on five occasions; and * Potassium Chloride ER 10mEq was ordered to be administered one dose on 03/07/23. There was no documented evidence the medication was administered. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (MCC Director/Business Office Manager), and Staff 17 (Regional RN) on 04/13/23 at 12:20 pm. They acknowledged the findings. No further information was provided.

QMAR changes were made to include yes or no answers/notifications to RN and PCP on med pass. Med Tech trainings will now be held twice a month instead of monthly by the RN to continue med administration training and follow through.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 4 sampled residents (#4). Findings include, but are not limited to: Resident 4 was admitted in 08/2019 with diagnoses which included diabetes, edema and a skin rash. Residents 4's MARs were reviewed from 10/01/22 through 11/14/22 and the following was noted: * Reasons for use was not indicated for all medications; * Lack of resident-specific instructions for daily weights; and * S/he had an order for Nystatin powder (antifungal) twice daily. According to the MARs, MTs were initialing that they administered the powder. However, in an interview on 11/15/22 at 10:35 am, Staff 12 (MT) reviewed the MAR and stated the resident applied the Nystatin, not the MTs. On 11/16/22 at 11:15 am, the need for the facility to ensure MARs were accurate was discussed with Staff 1 (Executive Director). She reviewed the MARs and acknowledged the findings.

Weekly audit for discrepancies in parameters. Will go through MAR and make sure daily weights, blood pressure, CBG and further have directions on what to do with the information gathered. Ex: Notify RN, Fax PCP weekly, etc. RN/ED will audit weekly

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 6, 12 and 14) completed all required pre-service orientation training prior to beginning their job responsibilities, and 2 of 2 long-term staff (#s 7 and 8) completed approved infectious disease prevention training prior to 07/01/22. Findings include, but are not limited to: Staff training records were reviewed on 11/16/22. The following deficiencies were identified: a. There was no documented evidence Staff 6 (Dietary Aide), Staff 12 (MT), or Staff 14 (MT), hired 07/21/22, 07/22/22, and 07/15/22, respectively, completed approved infectious disease prevention training prior to beginning their job responsibilities. b. There was no documented evidence Staff 7 (Cook), hired 09/08/20, and Staff 8 (Cook), hired 01/01/19, had completed approved infectious disease prevention training prior to 07/01/22 as required. The need to ensure newly hired staff completed all required pre-service orientation training prior to beginning their job responsibilities and all long-term staff completed approved infectious disease prevention training in a timely manner was discussed with Staff 1 (Executive Director) and Staff 3 (RCC) on 11/16/22. They acknowledged the findings.

Proper Infectious Disease modules were added to relias and will be automatically added to all trainings for new hires. Preservice oientation will be complete prior to working the floor. Business Office Manager to oversee all trainings for new hires and veteran staff. BOM to audit trainings monthly

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months from fire drills and include all required components on fire drill records. Findings include, but are not limited to: Fire and Life Safety records for the previous six months were reviewed on 11/016/22. Review of the documentation provided identified the following: a. There was no documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills; and b. Fire drill records did not contain the following required elements: * Number of residents evacuated; and * Problems encountered and comments relating to residents who resisted or failed to participate in the drills. The requirements regarding fire and life safety instruction for staff and fire drill record components were reviewed with Staff 1 (Executive Director), Staff 3 (RCC), and Staff 11 (Environmental Services Director) on 11/16/22. They acknowledged the findings.

Fire/Life Safety training will be held on alternating months at all staff meetings. Fire drills form will include # of residents who participated, # of residents who resisted to participate and why they chose not to participate. ESD/ED to hold trainings

Based on interview and record review, it was determined the facility failed to include all required components on fire drill records. This is a repeat citation. Findings include, but are not limited to: On 04/12/23, fire drill and fire and life safety training records since 01/30/23 were requested. Review of the documentation provided identified that fire drill records did not contain the following required elements: * Number of residents evacuated; and * Problems encountered and comments relating to residents who resisted or failed to participate in the drills. The requirements regarding fire drill documentation were reviewed with Staff 1 (Executive Director) on 04/012/23. She acknowledged the findings.

Fire Drill logs have been updated to include sections to contain the number of residents evacuated, problems encountered and comments relating to residents who resisted or failed to participate in the drills. ESD to conduct fire drills every other month.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways smooth and in good repair, and ensure the grounds were kept free of litter and refuse. Findings include, but are not limited to: The exterior of the building was toured on 11/15/22. The following deficiencies were identified: a. On the pathway between the dining room and parking lot a section of sidewalk was raised, creating an uneven surface approximately 1" deep across the length of the pathway; and b. Three mini-refrigerators were against the back of the building. On top of the refrigerators were towels and empty potting containers. The findings were reviewed with Staff 1 (Executive Director) and Staff 11 (Environmental Services Director) on 11/17/22. They acknowledged the findings.

Sidewalk repair completed on November 23, 2022 Mini fridges removed on 11/22/22. ESD and ED to conduct walk throughs weekly of building inside and out.

2. Room 204 was observed on 11/14/22 and the following was revealed: * Brown matter was observed on the bathroom floor in front of the toilet; * The bathroom door frame was scraped and gouged in several areas; * The bathroom wall had an approximate 2 x 6 inch scrape near the entrance; * Carpet throughout the apartment had several stained areas; and * The kitchen area had loose vinyl flooring, baseboard coming apart from the wall, gouged wall corners and baseboard, and broken or missing cupboard handles. The surveyor and Staff 1 (Executive Director) toured the apartment on 11/16/22 at 11:15 am. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: 1. The interior of the facility was toured on 11/15/22. The following areas needed cleaning or repair: * Stains on carpet throughout common areas of the facility; * Gouges and chunks of missing plaster on pillar edges throughout the facility; * Rust-covered drain in drinking fountain on 2nd floor; and * Chipped and bubbling shelf liner, along with brown debris build-up, in beverage bar drawers. The building was toured and areas needing cleaning or repair were discussed with Staff 1 (Executive Director) and Staff 11 (Environmental Services Director) on 11/17/22. They acknowledged the areas needing cleaning and repair.

ED scheduled carpet cleaning for Dec 13, 2022 and January 10. 2023. We will remove drinking fountain upstairs due to poor repair. ESD to order clear plaster corner covers for pillars. Room 204, complete renovation started 12/5/22. ESD and ED to walk through building monthly

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to: The facility was toured on 11/15/22. Resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls. The lack of a mechanism to prevent accidental falls was discussed with Staff 1 (Executive Director) and Staff 11 (Environmental Services Director) on 11/16/22. They acknowledged the findings.

ESD will order window locks and install on all second story windows to lock at a certain point to prevent accidental falls.

Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to: The facility laundry process was observed on 11/15/22. The washing machines had general temperature settings but no device to determine the water temperature. Soiled linens were washed with laundry detergent, which was identified as lacking a chemical disinfectant. The facility's failure to properly launder soiled resident linens and clothing was reviewed with Staff 1 (Executive Director) and Staff 11 (Environmental Services Director) on 11/16/22. They acknowledged the findings.

ESD will order a chemical disinfectent to be added to wash/rinse cycles to ensure proper sanitization of soiled linens. ESD to order disinfecting chemicals monthly

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C282, C303 and C420.

See C282, C303 and C420.

The findings of the change of ownership survey conducted 11/14/22 through 11/17/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the revisit to the re-licensure survey of 11/17/22, conducted, 04/12/23 through 04/13/23 are documented in this report. The survey was conducted to determine compliance with the OAR 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OAR 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second revisit to the re-licensure survey of 11/17/22, conducted 07/27/23, 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.

Based on interview, observation, record review it was confirmed the facility failed to keep clean and in good repair, all interior surfaces and equipment necessary for the health, safety, and comfort of the resident. Findings include: During separate interviews on 10/11/2022 Staff #1 (S1) and Resident #1 (R1) both stated that R1 ' s floor needed to be replaced. R1 stated that s/he voiced concerns about their carpet needing to be replaced to maintenance and management for months. R1 stated that s/he sneezes, and s/he eyes water due to the condition of the floor. During an anannounced site visit on 10/11/2022, Compliance Specialist (CS) observed R1 ' s belonging to be in boxes and the floor to be discolored and have multiple stains. A Review of maintenance notes on 9/22/2022 shows the facilities awareness of residents '  discomfort of their floor. On 10/11/2022, these findings were reviewed with and acknowledged by S1. Facility Plan of Correction: By the end of the day of 10/11/2022 S1 and R1 will create an agreement of time for when the carpet will be replaced. S1 sent follow-up email to CS stating that starting 10/12/2022 R1 has 5 days to remove their belongings from current apartment so that renovation of the apartment can begin on 10/17/2022.

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 10/11/2022.  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