Nyssa Gardens Assisted Living Facility

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

Based on observation, interview and record review, it was determined the facility failed to report a physical injury of unknown cause to the local Department office as suspected abuse unless an immediate facility investigation reasonably concluded and documented that the physical injury was not the result of abuse, for 1 of 1 sampled residents (#2) with a documented injury of unknown cause. Findings include, but are not limited to: Resident 2 was admitted to the facility in 02/2022 with diagnoses of Alzheimer’s disease and edema. Staff documented in a progress note dated 04/11/26, “Resident has a big bruise on [his/her] left outer arm below [his/her] elbow. Not sure where or when it came.” The bruise represented an injury of unknown cause for which the facility was required to either immediately investigate and document that it reasonably concluded the bruise was not the result of abuse or neglect or report the bruise to the local Department office as suspected abuse. There was no documented evidence the facility investigated the injury and documented it was not the result of abuse. The facility did not report the injury to the local Department office as suspected abuse. On 06/23/26, staff were observed providing personal care to the resident. No bruise was observed on the resident’s left arm. In an interview on 06/24/26, Staff 2 (LPN) confirmed the facility had not conducted an investigation of the injury or reported the injury to the local Department office. She was not able to provide any additional documentation about the injury. The need to ensure the facility either immediately investigated an injury of unknown cause and documented that it reasonably concluded the injury was not the result of abuse or neglect, or reported the injury to the local Department office as suspected abuse, was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (RN) and Witness 1 (Consultant) on 06/25/26 at 12:55 pm. They acknowledged the findings.

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 ensure the initial evaluation contained the elements specified in the rule and addressed sufficient information to develop the initial service plan to meet the resident’s needs for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 was admitted in 05/2026 with diagnoses including severe obesity, osteoarthritis and a compression fracture of the third lumbar vertebra. Resident 1’s initial evaluation, titled the “Level of Care Assessment/Evaluation V2,” did not address the following required elements: * Preferred name, pronouns and gender identity: * Bathing routine, including frequency and preferred time of day; * Cultural preferences and traditions; * Dental status; * Unexplained weight loss or gain; and * Unsuccessful prior placements. The need to ensure all elements were addressed in the resident’s initial evaluation was reviewed with Staff 2 (LPN), Staff 3 (RN) and Witness 1 (Consultant) on 06/25/26 at 12:55 pm and with Staff 1 (Administrator) on 06/25/26 at 12:55 pm. They acknowledged the information that was not addressed in Resident 1’s initial evaluation.

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 resident service plans reflected the resident’s needs and provided clear direction regarding the delivery of services for 2 of 2 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 02/2022 with diagnoses of Alzheimer’s disease and edema. Observations were made of the resident, interviews were conducted with care staff and records were reviewed. Except for meals, the resident spent his/her time in his/her room in bed. The resident used an alternating pressure air mattress that was scooped on the sides. Staff floated the resident’s heels with a pillow, positioned another pillow between his/her feet and put heel protectors on both the resident’s feet. Staff positioned a vinyl fall mat next to the resident’s bed. The resident’s TV was on during the day. When staff escorted the resident to meals in his/her manual wheelchair, because the resident did not bend his/her knees, the resident’s feet did not fit on the footrests but, rather, rested on the top of them. In an interview on 06/24/26 at 11:00 am, Staff 6 (CG) reported staff used the fall mat and lowered the resident’s bed to prevent falls and injuries. She reported hospice staff provided all bathing for the resident; the facility staff no longer provided bathing services. She said the family told her Resident 2 liked Disney movies and “lighter” [lighthearted] TV shows and movies. Resident 2’s current service plan, dated 05/07/26, was not reflective or lacked clear direction for staff in the following areas: * There was no information about the air mattress, use of pillows to float and cushion the resident’s feet or use of the heel protectors; * There was no information about the use of the fall mat and lowering the resident’s bed; * The service plan still indicated facility staff assisted with showers; * There was no information regarding the resident’s preferred TV programs; and * There were no instructions for staff about safely positioning the resident’s feet on the wheelchair footrests. The need to ensure service plans were reflective of the resident’s care needs and provided clear direction regarding the delivery of services was reviewed with Staff 1 (Administrator), Staff 2 (LPN), Staff 3 (RN) and Witness 1 (Consultant) on 06/25/26 at 12:55 pm. They acknowledged the information lacking from the current service plan. 2. Resident 3 was admitted to the facility in 07/2022 with diagnoses including multiple sclerosis and cellulitis. Observations were made of the resident, interviews were conducted with care staff and records were reviewed. During the survey, the resident wore a hip abductor orthotic on his/her upper thighs. The resident wore eyeglasses. The resident had a bedrail, approximately 24 inches wide, on the exit side of the bed, positioned securely near the head of the bed. In an interview on 06/24/26 at 11:00 am, Staff 6 (CG) reported the resident returned from rehab recently with the brace following a fall and fractured hip. She confirmed the resident wore the eyeglasses routinely, rather than just for reading. She explained the resident sometimes spoke quickly, making him/her difficult to understand. Staff were instructed to be patient and ask the resident to repeat him/herself and to speak slower. Staff 6 reported Resident 3 preferred to eat breakfast in his/her room rather than in the dining room. Resident 3’s current service plan, dated 06/16/26, was not reflective or lacked clear direction for staff in the following areas: * There was no information in the service plan, in the section titled “My Story,” about the resident’s preferred activities and hobbies, favorite foods, family connections, etc;. * The service plan directed staff to assist with applying the hip abductor brace but lacked instructions for how it was to be applied; * The service plan did not indicate the resident preferred to eat breakfast in his/her room; * Information in the service plan was contradictory about the resident’s ability to communicate with others; * The service plan did not indicate if the resident wore eyeglasses routinely or for reading; and * The use of the bed rail was noted, but there were no instructions for staff for monitoring the bed rail for safety. The need to ensure service plans were reflective of the resident’s care needs and provided clear direction regarding the delivery of services, was reviewed with Staff 1 (Administrator), Staff 2 (LPN), Staff 3 (RN) and Witness 1 (Consultant) on 06/25/26 at 12:55 pm. They acknowledged the information lacking from the current service plan.

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 determine, document and communicate to staff what action or intervention was needed for a resident following a change of condition, ensure the instructions or interventions were resident-specific, note weekly progress of the condition until resolved and monitor the resident consistent with his or her evaluated needs and service plan for 1 of 2 sampled residents (#2) with multiple short term changes of condition. Findings include, but are not limited to: Resident 2 was admitted to the facility in 02/2022 with diagnoses of Alzheimer’s disease and edema. The resident’s current service plan, dated 05/07/26, and progress notes, incident reports and temporary service plans (TSPs) from 03/12/26 through 06/22/26 were reviewed. The following was identified: a. On 03/12/26 and 03/13/26 the resident was found on the floor in his/her room; the facility identified these as falls. No injuries were observed or reported. Following each event, the facility failed to determine, document and communicate to staff what actions or interventions were needed for the resident, other than to place the resident on “alert charting.” Following the first fall, the facility did not monitor whether the existing fall interventions were effective or new interventions needed to be developed to try to prevent future falls. Following the second fall, the facility documented in the incident report that staff were not to leave the resident unattended in his/her wheelchair. However, this new intervention was not added to the resident’s service plan. In an interview on 06/24/26 at 12:00 pm, Staff 2 (LPN) stated she had verbally instructed staff not to leave the resident in the wheelchair unattended but was unaware that the intervention had not been added to the resident’s service plan. b. Staff documented in a progress note dated 04/11/26 that Resident 2 had a big bruise on the left outer arm. There was no documented evidence the facility determined, documented and communicated to staff what action or intervention was needed for the resident or documented weekly progress of the condition until it resolved. On 06/23/26, staff were observed providing personal care to the resident. No bruise was observed on the resident’s left arm. In an interview on 06/24/26 at 12:00 pm, Staff 2 (LPN) confirmed there was no additional documentation about the bruise. She stated the staff should have completed an incident report which would have triggered the nurses to evaluate the injury and implement interventions, including monitoring of the bruise. The need to ensure the facility consistently determined, documented and communicated to staff what action or intervention was needed for a resident following a change of condition, ensured the instructions or interventions were resident-specific, noted weekly progress of the condition until resolved and monitored the resident consistent with his or her evaluated needs and service plan was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (RN) and Witness 1 (Consultant) on 06/25/26 at 12:55 pm. They acknowledged the findings.

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

Based on observation and interview, it was determined the facility failed to ensure it maintained infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 1 of 1 sampled resident (#2) who received incontinence care. Resident 2 was admitted to the facility in 02/2022 with diagnoses of Alzheimer’s disease and edema. During the acuity interview on 06/22/26, Resident 2 was identified as needing 2-person full assistance with ADLs, including toileting and incontinence care. On 06/23/26 at 12:34 pm, the surveyor obtained permission to observe personal care to determine adherence to universal precautions for infection control. During the observation, Staff 6 (CG) and Staff 7 (CG) provided incontinence care to Resident 2 while the resident was in his/her bed. Both staff donned gloves, lowered the resident’s pants, removed the soiled brief and wiped the resident’s bottom. Then, without changing the soiled gloves, the staff applied a clean brief, adjusted the resident’s pants, positioned pillows under the resident’s legs, put heel protectors on the resident’s feet, covered the resident with a comforter and put the resident’s oxygen cannula on him/her. The staff did not follow basic universal precautions for infection control by neglecting to change their gloves between clean and dirty tasks. The need to ensure staff adhered to infection prevention and control protocols during the provision of personal care was reviewed with Staff 1 (Administrator), Staff 2 (LPN), Staff 3 (RN) and Witness 1 (Consultant) on 06/25/26 at 12:55 pm. They acknowledged the staff did not follow proper infection control practices.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Based on interview and record review, it was determined the facility failed to ensure all employees completed orientation training prior to beginning their job responsibilities for 4 of 4 sampled newly-hired employees. Findings include, but are not limited to: Staff training records were reviewed on 06/24/26 at 2:10 pm with Staff 1 (Administrator). Staff 9 (CG) was hired 04/06/26; Staff 10 (CG) was hired 04/20/26; Staff 11 (MT) was hired 12/16/25; and Staff 12 (Cook) was hired 01/13/26. The following was identified: * Staff 9, 10, 11 and 12 had not completed preservice orientation training regarding resident rights and the values of community-based care, abuse and reporting requirements, and fire safety and emergency procedures; * Staff 9, 10, 11 and 12 had not been provided a written position description with their job responsibilities; and * Staff 11 had not completed preservice orientation training regarding infectious disease prevention. During the review, Staff 1 stated the facility had not been providing a written job description because the documents needed revision and updating. She also acknowledged she was not aware employees needed to complete the resident rights, abuse reporting and fire safety trainings prior to beginning their job duties. The need to ensure all employees completed orientation training prior to beginning their job responsibilities was reviewed with Staff 1, Staff 2 (LPN), Staff 3 (RN) and Witness 1 (Consultant) on 06/25/26 at 12:55 pm. They acknowledged the findings.

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

Based on interview and record review, it was determined the facility failed to ensure direct care staff demonstrated satisfactory performance in all required areas and completed first aid and abdominal thrust training within the first 30 days of hire for 3 of 3 sampled newly-hired direct care staff. Findings include, but are not limited to: Staff training records were discussed on 06/24/26 at 2:10 pm with Staff 1 (Administrator). Staff 9 (CG) was hired 04/06/26; Staff 10 (CG) was hired 04/20/26; and Staff 11 (MT) was hired 12/16/25. a. The facility was unable to provide documented evidence Staff 9, 10 and 11 had demonstrated satisfactory performance in all required areas within the first 30 days of hire and prior to working unsupervised. Staff 11 completed training in the areas of changes associated with normal aging and conditions that require assessment, treatment, observation and reporting on 04/26/26 and 05/11/26, respectively, which was not within 30 days of hire. The facility did provide documented evidence Staff 11 demonstrated satisfactory performance in her role as a medication technician. b. Staff 10 and 11 had not completed training in the use of first aid and abdominal thrust within 30 days of hire. The need to ensure the facility had a system for documenting newly-hired direct care staff demonstrated satisfactory performance in all required areas within the first 30 days of hire was reviewed with Staff 1, Staff 2 (LPN), Staff 3 (RN) and Witness 1 (Consultant) on 06/25/26 at 12:55 pm. They acknowledged the findings.

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

Based on interview and record review, it was determined the facility failed to conduct and document fire drills every other month and failed to provide fire and life safety (F&LS) instruction to staff on alternate months. Findings include, but are not limited to: Fire drills and fire and life safety instruction were discussed with Staff 5 (Maintenance) on 06/24/26 at 11:23 am. Staff 5 reported two previous employees had been responsible for the fire drill and fire and life safety training program for approximately the past year and a half and were discovered to have not implemented the program as required. Staff 5 stated that when the employees were terminated, they deleted electronic records they had stored on their computers. Review of the available fire drill and F&LS training records indicated no documentation of fire drills or F&LS training having been conducted in the past 12 months. The need to ensure the facility had a system for conducting and documenting fire drills every other month and providing F&LS instruction to staff on alternate months was reviewed with Staff 1 (Administrator), Staff 2 (LPN), Staff 3 (RN) and Witness 1 (Consultant) on 06/25/26 at 12:55 pm. They acknowledged the lack of fire drills and F&LS training.

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 each resident was 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. Findings include, but are not limited to: The process for instructing residents on fire and safety procedures upon admission and re-instructing them at least annually was discussed with Staff 1 (Administrator) on 06/24/26 at 1:55 pm. She stated she was not aware of whether residents were being instructed on fire and safety procedures upon admission and re-instructed annually. She was not able to provide any documented evidence of such instruction. In an earlier discussion on 06/24/26 at 11:23 am, Staff 5 (Maintenance) stated he did not provide fire and safety instruction to residents upon admission or re-instruction annually. The need to ensure the facility had a system for providing fire and safety instruction for residents upon admission and re-instruction annually was reviewed with Staff 1, Staff 2 (LPN), Staff 3 (RN) and Witness 1 (Consultant) on 06/25/26 at 12:55 pm. They acknowledged the findings.

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 provide exit door alarms or another acceptable system for security purposes and to alert staff when residents exited the ALF. Findings include, but are not limited to: The facility was toured on 06/23/26 at 9:30 am. There were three doorways leading to an interior courtyard and another doorway leading from the dining room outside to the rear patio. None of the doors had an alarm or other acceptable system to alert staff when residents exited the ALF. The doors were discussed with Staff 5 (Maintenance) on 06/23/26 at 1:05 pm. He confirmed there were no operating alarms or other system on those doors to alert staff when residents went outside. The need to ensure there were exit door alarms or another acceptable system for security purposes and to alert staff when residents exited the ALF was reviewed with Staff 1 (Administrator) on 06/23/26 at 3:30 pm. She acknowledged the lack of door alarms on the doors leading to the courtyard and the rear patio.

OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (c) Each resident record must, before move-in and when updated, include the following information: (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (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.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation contained the elements specified in the rule, including preferred name, pronouns and gender identity, for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Refer to: C 252.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: a. Observations of the facility kitchen, food storage areas, food preparation, and food service on 03/14/24 revealed splatters, spills, drips, debris and black matter noted on: * Wall behind sink (adjacent to stove); * Wall and top of cove base in dish machine area; * Pipes and floor drain underneath three-compartment sink; and * Three of four ceiling vents. b. Cove base in the dish machine area was coming apart from the wall. The surveyor and Staff 2 (Dietary Supervisor) toured the kitchen on 03/14/24. The areas in need of cleaning and repair were reviewed. He acknowledged the findings. The need to ensure the kitchen was maintained in accordance with the Food Sanitation Rules was discussed with Staff 1 (Administrator) on 3/14/24 during the exit interview. She acknowledged the findings.

The cleaning of all areas of concern has been started, and added to the weekly cleaning chart. The dietary supervisor will be in charge of monitoring and inspecting to ensure these areas stay clean. These inspections will take place weekly. Cove base in the dishwashing area is being repaired and we will continue to monitor for any further breakdowns. An in-service was held with kitchen staff on proper sanitation and cleaning procedures. Maintenance cleaned and will monitor ceiling vents and floor drains for cleanliness on a monthly basis.

The findings of the kitchen inspection, conducted 03/14/24, 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.

The findings of the revisit to the kitchen survey of 03/14/24, conducted on 06/27/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review, it was determined the facility failed to ensure resident evaluations contained all required elements and were updated within 30 days of move-in to the facility for 1 of 1 sampled resident (#2) whose new move-in evaluation was reviewed. Findings include, but are not limited to: Resident 2 was admitted in 03/2023. The new move-in evaluation, completed on 03/23/23 and 03/28/23, failed to address the following areas: * Customary routine: bathing; * Interests, hobbies, social, and leisure activities; * Spiritual, cultural preferences and traditions; * Mental Health issues: Presence of depression, thought disorders, behavioral or mood problems, history of treatment, and effective non-drug interventions; * Personality, including how a person copes with change or challenging situations; * Housework and laundry; * Nutrition habits, fluid preferences, and weight if indicated; * List of treatments: type, frequency, and level of assistance needed; * Emergency evacuation ability; * Complex medication regimen; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behavior including noise, lighting and room temp. Additionally, the initial evaluation was not updated as needed during the 30 days following the resident's move into the facility. The need to ensure new move-in evaluations contained all required elements and were updated within 30 days following the resident's move into the facility was discussed with Staff 1 (Administrator) on 05/18/23 at 8:50 am. She acknowledged the findings.

The pre-move in evaluation form was reviewed and updated to assure all elements are incorporated in the evaluation process.   The 30 day assessments that were previously being noted in the progress notes, are being done through the evaluation forms.   All changes and information from the evaluation process was put onto the care plans and staff was inserviced on all changes. The evaluation form will be completed by the Administrator and nursing staff before resident is admitted to facility as well as 30 days, change of condition, and Quarterly reviews.

Based on interview and record review, it was determined the facility failed to ensure initial evaluations contained all required elements for 1 of 1 sampled resident (#4) whose new move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 4 was admitted in 12/2023. The new move-in evaluation, completed on 11/28/23, failed to address the following areas: * Customary routine: eating and bathing; * Eating: dental status and assistive devices; * Housework and laundry; * Pain: how a person expresses pain or discomfort; * Fall risk or history; * History of dehydration or unexplained weight loss or gain; and * Unsuccessful prior placements. The need to ensure new move-in evaluations contained all required elements was discussed with Staff 1 (Administrator) on 03/13/24 at 9:00 am. She acknowledged the findings.

A new form was created to incorporate all elements of the move-in and evaluation process. The form will be updated and modified within the first 30 days of move-in, as well as quarterly, and for any change of condition. Resident 4, 5 and 6 were updated with the new updated forms.  All missing information has been completed on the new updated forms.     The RN-LPN and Administrator will be monitoring the form and doing all updates and revisions as required and needed.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, and updated as appropriate within the first 30 days of move-in for 1 of 3 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services. Interviews with care staff and family, and observations of Resident 2 during the survey revealed s/he was incontinent, dependent on staff for ADL care, did not use a call light to summon assistance, needed meal assistance, used side rails and was bedbound. Resident 2's service plan, dated 03/23/23, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas: * Pain; * Use of a hospital bed and side rails; * Falls; * Oral care; * Bowel and bladder management; * Bed bound status; * Floating heels; * Dressing status; * Use of an air mattress; * Decline in cognition; and * Risk for choking. Additionally, the service plan had not been reviewed and updated as appropriate within the first 30 days of move-in. The need to ensure the service plan was reflective of Resident 2's current care needs, provided clear direction to staff, and was reviewed and updated within the first 30-days of move-in was discussed with Staff 1 (Administrator) during an interview on 05/18/23 at 8:50 am. She acknowledged it had not been reviewed within 30 days of move-in and needed to be updated. No further information was provided.

Care plans have been reviewed and updated to reflect all new changes:  including but not limited to:   Pain, Use of a hospital bed and side rails., falls, oral care, etc.  Clear direction to care givers for all care needs was included in all new changes on care plans. Care Plans will be monitored and Quarterly reviews to assure dates remain within the 30 to 90 day window. New 30 day evaluation form will be used for assisting with the 30 day review as well as the 90 day Quarterly. The LPN, RN and Administator will be monitoring care plans and reviews on scheduled dates and PRN

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition had weekly progress documented until the condition resolved for 2 of 3 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 07/2021 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease), depression and esophageal reflux. The resident's 04/10/23 service plan, 02/01/23 through 05/17/23 progress notes, and physician communications were reviewed. The resident experienced multiple short-term changes without weekly progress noted until resolution in the following areas: * Medication changes; * ER visit for difficulty breathing and panic attack; and * Falls. Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's condition until resolution. The need to ensure short-term changes of condition had documented resolution was discussed with Staff 1 (Administrator) on 05/16/23 at 10:20 am. She acknowledged the findings. 2. Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services. Resident 2's clinical record and progress notes, reviewed from 3/27/23 through 5/16/23, revealed the following: * The resident fell on 05/06/23. Review of the record revealed no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved. On 05/08/23 at 9:00 am, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term change in condition had no documented resolution. No further information was provided.

Policies are in place for monitoring resident for change of condition.  Direct care staff receive training during staff oriendtation on how to idenitity and report a change of condition.  Direct care staff will report changes to facility LPN, RN or Administrator as they occur.  Both LPN and Administrator are avaliable 24 hours a day 7 days a week. RN will be responsible for assessing the change of condition and if further action is required. All staff were inserviced on monitoring and charting of new admits, change of conditions, Med changes and ER/Hospital visits.  All shifts will monitor for 7 days with progress notes on the electronic records.  New forms  were created to assist with  monitoring from start to resolution of all charting.

Based on interview and record review, it was determined the facility failed to ensure short term changes of condition were monitored until resolution, interventions were determined, and documented, communicated to staff on each shift, and reviewed for effectiveness for 2 of 2 sampled residents (#s 4 and 5) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 was admitted in 07/2022. Resident 5's clinical record and charting notes, reviewed from 12/21/23 through 03/12/24, revealed the following: a. Resident 5 fell or was found on the floor 13 times between 12/21/23 and 03/12/24. The facility failed to investigate the circumstances for several of the falls to determine if service-planned interventions were implemented, were effective or if new interventions were needed, and failed to communicate determined actions/interventions to staff on each shift. Additionally, there was no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved. b. Resident 5 had a medication change on 01/26/24. Although alert monitoring was initiated for the change, there was no documented monitoring of resident's condition until resolution. The need to ensure short term changes of condition were monitored until resolution, interventions were determined, documented, communicated to staff on each shift, and reviewed for effectiveness was shared with Staff 1 (Administrator) and Staff 3 (LPN) on 03/14/24. They acknowledged the findings. 2. Resident 4 was admitted to the facility on 12/04/23. The resident's current service plan, 12/04/23 through 03/12/24 progress notes, and physician communications were reviewed. The resident experienced multiple short-term changes without weekly progress noted until resolution in the following areas: * 12/04/23: New move-in; * 01/05/24: Nasal congestion; and * 02/26/24: Nausea and vomiting. Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's conditions until resolution. Additional information was requested from Staff 1 (Administrator) on 03/14/24 at 9:15 am. On 03/14/24 at 9:15 am, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term changes in condition had no documented resolution.

A complete update was made to the 24-hour shift report sheet.  This ensures appropriate communication between each staff member, LPN, RN and administration.  The updated report sheet now includes a section in which falls for each shift are recorded.  This consists of ensuring staff that found or witnesses a resident fall to complete incident reports and notifying nurse on call of fall or incident.  A section was also added to the report sheet to report any new or medication change for specific resident on specific date.  Information to include when a new med or change was initiated, how resident is tolerating the new or changed medication.  Also, the section included that if adverse reaction is observed , contact was made to nurse on call to take appropriate measures.  The last section added to the report sheet was if a change of condition was noted in a resident.  Education from nursing staff provided to caregivers and med-techs on reporting in this section when a resident has cold/flu symptoms, nausea/vomiting, or condition in which it warrants a PRN medication. A short term service plan book was implemented to communicate to all staff new actions/interventions initiated for specific residents on a specific situation.  All staff were educated and encouraged to check the book at the beginning of each shift.  A signature section was included for staff to acknowledge awareness of reading and understanding the actions/interventions.  Incident log was created for LPN and RN to ensure a record is kept for changes occurring.  This consists of falls, new or medication changes, skin changes, infections and change of condition.  Log allows nursing staff to ensure follow up is occurring at each shift and resolving when appropriate.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer for 2 of 3 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2021 with diagnoses which included hypertension. a. The resident had an order for Amlodipine 10 mg one tablet daily for high blood pressure. Staff were to hold the medication if the systolic BP (upper number) was less than 110. Resident 1's MAR, reviewed from 05/01/23 - 05/17/23, revealed the blood pressure was outside the parameters on 05/01/23. Per the physician order, the Amlodipine should have been held, but staff administered it. b. Resident 1 had an order for Losartan Potassium 100 mg one twice a day. Staff were to hold the medication if the BP was less than 100/60 or pulse was under 50. According to the MAR, the BP was outside parameters on one occasion and the medication was still administered. The need to ensure medications were administered as prescribed was reviewed with Staff 1 (Administrator) on 05/18/23 at 10:15 am. She reviewed the MAR and acknowledged the orders were not followed. 2. Resident 3 was admitted in 2016 with diagnoses which included multiple sclerosis. Resident 3 had an order for Breo Ellipta Aerosol inhaler one puff daily. According to the MAR, reviewed from 05/01/23- 05/17/23, s/he did not receive the medication between 05/01/23 and 05/17/23 because it was "unavailable". In an interview with Staff 1 (Administrator) on 05/18/23 at 9:00 am, she verified the medication had not been given as ordered. She said the facility contacted the physician to obtain a re-fill order but had no documentation verifying when the MD had been contacted. The need to ensure medications were available and administered as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (LPN) and Staff 3 (LPN) during the exit conference on 05/18/23. They acknowledged the findings. No further information was provided.

All Med-Tech staff have been given inservices  regarding parameters of Hypertensive medications.  Vitals will be taken before administration of hypertensive medications.  Hypertensive medication will be kept separate from other medications until it is proven within parameters of giving. If not within parameters vitals will be rechecked in one hour to determine if medication willl be held for that medication pass. LPN will monitor Mar's weekly Protcols for re-fill requests have been updated.  LPN or Med-Techs will send a written request via fax to provider for re-fills.  If no response from provider after 48 hours, a follow up telephone call will be made by facility LPN or if directed the Med Tech.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 2021 with diagnoses which included hypertension. Residents 1's MARs, reviewed from 05/01/23 through 05/17/23 revealed the following: * Lack of resident-specific instructions for multiple PRN anxiety medications, including sequence of administration. The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) on 05/18/23 at 10:15 am. No further information was provided. 2. Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services. Residents 2's MARs, reviewed from 05/01/23 through 05/17/23 revealed the following: * Lack of resident-specific instructions for multiple PRN medications for pain and anxiety, including sequential order of use. The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) on 05/08/23 at 10:15 am. No further information was provided.

Residents with multiple pain and pyschotropic medication PRN orders were updated to reflect in what sequence the each medication would be administered. LPN will monitor new PRN pain and pyschotropic medication orders to ensure that the sequence is noted on the EMAR.

Based on interview and record review, it was determined the facility failed to ensure resident MARs included resident specific parameters and instructions for PRN medications, for 1 of 3 sampled residents (#6) whose MARs included multiple PRN medications used to treat the same condition. This is a repeat citation. Findings include, but are not limited to: Resident 6 was admitted to the facility in 08/2023. Residents 6's MARs were reviewed from 03/01/24 through 03/12/24 and the following was noted: * Lack of resident-specific instructions for multiple PRN pain and anxiety medications, including which one to administer first. In an interview on 03/13/24 at 12:20 pm, Staff 12 (MA) reviewed the resident's MAR. She confirmed the multiple PRN pain and anxiety medications lacked specific instructions for staff including sequence of administration. The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) and Staff 3 (LPN) on 03/14/24. They acknowledged the findings.

We contacted all providers who prescribe pain and anxiety medications to clarify and individualize parameters for each resident who are currently using PRN pain and anxiety medications. All of our PRN medications used to treat the same condition have been updated and indicated which medication to use first. Parameters have been included for all of our psychotropic and pain medications. We have notified our hospice agencies to remind them that all PRN pain and anxiety medications being used require parameters and specific instructions on sequence of administration. An in-service was held with the med techs regarding parameters and which medications are used first.  The RN,LPN will be responsible for checking to assure medications coming in from physicians are checked for parameters and usage.  Medications are checked through monthly cycle fill.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had documentation that non-pharmacological interventions had been tried with ineffective results prior to administering the medications and all direct care staff had knowledge of non-pharmacological interventions for 1 of 2 sampled residents (#1) who received PRN psychotropic medications. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2021 and had diagnoses which included anxiety. Review of the resident's service plan, physician orders, and 05/01/23 - 05/17/23 MAR revealed the following:     Resident 1 was prescribed lorazepam 1 mg (anti-anxiety medication) one tablet every eight hours PRN for anxiety. The facility failed to ensure the resident's MAR and clinical record included the following required information: * Documentation that all direct care staff had been informed of non-pharmacological interventions for Resident 1; and * Staff administered the PRN lorazepam on 17 occasions without documentation that non-pharmacological interventions were attempted prior to administration of the medication. During an interview with Staff 10 (MT) on 05/18/23 at 10:10 am, she reviewed the resident's record and confirmed staff had not documented that non-pharmacological interventions had been attempted prior to administering the medication. The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 1 (Administrator) on 05/18/23 at 10:15 am. She acknowledged the findings. No further information was provided.

All PRN psychoactive medications have been updated with parameters for behavioral use or hospice services. Parameters also include non-pharmaceutical interventions before medication use, unless residents are able to self direct their own care.   All Med-tech and direct care staff have been inserviced on non-pharmaceutical interventions and documenting prior to adminstering medications.  All residents have been reviewed and updated to assure medications requiring interventions and non-pharmaceutical interventions were incorporated into their individual records.   LPN and RN will monitor and maintain MAR's as medication changes occur.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use of and precautions for the device, and documentation of the use of the device in the resident's evaluation and service plan for 1 of 1 sampled resident (#2) who had side rails on their bed. Findings include, but are not limited to: Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services. On 05/17/23 at 10:25 am, the resident's bed was observed to have bilateral half-length side rails in the up position. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan. The above information was discussed with Staff 1 (Administrator) on 05/18/23 at 9:00 am. She was unaware the resident had side rails on his/her bed. She acknowledged the resident's record lacked an assessment by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation in the evaluation and service plan.

Half rail assessment was completed and added to the quarterly review schedule.  Use of half rail was added to the resident's care plan.  Inservice to direct care staff on correct use and pre-cautions on using half rails.

Based on interview and record review, it was determined the facility failed to ensure an Acuity Based Staffing Tool (ABST) was reviewed and amended for each resident at least quarterly. Findings include, but are not limited to: Review of the facility's online ABST information with Staff 2 (LPN) on 05/17/23 at 11:45 am revealed the facility was not reviewing and amending the ABST tool for residents at least quarterly. The need to ensure the facility reviewed the ABST assessments quarterly was discussed during the exit interview with Staff 1 (Administrator) and Staff 2 on 05/18/23. They acknowledged the findings.

Facility has been in contact with DHS regarding the use of the ABST to gain a greater understanding of how to calculate and enter each resident information.  The ABST has been added to the quarterly review schedule to ensure an accurate information and accounting for all residents.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 direct care staff (#s 6, 7 and 8) had documented evidence of completion of First Aid certification and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 05/17/23 and revealed Staff 6 (CG) hired 03/01/23, Staff 7 (CG) hired 03/09/23, and Staff 8 (CG) hired 02/01/23, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire. The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (Administrator) on 05/17/23 at 12:45 pm. She acknowledged the findings.

All current staff have completed the First Aide and Abdominal Thrust course.  Alll new and incoming staff are required to show proof of First Aide and Abdominal Thrust certification or obtain certification prior to being allowed to start employment.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training at least annually. Findings include, but are not limited to: Fire and life safety records were requested during the survey. The following deficiencies were identified: * Documentation of annual fire and life safety training provided to residents. The need to ensure residents received fire and life safety training at least annually was discussed with Staff 1 (Administrator) on 05/08/23 at 10:30 am. She acknowledged the findings. No further information was provided.

Resident Annual Fire and Life Safety training was conducted on 6/16/2023.  A floor plan with marked exits is posted in all resident rooms and hallways along with evacuation instructions an procedures.

Based on observation and interview, it was determined the facility failed to ensure pathways were maintained in good repair and did not have potential hazards. Findings include, but are not limited to: Observations of the outer courtyard surfaces and pathways on 05/18/23 showed the following: * Multiple drop-offs of 2-5 inches along several pathway edges. The need to ensure pathways were maintained in good repair and did not have potential hazards was discussed with Staff 1 (Administrator) during a tour of the exterior grounds on 05/18/23 at 11:15 am. The findings were acknowledged.

Decorative bark was ordered and placed in areas around the sidewalk and patio areas to eliminate hazardous drop offs. Maintenance staff will monitor areas and report any hazards to administration in a timely manner.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 252, C 270, and C 310.

See plans of correction for C 252, C 270, and C 310.

The findings of the re-licensure survey, conducted 05/16/23 through 05/18/23, 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 for 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 first revisit to the re-licensure survey of 05/18/23, conducted 03/12/24 to 03/14/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for 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 second re-visit to the re-licensure survey of 05/18/23, conducted 06/27/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was clean and good repair, and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facilities kitchen, food storage areas, food preparation, and food service on 11/01/22 revealed: * Splatters, spills, drips, and debris noted on: - Walls behind counters; - Stand mixer and blender; - Behind the ice machine; - The blades and cage of a box fan blowing on the trayline; - Both sides and the interior of the range, grill, and convection oven; and - The shelving posts of the trayline steam table. * The laminate was damaged on the counter adjacent to the refrigerator, creating an un-cleanable surface. * Undated and unlabeled food items were noted in the refrigerator. * No documented evidence the wiping cloth sanitizer bucket was monitored to ensure the bleach sanitizer was at the correct parts per million. * Pasteurized eggs were not available for soft cooked entrees. * There was not a small diameter probe thermometer available to temp thin foods. The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) and Staff 2 (Dietary Manager). They acknowledged the findings.

The kitchen areas of concern have been cleaned and sanitized and a new cleaning schedule has been adopted to ensure all areas of the kitchen and dining room are well maintained, and meet the standards in accordance with food sanitation rules.                              Kitchen supervisor and Maintenance will monitor areas ongoing.                                                                           The laminate on the countertop has been repaired and is now a cleanable surface.  All areas of concerns will be reported to the maintenance department to ensure we remain with the standards of the rules.                       Bleach is no longer being used for cleaning and sanitizing the kitchen and dining room areas.  A premeasured cleaning agent tablet will be added to the correct amount of water recommended from the manufacturer.  Test strips will be used to monitor that proper measurements are being followed.  A log will be kept to ensure staff is following all regulations under the standards of sanitation rules.                                     All food in the refrigerator was labeled and taken care of in accordance with food standards sanitation rules.    The box fan was removed from the kitchen and will no longer be used.                                                                Pasteurized eggs will be avaliable for soft cook entrees.                                                                            Staff will be inserviced on all new products, cleaning schedules, test strips, food labeling and general sanitation and food standards rules.                                The kitchen supervisor, lead cook, maintenance and administrator will monitor and maintain  all areas of the kitchen to ensure we remain in accordance with all food standards and sanitation rules.

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

The findings of the first revisit to the kitchen inspection of 11/01/22, conducted 05/16/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and observations it was confirmed the facility is not exercising reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include: During tour of facility on 05/24/2022 Compliance specialist observed the following: * No screening for COVID was done upon entering facility * staff member observed with mask below the nose and mouth * multiple staff members not wearing masks in the facility Interview with Staff # 1 on 05/24/2022 who acknowledged the findings

Based on interview and record review, it was determined the facility failed to ensure the new move in evaluation contained all required elements for 1 of 1 sampled resident (#3) reviewed as a new move in.  Findings include, but are not limited to: Review of Resident 3's new move in evaluation, dated 6/23/21, lacked the following elements: * Customary routines: eating and bathing; * Spiritual cultural preferences and traditions; * List of current diagnosis; * List of medications and PRN use; * Visits to health practitioner, ER or hospital stays in the past year; * History of mental health treatment; * Effective non-drug interventions for mental health; * Memory, orientation, confusion and decision making abilities; * Personality and how the person copes with change and challenging situations; * Pharmaceutical interventions for back pain; * Nutrition habits, fluid preferences and weight; * List of treatment types frequency and level of assistance needed; * Environmental factors that impact the resident's behavior including noise, lighting    and room temperature. * Fall risk and history; and * History of dehydration and or unexplained weight loss or gain. The need to ensure all required components were included in the new move in evaluation was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.

Pre-move evaulation was updated, reviewed and the fire safety evacuation was incorporated into the evaluation form. All new changes from the evaluation were put onto the care plans and staff was inserviced on all changes. Each Section of the pre-move in evaluation will be acknowledged and completed by Admininstrator, LPN or RN before resident is admitted to the facility.

Based on observation, interview and record review, it was determined the facility failed to ensure resident evaluations addressed all required components for 2 of 3 sampled residents (#s 5 and 6) whose new move-in or quarterly evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 was admitted in 02/2022. The new move in evaluation failed to address the following areas: * Customary routine: Eating and bathing; * Mental Health issues: History of treatment; * Personality, including how a person copes with change or challenging situations; * Housework and laundry; * Pain: How a person expresses pain and discomfort; * Nutrition habits, fluid preferences, and weight if indicated; * Complex medication regimen; * Recent losses; and * Environmental factors that impact the resident's behavior including noise, lighting and room temp. The need to ensure move-in evaluations included all required components was discussed with Staff 1 (Administrator) on 03/31/22. She acknowledged the findings. No further information was provided. 2. Resident 6 was admitted to the facility in 2019 with diagnoses which included Alzheimer's dementia, anxiety and hypertension. Observations, staff interviews and review of the record during the survey revealed s/he required full assistance with most ADLs and was currently receiving hospice services. The most recent evaluation, dated 02/28/22, was not reflective of the resident's health status, current needs or did not address the required components in the following areas: * Visits to health practitioner(s), ER, hospital or NF in the past year; * Personality: including how the person copes with change or challenging situations; * Ability to use a call system; * Indicators of nursing needs including potential for delegated nursing tasks; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature. On 03/31/22, the need to ensure Resident 6's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator). She acknowledged the findings. No other information was shared.

The pre-move evaluation was updated and a new form including the fire and life safety was added to the packet.  The form requires a signature demonstrating knowledge of instructions.  The form will also be used for yearly reviews with all residents.  A notation will be made for those residents with limited cognition and abilities. A map of the facility was placed in all resident rooms indicating individual and personalized fire routes, staging areas, and exits that each resident would follow in an emergency situation.    All information will be addressed on the care plans and temporary care plans will be created to alert staff of any new and changing cares. Each section of the pre-move in evaluation will be acknowledged and completed by LPN, Administrator or RN before resident is admitted to the facility. Staff was inserviced on all new forms

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status, care needs and provided clear direction to staff for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 8/2018. Staff identified Resident 1 to be dependent for all ADL care and required two staff for transfers. Resident 1 had a wound to the left heel being treated by a Home Health agency.  Staff also reported Resident 1 was in a relationship with another resident. Resident 1 was observed to utilize a wheelchair for mobility and had bi-lateral side rails on his/her bed. Resident 1's service plan did not provide clear direction to staff for: * Transfer assistance including the use of a lift; * Side rail use including risks and precautions; * Instructions for wound care during bathing; and * Relationship with another resident. 2. Review of resident 2's most current service plan dated 1/22/21 revealed his/her service plan was not updated at least quarterly. 3. Review of Resident 3's initial service plan dated 6/29/21 revealed his/her service plan was not updated within 30 days of move in. The need to ensure service plans were reflective of care needs, provided clear direction to staff, and were updated within 30 days and quarterly was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Care plans have been updated, reviewed and all new information including but not limited to was included: lift use, wound care, relationships, side rails, wheelchair use etc. The LPN, RN and Administrator will be monitoring care plans and Quarterly reviews to assure dates remain within the 30 to 90 day window.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction regarding the delivery of services for 2 of 3 sampled residents (#s 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 5 wad admitted in 03/2022. During the entrance conference acuity interview on 01/03/22, staff indicated Resident 5 needed assistance with ADLs, two staff were often needed for transfers, and was receiving hospice services. Observations, interviews with the resident and staff, and review of the clinical record revealed the service plan was not reflective or failed to provide clear direction to staff in the following areas: * Oxygen use; * Velcro boot on left foot; * Laundry and housekeeping services; * Staff assistance to make bed; * Use of a walker and wheelchair; and * Glasses for visual impairment. The need to ensure the service plan was reflective of Resident 5's current needs and provided clear direction to staff was reviewed with Staff 1 (Administrator) on 03/31/22 at 3:00 pm. She acknowledged the findings. 2. Resident 6 was admitted in 2019. Review of the clinical record, interviews with care staff and observations of Resident 6 were made during the survey. His/her service plan, dated 02/28/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas: * Hospice services; * Bathing; and * Ability to use a call light. The need to ensure the service plan was reflective of Resident 6's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 03/31/22. She acknowledged the findings. No further information was provided.

Care plans have been updated and reviewed. All care plans have been incorporated with all elements  for a person-centered plan, identifying each residents preferences of dignity, privacy, choice, individuality and independence.   Temporary service plans are being done on changes that occur and will be monitored until resolved or deemed permanent. A new form was implemented to assist staff in alerting the nurse of changes to each residents preferences to their person-centered care. Care plans will be monitored and reviewed quarterly and PRN by the LPN, Administrator and RN.

3. Resident 1 was admitted to the facility in 8/2018 with diagnoses including insulin dependent diabetes and was identified with behaviors. a. Staff reported Resident 1 would intentionally get on the floor when staff did not respond to the call system fast enough. A Behavior Support Services Behavior Plan providing strategies and interventions for care staff to reduce Resident 1 staging falls was in place. Progress notes indicated Resident 1 was observed to place him/herself, or was found, on the floor 20 times between 5/1/21 and 8/30/21. There was no documented evidence of a thorough evaluation of the incidents to determine if interventions were implemented and/or effective. b. Resident 1 was identified to have skin tears and abrasions on seven occasions following incidents of being found on the floor. There was no documented evidence the injuries were monitored until resolved. c. Resident 1 was sent to the emergency department twice related to low blood sugars and changes in awareness/cognition. There was no documented evidence Resident 1 was monitored following the hospital visits. d. Resident 1 had multiple medication changes, including insulin and psychoactive medications. There was no documented evidence the changes in critical medications were monitored. The need to ensure Residents 1, 2 and 3 were monitored per their evaluated needs and changes in condition were evaluated and monitored until resolved was discussed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and monitored to resolution, and failed to determine and document actions or interventions and communicate those to staff for 3 of 3 sampled residents (#s 1, 2 and 3) who had changes of condition. Findings include, but are not limited to: 1. Review of Resident 3's progress notes and nursing notes dated 6/29/21 through 8/30/21 revealed s/he was not monitored after being admitted to the facility in 6/2021. Physician orders dated 8/2/21 indicated Fluticase Proprionate 50mcg was changed to PRN and the resident was prescribed Hydrocortizone-10 to be applied twice daily. There was no indication Resident 3 was monitored after the medication changes. Interview with Staff 2 (LPN) on 8/31/21 confirmed facility staff did not monitor Resident 3 after moving into the facility or when his/her medications were changed. 2. Resident 2 was admitted to the facility with diagnoses including agitation. Physician orders dated 8/5/21 directed staff to administer PRN Risperidone 0.5 mg for agitation. During an Interview with Staff 2 on 8/31/21, she stated Resident 2 was verbally aggressive and threatened physical harm towards her including "he was going to kill me." Resident 2 experienced a change of condition related to behaviors and the addition of a PRN behavior medication.  There was no documented evidence actions or interventions were developed and communicated to staff and no evidence the resident was monitored through resolution.

Policies are in place for monitoring residents for change of condition.   Direct care staff receive training during staff orientation on how to idenitify and report a change of condition.  Direct care staff will report changes to facility LPN, RN or Administrator as they occur.  Both LPN and Administrator are available 24 hours a day 7 days a week.  RN will be responsible for assessing the change of condition and if further action is required.   All staff were inserviced on monitoring and charting of New admits, change of conditions, Med changes, and ER/Hospital visits.  All shifts will monitor for 7 days with progress notes on the electronic records.   All PRN psychoactive medications have been updated with parameters for behavioral use.  Parameters also  include non-pharmaceutical interventions, before medication use.  Exempt from these non-pharmaceutical interventions are residents who are able to self direct.  All direct care staff have been inserviced on non-pharmaceutical interventions and documenting results of interventions prior to giving psychoactive medications.   All residents in current survery were updated and approaches, parameters and interventions were incorporated into their individual records.  LPN and RN will monitor and maintain care plans and MAR's as events occur.

Based on interview and record review, it was determined the facility failed to monitor short-term changes consistent with evaluated needs and service plan until resolution for 2 of 3 sampled residents (#s 5 and 6). This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted in 2019 and had diagnoses which included Alzheimer's dementia. Resident 6's clinical record and charting notes, reviewed from 01/01/22 through 03/30/22, revealed the following: * On 01/02/22, the facility initiated short-term monitoring for behaviors. However, no monitoring until resolution was documented for the change in condition. * On 01/10/22, staff documented that the resident had a blood blister on his/her left big toe. No on-going monitoring of the injury was noted in the record. * A chart note, dated 01/13/22, indicated the resident had a wound on his/her right toe. The record revealed no documented monitoring of the resident's wound at least weekly until resolved. * The resident was sent to the ER on 02/14/22 and was admitted for aspiration pneumonia. S/he returned to the facility on 02/22/22. Although the facility initiated short term monitoring, the record revealed no documented monitoring of the resident's condition at least weekly until resolved. * On 03/01/22, the resident was placed on monitoring because s/he was "slumped" at the dining table and had a decreased level of consciousness. Review of the record revealed no documentation on the progress of the resident's condition at least weekly until resolved. * On 03/03/22, staff documented that the resident injured his/her right-hand knuckle related to a fall. There was no documented treatment nor monitoring of the wound until resolved. * On 03/16/22, progress notes indicated the resident had a wound on his/her right hand. Documentation lacked further information about the wound, including treatment and monitoring until resolved. * Between 01/01/22 and 03/30/22, the resident had fallen 15 times. The facility failed to investigate the circumstances for each fall to determine if service-planned interventions were implemented, were effective or if new interventions were needed. Additionally, the facility failed to monitor the resident's status for each fall until resolved. Additional information was requested on 03/31/22 at 11:00 am. On 03/31/22 at 3:00 pm, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved. Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 and Staff 2 (LPN) on 03/31/22. They acknowledged the findings. No further information was provided. 2. Resident 5 was admitted in 02/07/22. Resident 5's clinical record and charting notes, reviewed from 02/07/22 through 03/30/22, revealed the following: * Short-term monitoring was initiated when the resident moved into the facility on 02/07/22. However, the facility failed to monitor the resident until resolution. * On 02/25/22, the resident reported vomiting. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the change in condition. * The resident had falls on 02/12/22, 02/26/22 and 03/25/22. The facility failed to investigate the circumstances for each fall to determine if service-planned interventions were implemented, were effective or if new interventions were needed. Additionally, the facility failed to monitor the resident's status for the falls on 02/12/22 and 02/26/22 until resolved. Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 03/31/22. They acknowledged the findings. No further information was provided.

Policies are in place for monitoring residents change of condition.  The policy was reviewed and a new form was implemented to assist staff with alerting nursing of changes they are oberserving.   Direct care staff continue to receive training during staff orientation on how to idenitfy and report changes of condition.  Additional inservices are scheduled for extended trainings on person-centered plans of care.  identifying changes, dignity, privacy, choice, individuality, and independence. RN will be responsible for assessing the change of condition and if further action is required.   Inservices are scheduled for charting and documentation from beginning to resolved.  From short term charting, to change of condition, wound cares, and behaviors.   Fall preventions have been updated and a new alarm system was implemented as coordinated with Hospice services.  Bed and chair alarms will continue to be used for residents who are at risk for falls.  Each fall will be investigated for the circumstances of the fall and it will be determined if service plan interventions need to be inplemented, were they effective or if new interventions are needed.   LPN and Administrator are on call 7 days a week 24 hours a day to be contacted of any and all changes.

2. Resident 1 was admitted to the facility in 8/2018 and was identified to have behaviors. Resident 1 had a physician's order for Risperidone 0.25 mg as needed for behaviors. Resident 1's 8/1/21-8/27/21 MARs were reviewed. The facility failed to ensure there were specific parameters for staff describing what behaviors Resident 1 expressed that would require medication. There were no non-pharmaceutical interventions on the MAR for staff to attempt prior to administering the medication. The need to ensure there were resident-specific descriptions of behaviors and non-drug interventions for staff to attempt prior to the administration of psychotropic medications was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

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 and clear direction for the specific reasons for the use of the psychotropic medication for 2 of 2 sampled residents (#s 1 and 2) who were prescribed PRN medications to treat behaviors. Findings include, but are not limited to: 1.  Resident 2 had a physician's order for Risperidone 0.5 mg as needed for behaviors. The medication was administered on 8/11/21 and 8/12/21. The facility failed to ensure there were specific parameters for staff describing what behaviors Resident 2 expressed that would require medication. There were no non-pharmaceutical interventions on the MAR for staff to attempt prior to administering the medication. The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.

All PRN psychoactive medications have been updated with parameters for use.  Parameters describe  behaviors for use such as:  exit seeking, threatening staff, angry outburst, false believes, uncorporative, throwing themselves on the floor.  Parameters also include non-pharmaceutical interventions such as: checking for pain/discomfort, using the restroom, gardening outside, going for a walk, calls to family and friends, one/one visits, working on small appliances  etc. before use of medications.   All direct care staff have been inserviced on non-pharmaceutical interventions and documenting results of interventions prior to giving psychoactive medications.   All residents in current survery were updated and approaches, parameters and interventions were incorporated into their individual records.   LPN, RN and Administrator will montitor records weekly.

Based on interview and record review, it was determined the facility failed to follow parameters prior to administering a PRN psychoactive medication for 1 of 2 sampled residents (#5) reviewed for PRN psychoactive use. This is a repeat citation. Findings include, but are not limited to: Resident 5 moved into the facility in 02/2022 and was receiving hospice services as of the re-visit survey. Resident 5 had an order for Lorazepam 0.5 mg ½ tablet every two hours as needed for anxiety. Parameters for administration included notifying hospice prior to giving the medication. Review of the clinical record and MAR, from 03/01/22 through 03/30/22 revealed eight occasions when staff gave the PRN Lorazepam without notifying hospice prior to administration. During an interview with Staff 9 (MT) on 03/30 22 at 3:40 pm, she reviewed the computer MAR and acknowledged staff had not followed parameters and notified hospice prior to administering the medication. The need to ensure parameters were followed for PRN psychoactive medication was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 03/31/22. They acknowledged the findings.

All PRN psychoactive medications have been updated with parameters for use. Hospice was consulted and phyisican and RN reviewed their residents medications and clarified orders for administration. Med-techs will alert hospice on administration of all prn medications if directed by hospice. Med-techs were inserviced and they reviewed parameters and non-pharmaceutical interventions before administering psychoactive medications. All residents in current survey were updated and parameters were reviewed by Hopsice physician.   LPN, Hospice team and RN will be responsible for assuring medications are given under the parameters prescribed by physician.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training was completed prior to providing services to residents for 3 of 3 newly hired staff (#s 7, 10 and 11) whose training records were reviewed. Findings include, but are not limited to: Staff training records were reviewed on 8/31/21. Staff 7 (MT), hired 6/2/21, Staff 10 (MT), hired 6/7/21, and Staff 11 (CG), hired 7/22/21, lacked documented evidence of having completed pre-service dementia training prior to beginning job responsibilities. The need for staff to complete all required pre-service dementia training before working with residents was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Current Staff will have completed their six hour dementia training on or before October 30th. All new and incoming staff will have to complete their 6 hour dementia training prior to beginning job responsibilities. Yearly competencies will be conducted to evaluate care needs and abilities learned from trainings. Care trainings will be done through Oregon Care Partners, Relias or licensed dementia training professional. Records, inservices and training information will be monitored and maintained by LPN and Administrator.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired caregiving staff (#s 7, 10 and 11) demonstrated satisfactory performance in all job duties, and 2 of 2 (#s 7 and 11) were certified in First Aid and trained in abdominal thrust within 30 days of hire. Findings include, but are not limited to: Training records were reviewed on 8/31/21. 1. There was no documented evidence Staff 7 (MT), hired 6/2/21, Staff 10 (MT), hired 6/7/21, and Staff 11 (CG), hired 7/22/21, had demonstrated competence in providing assistance with ADLs within 30 days of hire. 2. There was no documented evidence Staff 7 and Staff 10 had demonstrated competence in medication administration. Staff 2 (LPN) immediately completed and documented medication pass training, including demonstration of competence. 3. There was no documented evidence Staff 7 and Staff 11 had completed First Aid certification and abdominal thrust training within 30 days of hire. The need to ensure staff had documentation of demonstrated competence in all job duties within 30 days and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

First Aide and Abdominal thrust will be completed on all current staff who are not licensed on or before October 30th.  All new and incoming staff will be requred to have First aide and abdominal thrust before being allowed to work on floor with residents. All current staff have completed and demonstrated their ADL competencies.  All Med-staff have demonstrated-completed their skills for delegations.   All new and incoming staff will have their 30 day competencies completed within their first 30 days of employment. LPN, Administrator will monitor, complete and maintain records for all employee's.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 2 long-term staff (#s 6 and 9) whose training records were reviewed. Findings include, but are not limited to: The annual in-service training records for the Year 2020 were reviewed on 8/31/21. Staff 6 (MT), hired 4/29/09, and Staff 9 (MT), hired 6/9/03, failed to have documented evidence of completing 12 hours of required in-service training. There need to ensure staff completed 12 hours of on-going training, including 6 hours related to dementia, was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Monthly inservices will be scheuled through the RN, LPN or scheduled through Oregon Care Partners , Relias or a certified professional to complete each staff members yearly requirement for their ongoing training needs. All staff will be required to have the six hour dementia training prior to working with residents on the floor. Records, inservices and training information will be monitored and maintained by LPN and Administrator.

Based on interview and record review, it was determined the facility failed to conduct fire drills and failed to provide fire and life safety instruction to staff on alternating months. Findings include, but are not limited to: Review of fire drill records dated 2/24/21 through 8/31/21 revealed no documented evidence fire drills, including all required components, were conducted every other month. Review of safety committee meetings dated 2/1/21 through 7/31/21 determined the facility did not provide fire and life safety training to staff on alternating months. The need to ensure the facility conducted fire drills and provided fire and life safety instruction to staff on alternating months was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.

Fire drill policies and procedures were updated and reviewed.  A fire drill and fire life safety inservice has been completed for current month and a schedule made to assure we stay in complience with the rules or OAR 411-054-0090 fire and life safety : drills and instructions. Fire drills will be conducted monthly, with monthly life and safety inservices to coincide with monthly staff meetings and nursing trainings. Fire drills will be done on alternating shifts, alternate locations within the building.  It will include but not limited to: dates, times, escape routes, any problems encountered, number of residents evacuated and staff members on duty. Maintenance will maintain all records and provide copies for administrator to attach to all current staff members inservice records.

Based on interview and record review, it was determined the facility failed to ensure alternate routes during fire drills were used and new residents were being instructed on fire and life safety procedures within 24 hours of admission. Findings include, but are not limited to: 1. Review of fire drill records revealed the facility conducted fire drills in the same location on 2/24/21 and 5/6/21 and used the same evacuation route. 2. Interview with Staff 1 (Administrator) on 8/31/21 revealed the facility did not provide fire and life safety procedures to new residents within 24 hours of admission. The need to ensure the use of alternate routes during fire drills and new residents were instructed on fire and life safety procedures within 24 hours of admission was discussed with Staff 1, Staff 2 (LPN) and Staff 3 (Maintenance Director) on 8/31/21. They acknowledged the findings.

Life and safety inservice training was reviewed and updated.  A new scheduled was adopted for monthly life and fire training inservices including but not limited to:  Avoiding Hazards, dangerous substances, sharp objects, slippery floors, water temperatures,and fire prevention.   All new residents will be instructed about the facilities fire and evacuation process and procedures within 24 hours of admission and annually. All records and training inservices will be stored with maintenance as well as administrator. All new current residents have been instructed and inserviced on evacuation process, fire drill policies, and general life safety information. Administrator will assure all information goes into resident records as drills and new admission occur.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission. This is a repeat citation. Findings include, but are not limited to: Fire and life safety records were requested during the survey. The following deficiencies were identified: * There was no documentation of fire and life safety training provided to residents within 24 hours of move-in. The need to ensure residents received fire and life safety training within 24 hours of admission was discussed with Staff 1 (Executive Director) on 03/30/22 at 1:45 pm. She acknowledged the findings. No further information was provided.

Nyssa Gardens has implemented a fire and life safety form that addresses the facilities fire and evacuation process and procedures. This information is presented to the resident within 24 hours of admission and annually. All Service plans have been updated concerning fire and life safety. A map of the facility was placed in all resident rooms indicating individual and personalized fire routes, staging areas and exits that each resident would follow in an emergency situation.   Staff has been inserviced on updated care plans, room maps and forms. Continued trainings are ongoing. Maintenance department, LPN and Administrator will be responsible for assuring fire evacuation systems are in place within 24 hours of admittance and completed yearly.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to: During an environmental tour on 8/30/21, the surveyor measured water temperatures in three occupied resident units. Water temperatures exceeded 120 degrees Fahrenheit up to 126.8 degrees. The need to ensure hot water temperatures were between 110 and 120 degrees Fahrenheit was discussed with Staff 1 (Administrator) and Staff  2 (LPN) on 8/30/21. They acknowledged the findings.

All four water heaters are now back in working ordered and temperatures were set at levels to conform to the building codes of the facility. Water tempertures will be monitored each week, using different locations and  rooms within the building.  Temperatures will be taken from sinks, showers, kitchen area, bathrooms, etc. All tempertures will be documented and kept on a temperature log and maintained through maintenance weekly. Temperatures will remain within the 110-120 degrees fahrenheit. Maintenance will monitor and maintain all records.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents entered the courtyard. Findings include, but are not limited to: The facility was toured on 8/30/21. Exit doors to the courtyard were observed without an alarm system in place to alert staff of people entering or exiting the courtyard. The need to ensure exit door alarms or other acceptable system was in place to alert staff when residents entered the courtyard was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.

Exit doors to the inside court yard have now been installed with alarm systems to alert staff when residents are entering and exiting court yard area. Alarms will checked when they sound to assure residents are safe in their enviroment. Staff on duty will check alarms as they sound during their shift each day.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#4) whose orders were reviewed. Findings include, but are not limited to: Resident 4 moved into the facility in 2019 and had diagnoses which included high blood pressure. Physician orders and MARs, reviewed from 03/01/22 - 03/30/22, revealed the following orders were not followed: * Resident 4 had an order for Amlodopine 10 mg daily for high blood pressure. Staff were to hold the medication if the pulse was less than 50, systolic BP (top number) was less than 100 or diastolic (lower number) was less than 60. Documentation on the MAR revealed 12 occasions when the diastolic was less than 60 and the medication was not held. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 03/30/22 at 3:00 pm. They acknowledged the findings. No further information was provided.

All medications with parameters were reviewed and updated.  An individual one/one inservice was given to each Med-Tech regarding parameters for Hypertension medications. Staff was instructed if vitals are below the parameters as ordered by physician, to document vitals, hold medications, recheck vitals within the hour, and contact nurse. If above the parameters, document those vital signs, give medications, recheck vitals and contact nurse. Staff was instructed to never leave the MAR blank, always chart reasons for not giving medications. LPN and RN will be responsible for montoring that parameters are being followed and charting is accurate.

Based on observation, interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 252, C 260, C 270, C 330 and C 422.

Systems that had been implemented after the 2021 survey, were found not to be effective. The facility has reviewed, implemented new forms, approaches, and inservice trainings for all staff as well as residents.  The facility has been able to increase staffing, along with coordinating care with outside providers.   Facility will continue to strive for compliance with all rules and regulations, providing a safe environment where each resident will be treated with dignity, privacy, choice, individuality and independence. Each department will be responsible for assuring compliance with all state and federal regulations. Administrator, RN and LPN will continue to provide all current rules and guidelines to assure compliance is enforced.

The findings of the re-licensure survey, conducted 8/30/21 through 8/31/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004. Abbreviations possibly used in this document: ADL: activities of daily 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 re-visit to the relicensure survey of 08/31/21, conducted 03/30/22 through 03/31/22, 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey on 08/31/21, conducted  06/14/22 through 06/15/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.