Courtyard at Mt Tabor

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

Based on observation, interview, and record review, it was determined the facility failed to ensure resident’s rights to receive services in a manner that protected privacy and dignity for 1 of 1 sampled resident (#2) whose service plan was reviewed. Findings include, but are not limited to: Resident 2 moved into the assisted living in 03/2026 with diagnoses including unspecified dementia, diabetes, and was dependent on staff to transfer out of bed or chair and to assist with using a wheelchair. The resident’s clinical record was reviewed, interviews were conducted, and observations were made. The following was identified: The service plan, dated 04/26/26, indicated Resident 2 was unable to manage keys without assistance of another person; therefore, s/he was unable to independently lock and unlock the door for privacy. During an observation and interview on 06/08/26 at 11:50 am, Resident 2’s apartment door was open. The surveyor knocked and was given permission from the resident to enter. Resident 2 asked the surveyor to close the door during the meeting, stating “I prefer to have it closed.” While meeting with the resident from 11:50 am – 12:38 pm, the following was observed: At 12:18 pm, a MT knocked on the door and entered without permission. The MT left the door open and proceeded to give medication. Upon leaving, the MT left the door open. The surveyor called the MT back and requested she close the door, per resident request. At 12:26 pm, housekeeping staff opened the front door and entered without permission. The person didn’t announce who they were and began to take out the trash. Upon leaving, the housekeeping staff left the door open. Resident 2 reported “I prefer to go to the bathroom, but they say it’s easier for them if I just go right here and they will change me [in bed].” When asked if the care staff close the window blinds while providing care, the resident stated “I asked them about that, and they told me no one can see cause I’m up higher and there is a film so no one can see in. I don’t know why they just don’t close them.” On 06/09/26 at 1:38 pm, the resident’s door was observed open while the resident was in their apartment. On 06/09/26 at 3:04 pm the resident’s door was open. Staff 10 (CG) walked into Resident 2’s apartment without permission and stated, “it’s time to get up and I gotta do your catheter.” Resident 2 gave the surveyor permission to observe the provision of care. Staff 10 left the apartment door open and began providing catheter care. Surveyor asked the resident if they preferred the door open or closed. Per resident request, the surveyor closed the apartment door during care. The need to ensure residents' rights to receive services in a manner that protected privacy and dignity was discussed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), Witness 1 (Consultant RN) and Witness 2 (Consultant LPN) on 06/10/26 at 3:14 pm. They acknowledged the findings.

1. Action Taken to Correct the Violation: The facility immediately reviewed the resident’s privacy preferences and implemented a Temporary Service Plan for immediate and sustained correction. The resident’s service plan will be updated to reflect those preferences. All staff involved in direct care and environmental services were educated on resident rights, privacy expectations, knocking and announcing before entry, and maintaining privacy by closing doors and blinds during personal care. Staff were instructed to obtain resident permission before entering the apartment (knock and announce) and before continuing care when privacy concerns are identified. These corrective actions are designed to ensure ongoing compliance with OAR 411 051 0105 regarding resident rights to privacy and dignity. 2. How the System Will Be Corrected: The facility reviewed its resident rights and personal care procedures to ensure compliance to require staff to knock, announce themselves, wait for permission to enter, and close doors during all personal care unless the resident specifically chooses otherwise. Privacy expectations will be included in orientation, annual training, and ongoing coaching, and supervisors will complete routine compliance observations with immediate correction for noncompliance. 3. How Often the Area Will Be Evaluated: Compliance will be evaluated weekly for 90 days, then monthly ongoing, and more frequently if concerns are identified. Findings will be documented and reviewed through the facility’s quality assurance process. 4. Who Is Responsible: The Administrator is responsible for overall completion and monitoring. The Quality Assurance and Compliance Coordinator, Assisted Living Director, Director of Health Services, and Maintenance Director are responsible for staff compliance, coaching, and follow-up.

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

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 3 of 6 sampled residents (#s 2, 3 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the assisted living in 03/2026 with diagnoses including unspecified dementia, diabetes, a chronic skin condition, and had a catheter. Review of Resident 2’s physician orders and 05/01/26 to 06/08/26 MARs identified the following: The resident was prescribed the following medications or treatments that were not administered as prescribed because the medication or treatment was documented on the MAR as “not available”: * Triad Hydrophil wound paste on 05/26/26 and 05/29/26; * Solifenacin Succinate daily for overactive bladder from 05/01/26- 05/26/26; and * Tamsulosin daily for overactive bladder from 05/11/26 -05/13/26, 05/18/26, and 05/20/26. The need to ensure medication orders were carried out as prescribed was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), Witness 1 (Consultant RN) and Witness 2 (Consultant LPN) on 06/10/26 at 3:14 pm. They acknowledged the findings. 2. Resident 3 moved into the assisted living in 03/2026 with diagnoses including memory loss. Review of Resident 3’s physician orders and 05/01/26 to 06/08/26 MARs identified the following: On 05/02/26 Resident 3 was prescribed famotidine 20mg tablet for heartburn, give one tablet twice per day. The medication was entered on the MAR as twice per day as needed rather than scheduled twice per day. There was no documented evidence the medication was administered twice per day from 05/02/26 - 06/08/26. The need to ensure medication orders were carried out as prescribed was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), Witness 1 (Consultant RN) and Witness 2 (Consultant LPN) on 06/10/26 at 3:14 pm. They acknowledged the findings. 3. Resident 4 moved into the assisted living in 09/2021 with diagnoses including chronic obstructive pulmonary disease. Review of Resident 4's physician orders and MARs from 05/01/26 to 06/08/26 revealed the following: a. The resident had a physician’s order to administer Celecoxib100 mg every morning for pain. The MAR indicated the medication was not administered twelve times due to the medication not being available. b. The resident was not administered any of his/her morning medications on 05/02/26 due to “out of time frame.” c. The resident had an order to administer Mupirocin 2% ointment twice daily to an infected area on his/her left thumb. The medication was not administered on 05/07/26 due to the medication not being available. d. The resident had an order to administer Gabapentin 100 mg, three capsules in the morning and midday and two capsules every evening. The midday dose on 06/01/26 was not administered due to the medication being unavailable. The need to ensure medication orders were carried out as prescribed was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), and Witness 2 (Consultant LPN) on 06/10/26 at 1:50 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? The facility will immediately review resident #2, #3, #4 physician orders, MARs, and treatment records to identify missed medications, incorrect transcription, and any doses documented as unavailable or out of time frame. The nurse and/or designee will notify the prescribing provider of the omissions, assess the residents for any adverse effects or change in condition, and ensure the orders are corrected and current medications are obtained accurately and without delay. 2. How will the system be corrected so this violation will not happen again? The facility will strengthen its medication and treatment administration system to ensure that all prescribed medications and treatments are accurately transcribed, available, and administered in accordance with physician orders, consistent with OAR 411 054 0055 requirements for safe medication and treatment systems. The facility will ensure the standardized three person verification process for all new, changed, and resumed medication and treatment orders: Under the guidance of the Director of Health Services (RN) the Medication Technician or designee will verify each order against the provider order and pharmacy label before the first scheduled dose, and will initial and date the MAR and an associated verification log. Medication Technicians will receive focused re education on accurate transcription of orders, correct entry of scheduled versus PRN medications, timely administration within ordered time frames, and the requirement to escalate when medications or treatments are unavailable or delay occurs. 3. How often will the area needing correction be evaluated? The area needing correction will be evaluated daily for 30 days, then weekly thereafter through the quality assurance process if compliance is maintained. Audits will include MAR accuracy, treatment record accuracy, missed-dose documentation, refill status, and evidence that provider and pharmacy follow-up occurred when medication or treatment issues were identified. 4. Who on your staff will be responsible to see that the corrections are completed/monitored? The Administrator will be responsible for overall oversight of the correction plan and compliance with the medication and treatment administration system. The Director of Health Services or designee including Licensed Nurses, Medication Technicians, and Quality Assurance and Compliance Coordinator will be responsible for reviewing orders, verifying MAR accuracy, monitoring missed-dose follow-up, and documenting corrective action. Medication Technicians will be responsible for timely administration and immediate reporting of any unavailable medications or treatments to the DHS or designee.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements staff were providing to residents for 3 of 6 sampled residents (#s 2, 4, and 6) whose ABST data was reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the assisted living in 09/2021 with diagnoses including chronic obstructive pulmonary disease. Observations of the resident, interviews with staff, and review of the 04/09/26 service plan and Resident 4’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Safety checks, fall prevention; * Responding to call lights; * Repositioning; and * Toileting, bowel and bladder management. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), and Witness 2 (Consultant LPN) on 06/10/26 at 1:50 pm. They acknowledged the findings. 2. Resident 6 moved into the assisted living in 04/2026 with diagnoses including prostate cancer. Observations of the resident, interviews with staff, and review of the 04/04/26 service plan and Resident 6’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Safety checks, fall prevention; * Responding to call lights; and * Toileting, bowel and bladder management. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), and Witness 2 (Consultant LPN) on 06/10/26 at 1:50 pm. They acknowledged the findings. 3. Resident 2 moved into the assisted living in 03/2026 with diagnoses including diabetes, chronic skin condition, overactive bladder and unspecified dementia. Observations of the resident, interviews with staff, and review of the 04/26/26 service plan and Resident 2’s ABST data were completed. The following areas were not reflective of the time staff spent providing ADL assistance to the resident: * Responding to call lights; * Cognitive impairment or dementia; * Ambulation, escorting to and from meals and activities; * Repositioning in bed or chair; * Transfers; and * Additional care time for two-person care needs. The need to ensure resident ABST evaluations captured care time and care elements that staff were providing to each resident as outlined in each individual service plan was reviewed with Staff 1 (Senior ED), Staff 2 (Associate ED), Staff 3 (Interim Assisted Living Director), Witness 1 (Consultant RN) and Witness 2 (Consultant LPN) on 06/10/26 at 3:14 pm. They acknowledged the findings. ?

1. What actions will be taken to correct the rule violation? The facility immediately reviewed the ABST assessments for Residents #2, #4, and #6 against each resident’s current service plan, daily care needs, and direct care observations to identify all missing or underreported care elements and care time. The facility will correct each resident’s ABST to ensure the following needs are accurately reflected: safety checks, fall prevention, call light response, repositioning, toileting, and bowel and bladder management, and any other care elements that were not fully captured. 2. How will the system be corrected so this violation will not happen again? The facility will revise its ABST completion process to require that ABST entries be based on observed care delivery, resident service plan requirements, and shift reports. Staff responsible for completing ABST reviews will be retrained on the specific ABST care elements, how to document actual care time provided, and the requirement to update the ABST when resident ADLs change, so the staffing plan reflects true resident acuity and support needs. The ABST management revisions are intended to bring practice into full compliance with OAR 411 054 0037, including accurately capturing care element time based on time for each resident. 3. How often will the area needing correction be evaluated? The area needing correction will be evaluated weekly for 90 days, then monthly for 3 months, with quarterly review thereafter in conjunction with the resident service plan review. Audits will include comparison of ABST entries to service plans, direct care documentation, resident observations, and staffing records to verify that care time and care elements are accurately captured. 4. Who on your staff will be responsible to see that the corrections are completed/monitored? The Administrator will have overall responsibility for compliance and oversight. The Assisted Living Director and/or Director of Health Services, and/or Quality Assurance and Compliance Coordinator will complete and monitor ABST reviews and will verify that resident care needs are reflected accurately, and the staff member assigned to the facility’s staffing/QA process will track audit results and follow up on deficiencies.

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

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. Findings include, but are not limited to: The exterior of the facility was toured on 06/08/26 at 11:23 am, and the following was identified as needing repair: * Exterior concrete pathways located at the perimeter of the facility contained multiple drop-offs measuring greater than two inches from the concrete to the planting bed surface. These drop-offs created potential hazards for residents who frequently walked the pathways. * The exterior concrete steps, located at the southeast corner of the facility leading from the emergency exit door to the pathway, were not fitted with handrails and had drop-offs up to nine inches from the concrete to the planting bed surface on both sides of the steps. The facility’s exterior was toured on 06/10/26 at 10:24 am with Staff 1 (Senior Executive Director) and Staff 4 (Maintenance Director). They acknowledged these findings.

1. What actions will be taken to correct the rule violation? The facility will secure the identified exterior pathway hazards and steps by restricting resident access to the affected area until repairs are completed or a safe alternate route is established. The drop-offs adjacent to the concrete pathways will be corrected so the walking surface is level, stable, and free of hazardous height differences, and the exterior steps at the southeast corner will be fitted with compliant handrails on both sides and corrected so the step area is safe for resident use. 2. How will the system be corrected so this violation will not happen again? The facility will implement a routine environmental safety inspection process for exterior walkways, steps, landings, and emergency exits to identify and correct trip, fall, and egress hazards before residents are exposed. The maintenance process will include documented checks for concrete deterioration, grade changes, missing handrails, and other exterior conditions, with work orders generated immediately when hazards are found and completion verified before the area is returned to normal use. 3. How often will the area needing correction be evaluated? The exterior area will be evaluated weekly during the correction period, then monthly thereafter as part of the facility’s preventive maintenance and safety rounds. The evaluation will specifically include pathways, step condition, handrail integrity, and any change in grade or surface condition that could create a fall hazard or impede safe resident movement. 4. Who on your staff will be responsible to see that the corrections are completed/monitored? The Administrator will have overall responsibility for completion of the correction plan. The Maintenance Director will be responsible for ongoing site inspections, repair oversight and environmental checks, and the Assisted Living Director or designee will monitor resident safety concerns and report any continued hazard to the Administrator and Maintenance Director immediately.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

Based on observation and interview, it was determined the facility failed to provide each individual privacy in his or her own unit for 1 of 1 sampled resident (#2) whose service plan was reviewed. Findings include, but are not limited to: Refer to C200.

1. What actions will be taken to correct the rule violation? The facility will immediately review Resident #2’s service plan and care practices to ensure privacy preferences are clearly identified and followed during all personal care, medication administration, and staff entry into the resident’s unit. Staff involved in the resident’s care will be re-educated on knocking, announcing themselves, obtaining permission before entry when appropriate, closing the door during personal care, and maintaining visual and auditory privacy consistent with the resident’s preferences and dignity. Any staff practice that did not support privacy in the resident’s own unit will be corrected immediately. 2. How will the system be corrected so this violation will not happen again? The facility will update its resident care and staff training system to require privacy expectations to be addressed at admission, care plan review, and when resident preferences change. The system will require staff to follow a standardized privacy protocol for all residents, including knock-and-enter procedures, door closure during care, and use of privacy measures such as blinds or curtains when requested or clinically appropriate. Supervisors will reinforce these expectations during routine staff observation and coaching, so privacy is consistently supported across all shifts and departments. 3. How often will the area needing correction be evaluated? The privacy practices for Resident #2 and other residents will be evaluated daily during the correction period, then weekly for 90 days, and monthly thereafter through routine quality assurance monitoring. Observations will focus on staff entry practices, door and curtain/blind use, resident preference compliance, and whether privacy is maintained during hands-on care. 4. Who on your staff will be responsible to see that the corrections are completed/monitored? The Administrator will have overall responsibility for completion and oversight of the correction plan. The Assisted Living Director, Quality Assurance and Compliance Coordinator, and/or designee will monitor privacy practices and ongoing Care and Medication Technician staff compliance. Maintenance Director and Housekeeping Supervisor will ensure non-care staff follow privacy expectations when entering resident units.

OAR411-004-0020(2)(i) Individual freedom & Support: Activities (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (i) Each individual has the freedom and support to control his or her own schedule and activities.

Based on observation, interview, and record review, it was determined the facility failed to ensure individuals had the freedom and support to control his or her own schedule and activities for 1 of 1 sampled resident (#3). Findings include, but are not limited to: Resident 3 moved into the assisted living in 03/2026 with diagnoses including memory loss. Review of the resident’s clinical record, staff and resident interviews and observations were conducted during the survey. Resident 3’s initial evaluation indicated s/he was independent in all ADLs and IADLs except medication management. S/he didn’t have a history of wandering or elopement; however, s/he was issued a Wanderguard device, a device worn on the resident’s person that alerted staff when a resident attempted to leave all egresses on the first floor. Review of RN assessments completed on 02/24/26, prior to moving into the assisted living, and 04/01/26 determined the resident was independent in cognition and required no assistance for elopement or wandering. Review of Resident 3’s physician orders upon moving into the assisted living didn’t indicate the resident was prescribed any medications for a progressive dementia diagnosis. The initial service plan dated 02/26/26, 30-day service plan dated 04/01/26, and the quarterly service plan dated 05/27/26 indicated the resident had a Wanderguard. S/he stated “[s/he] does not know why [s/he] has to wear it and expresses that [s/he] is upset about having to wear it and would like to speak with [his/her] PCP about it. [Resident name] has not displayed any wandering or exit-seeking behaviors or any attempts to elope since moving into the community.” There were no clear instructions to staff on how to respond when Resident 3’s Wanderguard alerted staff and there were no instructions on how to support the resident’s desire to go outside of the assisted living community. The facility completed an additional elopement risk evaluation dated 04/01/26, and determined the resident was not at risk and presented as “alert and oriented, did not verbally express the desire to go home, was able to verbalize the importance of not leaving the community without first informing staff/requesting assistance, and did not wander (move around without a particular purpose or direction). During an interview and observation with the resident on 06/09/26 at 12:49 pm, the resident wore the Wanderguard on his/her left wrist. When asked about the device, s/he stated, “oh this thing, I don’t know why, they just said I have to wear it, I don’t know it’s really stupid.” During an interview on 06/09/26 at 1:28 pm, Staff 12 (CG) reported, the resident’s Wanderguard had alerted staff because the resident was trying to go to church services in another licensed facility across the parking lot. Staff 12 reported they were told to redirect resident back into the building. Staff 12 further reported they were told they can’t escort the resident to church services. “[S/he] was upset and didn’t understand why [s/he] wasn’t able to go to church or leave the building.” During an interview on 06/09/26 at 3:40 pm, Staff 10 (CG) reported “A Wanderguard, I don’t know anything about that. Does [s/he], oh yeah, [s/he] does.” When asked if the device had alerted staff in the past, Staff 10 reported, “oh no, cause [s/he] is mainly in [his/her] room most of the time. I don’t know why [s/he] has it honestly.” During an interview on 06/10/26 at 11:47 am, Staff 3 (Interim Assisted Living Director) reported a Wanderguard was used for “any dementia diagnosis, whenever someone has left the facility or was lost or the doctor puts on the physician orders when they come in that they are at risk and not allowed to leave due to cognitive decline, it’s a requirement.” Staff 3 confirmed Resident 3’s diagnosis upon moving into the assisted living was memory loss which was not a progressive dementia diagnosis. Staff 3 stated, she “would look into this.” The need to ensure individuals had the freedom and support to control his or her own schedule and activities was discussed with Staff 1 (Senior ED) Staff 2 (Associate ED) ) Staff 3, Witness 1 (Consultant RN) and Witness 2 (Consultant LPN) on 06/10/26 at 3:14 pm. They acknowledged the findings.

1. What actions will be taken to correct the rule violation? The facility will immediately review the resident’s current service plan, Wanderguard use, and any related risk rationale to verify that the device is supported by a documented assessed need and the resident’s preferences and legal representative consent, if applicable. If the Wanderguard was placed or used without proper service planning, the facility will convene the service planning team, review the resident’s current needs and risks, and update the person-centered plan to reflect the least restrictive approach necessary. 2. How will the system be corrected so this violation will not happen again? The facility will implement a required review process for all safety-related devices and restrictions, including Wanderguard, to ensure they are only used when based on an assessed need, clearly described in the service plan, and reviewed at least quarterly or sooner if the resident’s condition changes. Staff will be retrained on HCBS rights, individual freedom and support, informed choice, and the requirement that any limitation must be documented as an individualized support. 3. How often will the area needing correction be evaluated? The area needing correction will be evaluated weekly for 90 days, then monthly for 3 months, and at least quarterly thereafter during routine service plan review. The evaluation will verify that the Wanderguard remains appropriate, the resident’s preferences are honored, and any restriction continues to meet person-centered and assessed-need requirements. 4. Who on your staff will be responsible to see that the corrections are completed/monitored? The Administrator will have overall responsibility for compliance and oversight. The Director of Health Services, Health Services Coordinator, Quality Assurance and Compliance Coordinator, and Assisted Living Director will monitor service plan implementation, the case manager/service planning lead will ensure the Wanderguard is reviewed in the person-centered plan, and direct care staff will report any concerns about wandering risk, device use, or resident preference changes immediately.

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

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 12/11/25 at 10:40 am, the facility kitchen was observed to need cleaning in the following areas: * Ice maker interior – significant pink matter build up; * Hood vents – greasy/dusty; * Door handles on oven doors – sticky/tacky; * Shelf above grill/stove – greasy; * Commercial can opener – food debris/black matter/blade finish worn; * Lids of food bins – food debris build up; * Floor drain – heavily stained; * Caulking above splash guard behind spray hose in dishwashing area – black matter build up; and * Wall beneath spray hose sink in dishwashing area – heavy build up of brown drips/splatter. Other concerns included: * Multiple garbage cans uncovered when not in use; and * Colored cutting board – heavily scored and worn. The areas of concern were observed and discussed with Staff 1 (Food & Beverage Director) and discussed with Staff 2 (Assistant Executive Director) on 12/11/25. The findings were acknowledged.

What actions will be taken to correct the violation for each example/resident: 1. Actions taken to correct the violations are to complete a full cleaning of the areas noted in the SOD: -Ice maker interior, Hood vents, Door handles on oven doors, Shelf above grill/stove, Commercial can opener cleaned and blade replaced Lids of food bins, Floor drain, Caulking above splash guard behind spray hose in dishwashing area cleaned and re-caulked, Wall beneath spray hose sink in dishwashing area. -colored worn cutting boards with heavy scoring and ware are being replaced; -garbage can covers will be in place when not in use; How will the system be corrected so this violation will not happen again? 2. The system will be corrected through an in-service training, performing regular review of the cleaning schedule, and completion of scheduled compliance audits to ensure the areas cited are attended to according to MBK policy and Oregon Administrative Rules. How often will the area needing correction be evaluated? 3. The cited areas will be reviewed daily and documented to ensure compliance. Who will be responsible to see that these corrections are completed/monitored? 4. Kitchen employees including dishwashers, cooks, sous chef, Director of Food & Beverage, and Administrator.

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

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

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, kitchen staff did not follow hygienic practices, and proper food handling procedures were not followed in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 12/26/24 at 10:02 am the main kitchen, walk-in refrigerator and freezer were observed to need cleaning in the following areas: a. Kitchen area: * Pooling of a large amount of charred oil was observed on the floor on either side of the stove; * Pipes behind multiple appliances had grease, dirt, and debris on them; * Cooktop knobs and handles had sticky matter, built-up grease and dried food debris on them; * Interior walls of the ice-maker machine had unidentified yellow residue; * Cooktop and burners were covered with burnt-on grease and other residue; * Range hood filters were covered with grease; * Air return duct cover above the tray line was covered with dust; * Cooling racks had rust on them; * Waffle iron was covered with dirt and grease; and * Knobs, doors, and handles of various kitchen appliances were missing or covered with grease. b. Walk-in refrigerator and freezer: * Refrigerator and freezer cooling unit fans had a layer of dust and dirt. Ready-to-serve items stored under the cooling unit in the refrigerator were uncovered and open to direct dust and debris contamination from blowing fan; * Liquid discharge from box of defrosted meat products had leaked onto the refrigerator floor; and * Exterior surfaces and handles were covered with sticky residue. On 12/26/24 at 10:02 am, the main kitchen was observed to need the following repairs: * The molding around the door frame connecting the sous chef office and the main kitchen was missing and/or damaged, exposing underlying drywall and holes in the wall; * Holes in the ceiling up to approximately six inches surrounded the copper pipes from various appliances; * Displaced ceiling tile in dishwashing room in the far left corner exposing ventilation duct; * Drop ceiling tiles were cracked, missing, or out-of-place; and * Cabinets under serving station were missing doors. On 12/26/24 at 11:00 am, the following improper food handling practices were observed: * Multiple kitchen staff was observed using single-use gloves for multiple tasks, including food handling, cooking and operating appliances; * Industrial mixer was not covered when not in use as required; * Individual portions of food were plated on trays in the walk-in refrigerator and left uncovered; and * Multiple food items in the walk-in refrigerator and walk-in freezer were found not dated and only partially wrapped. Bulk food items were found not dated after opening. Kitchen staff was observed not following proper hygienic practices: * Kitchen staff were not wearing aprons when cooking and serving food; and * Three garbage cans in the kitchen were not covered with lids when not in use. Staff 3 (Cook), Staff 4 (Cook), and Staff 5 (Cook) did not have current food handler's permits. The findings were discussed with Staff 1 (Associate ED) and Staff 2 (Sous Chef) on 12/26/24. Both staff acknowledged the findings.

Section a: Kitchen Area Q1. What Actions will be taken to correct the rule Violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Daily cleanings according to policy have been implemented. An after hours deep clean of the kitchen and appliances is scheduled for January 18th to ensure kitchen is in compliance. A Back of House All Staff meeting is scheduled for January 20th re-educate staff on compliance policies and procedures. Q2. How will the system be corrected so the violation will not happen again. The Food & Beverage Director is accountable to all Dining Dept. policies and procedures as well as Oregon Administrative Rules. As such, we have had turnover in the position and the new Director will ensure compliance utilizing all available resources. The team will receive ongoing and adequate support to ensure sustainable compliance. Director, Sous Chef, Lead Cooks will review prior day's logs and perform visual inspection to confirm compliance and take corrective action immediately if found to not be in compliance. a. All cleaning, temperature, and other relevant logs are confirmed to be in their accurate locations, accessible, and clear. b. Cleaning schedules and assignments have been posted for the kitchen and dining room areas. Each item needing to be cleaned and the frequency of cleaning are included on the cleaning schedule. c. Monthly In-service for Dining staff has been scheduled and attendance is mandatory. Q3. How often will the area needing correction will be evaluated? Daily through substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance January 31, 2025 Section b. Walk-in refrigerator and freezer: Q1. What Actions will be taken to correct the rule Violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Daily cleanings according to policy have been implemented. An after hours deep clean of the kitchen and appliances is scheduled for January 18th to ensure kitchen is in compliance. A Back of House All Staff meeting is scheduled for January 20th re-educate staff on compliance policies and procedures. Q2. How the system will be corrected so this violation will not happen again? A cleaning schedule has been placed for the kitchen. Each item needing to be cleaned and the frequency of cleaning has been included on the cleaning schedule. A training for all Back of the house kitchen team has been scheduled for January 20th to retrain and ensure all compliance information has been provided. Q 3. How often will the area needing correction will be evaluated? Daily through substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance January 31, 2025 Kitchen repairs: Q1. What Action will be taken to correct the rule Violation? Team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to guide the correction of the rule violations. The team has Utilized Direct Supplies TELS system to place maintenance requests to fix all Items listed on the Statement of Deficiencies. All deficiencies noted have been fixed. Q2. How the system will be corrected so this violation will not happen again? A kitchen physical inspection schedule has been established for the Environmental Services Team to evaluate for needed service ticket requests and repair completion. The Food & Beverage Director and Environmental Services Director will complete weekly walkthrough inspections. Q 3. How often will the area needing correction will be evaluated? Daily through substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef, Dining room supervisor, and Environmental Services Director. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance January 31, 2025 Food handling practices: Q1. What Action will be taken to correct the rule Violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violations. I. Single use gloves: Retraining on MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL was held immediately followed up by visual inspection on all shifts daily. II. Industrial Mixer: All staff will follow the cleaning procedure in the DINING SERVICES POLICY & PROCEDURE MANUAL: CLEANING EQUIPMENT AND APPLIANCES. Mixer was cleaned and covered. III. Label and dating food items: Team will utilize MBK senior living Label ad dating procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Immediate retraining and visual inspection on all shifts daily. IV. Bulk Food items: Team will utilize MBK senior living Food Storing procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Immediate retraining and follow up daily. Q2. How the system will be corrected so this violation will not happen again? I. Immediate training and daily follow up to ensure all food is properly covered, wrapped and dated for all areas of the Kitchen. Collaboration between Food & Beverage Director, Sous Chef, Memory Care Director, and caregivers to ensure at least two people are accountable to policy and procedures for food handling. II. An all-staff training for all kitchen team members has been scheduled for January 18th to retrain and ensure all compliance information has been provided and will continue to be followed. Q 3. How often will the area needing correction be evaluated? Daily through substantial compliance and ongoing as well. Q 4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef, Dining room supervisor, Memory Care Director. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance January 31, 2025 Kitchen hygenic practices: Q1. What Action will be taken to correct the rule Violation? The team will utilize MBK senior living Uniform procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL. All staff will be outfitted in neat, clean uniforms and aprons. Chef hats on all associates working behind the action stations and name tags for all. a. All associates must always be in complete uniform during scheduled hours. Hair nets, hats, bowties, ties and aprons may be removed only during scheduled breaks away from food production and dining areas. b. Garbage can lids purchased from DDSI, Syco and placed on receptacles. c. Food handlers card received from all staff and copies in State mandated Food handlers Binder. Q2. How the system will be corrected so this violation will not happen again? An all-staff training for all kitchen team members has been scheduled for January 18th to retrain and ensure all compliance information has been provided and will continue to be followed. a. Garbage can lid inspections to be added to daily cleaning log. b. Additional compliance tracker created specifically for Food handlers’ binder and updated and corrected. Staff without or with expired Food Handler’s cards will be excluded from work. Q3. How often will the area needing correction be evaluated? Daily and weekly until substantial compliance and ongoing per policy. a. Food and beverage Director, Sous Chef, Dining room supervisor or lead Chef on duty will review the previous day’s cleaning log to ensure all areas were acknowledged and completed. A visual inspection will follow. If not complete successfully, Food and Beverage Director will be notified to take follow up corrective action/Training. b. Associate Executive Director will complete weekly Audits of compliance tracker. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Compliance tracking has been assigned to Associate Executive Director. Q5. Date facility alleges compliance January 31, 2025.

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

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: On 03/06/25 at 10:30 am, the main kitchen located in the assisted living was observed to need cleaning and/or repair in the following areas: * Pooling oil was observed on the floor underneath and on either side of the stove and grill area; * Multiple ceiling vents and ceiling tiles had a buildup of dust and debris; * Cooling racks, serving racks and carts had buildup of dust and debris; * Walk-in freezer door seal was worn, causing the freezer door to not close properly, and the bottom of the door was rusted and deteriorating; * The molding around the door frame connecting the sous chef office and the main kitchen was damaged, rendering the surface uncleanable; * Holes in the ceiling up to approximately six inches around pipes above prep table; and * Multiple garbage cans in the kitchen were not covered with lids when not in use. During a tour of the main kitchen the above findings were discussed with Staff 2 (Sous Chef) and Staff 8 (Dietary Manager) on 03/06/25 at 11:40 am. The need to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules was discussed with Staff 1 (ED) and Staff 8 on 03/06/25 at 12:15 pm. They acknowledged the findings.

Section A Q1. What actions will be taken to correct the rule violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Daily cleanings according to policy have been implemented. An after hours deep clean and maintenance of the kitchen stove grease Trap is scheduled for March 20th to ensure the stoves grease trap is cleaned and working efficiently. A Back of House All Staff meeting was scheduled for March 23rd re-educate staff on compliance policies and procedures. Q2. How will the system be corrected so this violation will not happen again? The Food & Beverage Director is accountable to all Dining Dept. policies and procedures as well as Oregon Administrative Rules. The Director will ensure compliance utilizing all available resources. The team will receive ongoing and adequate support to ensure sustainable compliance. Director, Sous Chef, Lead Cooks will review prior day's logs and perform visual inspection to confirm compliance and take corrective action immediately if found to not comply. A. All cleaning, and other relevant logs are confirmed to be in their accurate locations, accessible, and clear. B. Cleaning schedules and assignments have been posted for all kitchen areas. C. Each item needing to be cleaned and the frequency of cleaning are included on the cleaning schedule. D. An In-service for all back of house staff has been scheduled and attendance is mandatory. Q3. How often will the area needing correction will be evaluated? Daily inspection thorough and substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 23rd, 2025. Section B Q1. What actions will be taken to correct the rule violation? A. Maintenance team cleaned ceiling tiles in Park Kitchen on March 10th. Monthly purchases of a box of ten tils to be purchased every month until all tils are replaced. All vents in Park Kitchen have been cleaned on March 10th. Q2. How will the system be corrected so this violation will not happen again? A. Reoccurring TELS work order has been set up for a monthly deep cleaning of vents and tiles to be completed by Maintenance team. Weekly vacuuming of vents and tiles to be completed by back of house kitchen team. B. All cleaning, and other relevant logs are confirmed to be in their accurate locations, accessible, and clear. C. Cleaning schedules and assignments have been posted for all kitchen areas. D. Each item needing to be cleaned and the frequency of cleaning are included on the cleaning schedule. Q3. How often will the area needing correction will be evaluated? A. Weekly inspections thorough and substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A.Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 23rd, 2025. Section C Q1. What actions will be taken to correct the rule violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Daily cleanings according to policy have been implemented. An after hours deep clean and maintenance of the Cooling racks is scheduled for March 23rd to ensure racks are cleaned. A Back of House All Staff meeting was scheduled for March 23rd re-educate staff on compliance policies and procedures. Q2. How will the system be corrected so this violation will not happen again? The Food & Beverage Director is accountable to all Dining Dept. policies and procedures as well as Oregon Administrative Rules. The Director will ensure compliance utilizing all available resources. The team will receive ongoing and adequate support to ensure sustainable compliance. Director, Sous Chef, Lead Cooks will review prior day's logs and perform visual inspection to confirm compliance and take corrective action immediately if found to not comply. E.All cleaning, and other relevant logs are confirmed to be in their accurate locations, accessible, and clear. F. Cleaning schedules and assignments have been posted for all kitchen areas. G. Each item needing to be cleaned and the frequency of cleaning are included on the cleaning schedule. Q3. How often will the area needing correction will be evaluated? A.Weekly inspections will be conducted to ensure thorough and substantial compliance. Ongoing evaluations will follow policy guidelines. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A.Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 23rd, 2025. Section D Q1. What actions will be taken to correct the rule violation? Freezer maintenance company, TELS business services was called on March 16th, inspection date for company to inspect freezer door set for March 20th . Maintenance date to follow inspection process. Q2. How will the system be corrected so this violation will not happen again? A.The team will utilize MBK senior living GENERAL KITCHEN AND DINING ROOM SANITATION GUIDELINES: Freezer procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation and ensure proper maintenance of the freezer. Q3. How often will the area needing correction will be evaluated? A.Quarterly inspections will be conducted to ensure thorough and substantial compliance. Ongoing evaluations will follow policy guidelines. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A.Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 23rd, 2025 Section E Q1. What actions will be taken to correct the rule violation? A.Painting of the molding was completed on March 12th by community painter. Q2. How will the system be corrected so this violation will not happen again? A.Quarterly inspections will be conducted to ensure thorough and substantial compliance. Q3. How often will the area needing correction will be evaluated? A.Quarterly inspections will be conducted to ensure thorough and substantial compliance. Ongoing evaluations will follow policy guidelines. B. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A.Environmental Service Director. Executive Director, Associate Executive Director to support department when leadership is absent. Q5. Date facility alleges compliance March 12th, 2025 Section F Q1. What actions will be taken to correct the rule violation? A. Maintenance has filled the holes to ensure there are no gaps around hoses. Q2. How will the system be corrected so this violation will not happen again? A. Maintenance team is now aware of facility requirements regarding spacing of pipes running through ceiling openings. Q3. How often will the area needing correction will be evaluated? A. Quarterly inspections will be conducted to ensure thorough and substantial compliance. Ongoing evaluations will follow policy guidelines. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A.Environmental Service Director. Executive Director, Associate Executive Director to support department when leadership is absent. Q5. Date facility alleges compliance March 13th, 2025. Section G Q1. What actions will be taken to correct the rule violation? A. Garbage lids were purchased on DSSI 3/19/2025 Q2. How will the system be corrected so this violation will not happen again? A. An In-service for all back of house staff has been scheduled for March 23rd and attendance is mandatory. Education on state requirements for the placement of garbage lids. B. Disciplinary action for removal of garbage lids will be enforced. Q3. How often will the area needing correction will be evaluated? A. Daily inspection thorough and substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 19th, 2025.

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

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

Based on observation, interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

1. What actions will be taken to correct the rule violation? The team will utilize MBK senior living procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Re-education, Training and corrective actions, according to policy have been implemented. A Back of House All Staff meeting is scheduled for March 23rd re-educate staff on compliance, policies and procedures. Q2. How will the system be corrected so this violation will not happen again? The Food & Beverage Director is accountable to all Dining Dept. policies and procedures as well as Oregon Administrative Rules. The Director will ensure compliance utilizing all available resources. The team will receive ongoing and adequate support to ensure sustainable compliance. Director, Sous Chef, Lead Cooks will review prior day's logs and perform visual inspection to confirm compliance and take corrective action immediately if found to not comply. Q3. How often will the area needing correction will be evaluated? A. Daily, weekly and Quarterly inspections to ensure thorough and substantial compliance. Ongoing per policy. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 23rd, 2025

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

2. Resident 1 was admitted to the facility in 06/2022 with diagnoses including left diastolic heart failure. A review of the resident's clinical record, including progress notes, between 04/20/23 and 08/08/23, intermittent service plans, and staff interviews identified the following: * 06/21/23 - Left middle toenail is falling off and causing discomfort; and * 08/02/23 - Resident's big [toenail] is coming off. During an interview on 08/09/23 at 1:05 pm, Staff 12 (MT) reported she believed the toenail injuries occurred during compression sock removal. She confirmed Resident 1 was alert and oriented, and s/he would be able to answer questions regarding the cause of the injuries. There was no documented evidence these incidents had been investigated to rule out abuse and/or neglect, nor evidence the local SPD was immediately notified. The need to investigate resident incidents to rule out abuse and/or neglect or notify the local SPD if abuse could not be ruled out was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (Wellness Nurse LPN) on 08/10/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to report physical injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injuries were not the result of abuse for 2 of 2 sampled residents (#s 1 and 3) with injuries of unknown cause. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 09/2022 with diagnoses including atrial fibrillation, anticoagulation monitoring, chronic diastolic (congestive) heart failure, and macular degeneration. A review of the resident's clinical record between 05/08/23 and 08/08/23, and family and staff interviews identified the following: * Service Plan dated 05/18/23 indicated the resident "is oriented to time and place, but can wake up and be disoriented.";   * A Narrative Charting entry dated 06/23/23 noted: "I [caregiver] noticed a bruise on [resident's] bottom lip [s/he] doesn't know where it came from and [s/he] says it doesn't hurt at all."; and * A Skin Integrity Monitoring Form dated 07/11/23 noted a "small open area to R [right] ear." These incidents on 6/23/23 and 7/11/23 represented injuries of unknown cause. There was no documented evidence the facility immediately investigated the injuries to rule out abuse, nor reported them to the local SPD office as suspected abuse. Staff 2 (Associate ED) and Staff 3 (Wellness Nurse LPN) stated on 08/10/23 they would modify the facility's Occurrence Report form to add investigative steps for ruling out abuse or neglect for injuries of unknown cause. The need to ensure resident incidents were immediately investigated by the facility to reasonably conclude and document that the physical injury was not the result of abuse, and reported to the local SPD office as needed was discussed with Staff 1 (ED), Staff 2, and Staff 3 on 08/11/23 at 11:40 am. They acknowledged the findings. No further information was provided.

1. Immediate review of policies and procedures to ensure they meet regulatory compliance for investigating and reporting injuries of unknown cause. Director of Health Services conducted retrainings for staff to reorient to policies and procedures for writing and submitting incident reports, investigation procedures, and what to do when abuse cannot be ruled out.   Resident 3  and Resident 1 incidents were investigated and abuse and neglect were ruled out. 2. When a resident is reported to be injured, staff complete an Incident Report Form and file through electronic system (AL Advantage), notifying care team & Administrator. Director of Health Services (DHS), Associate Executive Director (AED) and/or Executive Director (ED) investigate injury and determine cause/rule out abuse/neglect. In the event an injury is investigated and abuse/neglect is unable to be ruled out, DHS, AED, ED report to authorities (APD/SPD/law enforcement). 3. Weekly at Quality Assurance meetings 4. DHS, AED, ED

Based on interview and record review, it was determined the facility failed to document investigations as required and/or report to the local Seniors and People with Disabilities (SPD) office if abuse or neglect could not be ruled out for 1 of 1 sampled resident (#10) reviewed for injuries of unknown cause. This is a repeat citation. Findings include, but are not limited to: Resident 10 was admitted to the facility in 04/2018 with diagnoses including acute gout attack, arthritis, and Diabetes Type II. A review of the resident's clinical record, including progress notes and incident reports dated 10/10/23 through 12/11/23 identified the following: * 10/23/23 - Rectal bleeding; * 11/17/23 - Bruise on left hand; and * 12/07/23 - Bruised right eye. The investigations did not document how abuse was ruled out, if the service plan was followed to rule out neglect, or include an administrator review. During an interview on 12/12/23, Staff 1 (ED) acknowledged the investigations lacked required components. The facility was requested to notify the SPD office of the incidents. Confirmation of the reporting was received on 12/13/23 prior to survey's exit. The need to document the investigation of injuries of unknown cause to rule out abuse or neglect and to notify the local SPD if abuse could not be ruled out was again discussed with Staff 1 on 12/13/23. She acknowledged the findings.

o C 231:  OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action 1. Abuse and Incident training to be provided to all direct care staff including documentation of investigation by 1/27/2024. 2. In addition to training for direct care staff, all incident reports and med error reports will be reviewed daily and investigations completed within 24 hours.  Incidents of abuse and suspected abuse will be reported to APS. 3. Daily and as needed 4. ED, AED, DHS, ALD, HSA or designee

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and was updated and modified as needed during the first 30 days for 1 of 1 sampled resident (# 6) whose evaluations were reviewed. Findings include, but are not limited to: Resident 6 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes, cellulitis of right lower limb, and right humerus fracture. Resident 6 returned from a hospital stay on 07/14/23 and the evaluation was updated 07/17/23. The move-in evaluation and updated evaluation was reviewed and there was no documented evidence the following required elements were addressed or completed to include: * Pain relating to pharmaceutical and non-pharmaceutical interventions, including how the resident expressed pain or discomfort; * Dressing ability with management of TED hose and/or tubigrip; * Medication management; and * Visits to health practitioner(s), ER, hospital, or NF in the past year. The need to address all required elements on the move-in evaluation was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (Wellness Nurse LPN) on 08/11/23. They acknowledged the findings.

1. Immediate review of policies and procedures to ensure compliance. Pre-admission assessment will be conducted and documented in electronic system (AL Advantage) prior to admission. Resident 6 move -in evaluation was updated to reflect the all required elements including non-pharm interventions including how the resident expressed pain, dressing ability with management of ted hose, non-pharmaceutical interventions; Visits to health practitioner(s), ER, hospital, or NF in the past year. 2. Facility care team will ensure resident information includes required elements and is complete prior to admission. Facility will ensure schedule of 30-day and/or quarterly updates are prescheduled in electonic system and monitored daily for completion/compliance. 3. Each resident admission will be reviewed for required elements prior to admission. 4. Director of Health Services, Health Services Assistant, Wellness Nurse, AED, and/or ED

2. Resident 4 was admitted to the facility in 11/2022 with diagnoses including dementia and chronic obstructive pulmonary disease. Observations of the resident, interviews with staff, and review of the resident's clinical record, including a review of the most recent service plan, dated 07/29/23, and intermittent service plans, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Increased confusion, hallucinations, and wandering; * An overall decline in physical health and an increase in ADL care needs; * Specific times of day for incontinent care; * Nutritional status; * Oxygen therapy care instructions; * Interventions to minimize falls; and * Specific evacuation instructions. The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 2 (Associate ED), Staff 3 (Wellness Nurse LPN) and Staff 16 (Health Services Technician) on 08/11/23. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes, and chronic pancreatitis. Observations of the resident, resident and staff interviews, and review of the resident's clinical record, including a review of the most recent service plan dated 08/04/23 and intermittent service plans, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Treatment instructions for pelvic fracture; * Mental health status and interventions for challenging behaviors; * Level of assistance needed with ADLs; * Frequency of incontinent episodes; * Interventions to prevent falls; * Skin condition and treatment; * Specific instructions for monitoring hypoglycemia and hyperglycemia; and * Status of alcohol use. The need to ensure service plans were reflective of current care needs and included clear directions to staff was discussed with Staff 2 (Associate ED), Staff 3 (Wellness Nurse LPN) and Staff 16 (Health Services Technician) on 08/11/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 4 of 5 sampled residents (#s 3, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 09/2022 with diagnoses including atrial fibrillation, anticoagulation monitoring, chronic diastolic (congestive) heart failure, and macular degeneration. Observations were made of the resident's care on 08/10/23. Interviews with facility staff and Witness 1 (Family) were conducted. The current service plan dated 05/18/23 was reviewed. Witness 1 (Family) accompanied the resident every day for approximately four to five hours to assist with ADLs, as well as daily taking of vital signs and weight. Resident 3's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Presence of depression, thought disorders, behavioral and mood problems; * Toileting; * Hearing and use of assistive devices; * Dental status; * Personality, including how the person copes with change or challenging situations; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Instructions for bleeding precautions and interventions while on Coumadin; * Oxygen equipment precautions and instructions for proper maintenance; * Delivery of services during hours when family members were not present; and * Skin condition. The need to ensure the service plan reflected the resident's current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (Wellness Nurse LPN) on 08/11/23 at 11:40 am. They acknowledged the findings. No further information was provided. 4. Resident 6 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes, cellulitis of right lower limb, and right humerus fracture. Observations of the resident, interviews with staff, and review of the resident's clinical record, including a review of the most recent service plan, dated 07/17/23, and intermittent service plans, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Safety checks; * Assistive devices used for ambulation and level of assist needed on outdoor surfaces; * Assistance with "TED hose and/or tubigrip"; * Instructions for bleeding precautions while on Coumadin; and * Outside providers, including HH RN and PT services being provided. The need to ensure service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Associate ED) and  Staff 3 (Wellness Nurse LPN) on 08/11/23. They acknowledged the findings.

1. Review existing resident service plans for content and revise for compliance to include specific instruction for care as evidenced in resident assessment. Ensure pre-admission service plans are thorough and compliant before resident is admitted. Resident 3 service plan was updated to ensure the current needs of the resident and to give clear instruction and direction to caregivers; including Presence of depression, thought disorders, behavioral and mood problems;Toileting;Hearing and use of assistive devices;Dental status;Personality, including how the person copes with change or challenging situations;Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; Instructions for bleeding precautions and interventions while on Coumadin; Oxygen equipment precautions and instructions for proper maintenance; Delivery of services during hours when family members were not present; and Skin condition. Resident 4 service plan was updated to ensure the current needs of the resident and to give clear instruction and direction to caregivers; including Increased confusion, hallucinations, and wandering; An overall decline in physical health and an increase in ADL care needs; Specific times of day for incontinent care; Nutritional status; Oxygen therapy care instructions;Interventions to minimize falls; and Specific evacuation instructions. Resident 5 service plan was updated to ensure the current needs of the resident and to give clear instruction and direction to caregivers;including Treatment instructions for pelvic fracture; Mental health status and intervention for challenging behaviors; Level of assistance needed with ADLs; Frequency of incontinent episodes; Interventions to prevent falls; Skin condition and treatment; Specific instructions for monitoring hypoglycemia and hyperglycemia; and Status of alcohol use Resident 6 service plan was updated to ensure the current needs of the resident and to give clear instruction and direction to caregivers; including safety checks;assistive devices used for ambulation and level of assist needed on outdoor surfaces; assistance with "TED hose", outside provider HH RN and HH PT serivces Resident 6 that is on Anticoagulation therapy will have a notation in their service plan and evaluation. This will include instructions to monitor for risk of bleeding, a detailed description of the medication, who provides and coordinates therapy, and instructions on who to notify for any changes. 2. Facility will ensure service plan aligns with assessment in electonic system (AL Advantage). 3. For pre-admission, prior to resident moving in and again at the required 30 days. At time of any change of condition/reassessment/any other change as required per resident care team/family/POA/etc. 4. Director of Health Services, Health Services Assistant, Wellness Nurse, AED, ED.

2. Resident 10 was admitted to the facility in 04/2018 with diagnoses including acute gout attack, arthritis, and Diabetes Type II. Interviews with caregivers indicated the most current service plan available to staff was dated 04/28/23. Observations and interviews conducted between 12/11/23 and 12/13/23 revealed Resident 10's service plan did not provide clear instruction to staff in the following areas: * Lactose intolerance; * Home health PT/OT services; and * Use of a leg immobilizer. The need to ensure service plans were readily available to staff, were updated quarterly, were reflective of the identified needs of the resident, and provided clear direction to staff was discussed with Staff 1 (ED) on 12/13/23. She acknowledged the findings. 3. Resident 12 was admitted to the facility on 08/18/23 with diagnoses including dementia, malnutrition, and perianal cyst. Interviews with caregivers on 12/11/23 indicated the most current service plan available to staff was dated 08/18/23. Review of the service plan showed staff had reviewed and signed the service plan from 08/18/23 through 12/08/23. Observations and interviews conducted between 12/11/23 and 12/13/23 revealed Resident 12's service plan was not reflective and did not provide clear instruction to staff in the following areas: * Hospice services; * Wound care; * Order for mechanical soft diet; * Monthly weights and nutritional supplements; and * Use of a walker. The need to ensure service plans were readily available to staff, were reflective of the identified needs of the resident, were updated quarterly, and provided clear direction to staff was discussed with Staff 1 (ED) on 12/13/23. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident service plans were updated, reflective of resident needs, were readily available to staff, and provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 10, 12, and 14) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 14 was admitted to the facility in 05/2023. During an interview with Staff 25 (CG) on 12/12/23, s/he stated Resident 14 used their wheelchair to self-propel inside facility. Previously they used a walker. There was no specific information on the service plan regarding Resident 14's change in mobility. The staff were using a service plan that was dated 06/20/23. The resident's service plan was not reflective of the resident's current needs and did not provide clear direction to staff in the following area: * Ambulation. The need to ensure service plans were updated quarterly, were reflective, and provided clear direction to staff was discussed with Staff 1 (ED) on 12/12/23. She acknowledged the findings.

o C 260:  OAR 411-054-0036 (1-4) Service Plan: General 1. DHS, ALD, CFLD, RN to will complete all service plans to reflect any changes through ISPs, orders, diagnosis, and  significant change in conditions.  All service plans will be printed, signed and placed within access to all care staff. 2. MBK to provide training to ALD, HSA, DHS in person centered care planning and chart reviews. 3. Quarterly and as significant changes occur 4. ED, DHS, ALD, HSA, and designee

Based on observation, interview, and record review, it was determined the facility failed to ensure the current resident service plans were readily available to staff and provided clear direction to staff regarding the delivery of services for 2 of 2 sampled residents (#s 1 and 15) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 1 moved  into the facility in 06/2022 with diagnoses including atrial fibrillation. Resident 1 was reported to have pressure wounds to his/her buttocks. a. Progress notes reviewed included documentation of the resident's pressure wounds identified on 01/24/24 and monitored through 02/28/24. Staff documented on 01/28/24 the bandage covering the wound(s) needed "to be changed after each" bowel movement. During an interview on 03/07/24, Staff 16 (MT) and Staff 19 (MT) were asked about instructions to staff regarding changing of the bandage. Staff 16 confirmed MT's changed the bandage as needed if it was soiled but was unable to locate directions for staff to follow regarding the bandage changes. b. The "service plan binder" direct care staff reportedly used to access the resident service plans was reviewed on 03/06/24. Resident 1's service plan in the binder was last updated 04/24/23. The 04/23 service plan available to staff did not include information in the following areas: * Evacuation needs in the event of an emergency; and * Turning and positioning in bed/chair. On 03/06/24, Staff 1 (ED) provided a copy of a more recent service plan for Resident 1, last updated 01/16/24. The 01/16/24 service plan was not included in the service plan binder available to staff. The need to ensure service plans were readily available to staff and provided clear direction regarding the delivery of services was discussed with Staff 1 (ED), Staff 37 (Associate ED), Staff 38 (RN) and Staff 39 (MCC Director) on 03/07/24. They acknowledged the findings. 2. Resident 15 was admitted to the facility in 02/2021 with diagnoses including shortness of breath. The resident's service plan dated 05/11/23, temporary service plans, and physician orders dated 03/01/24 were reviewed, observations were made, and interviews were conducted. The following was identified: a. The service plan did not provide clear direction regarding the delivery of services in the following area: * Oxygen use when the resident was outside of his/her room. b. The "service plan binder" direct care staff reportedly used to access the resident service plans was reviewed on 03/06/24. Resident 2's service plan in the binder was last updated 05/11/23. The service plan available to staff did not include information in the following areas: * Ambulation; * Call pendant use; * Cueing and redirection due to dementia; * Eating/meals; * Fall risk; * Housekeeping; * Laundry; * Leisure Activity; * Monitoring physical/behavioral conditions or symptoms; * Pain management; * Personal hygiene/oral care; * Repositioning; * Impaired skin integrity; * Treatments; and * Evacuation needs in the event of an emergency. On 03/06/24, Staff 1 (ED) provided a copy of a more recent service plan for Resident 1, last updated 12/01/23. The 12/01/23 service plan was not included in the service plan binder available to staff. The need to ensure the service plan provided clear direction regarding the delivery of services and was available to staff was discussed with Staff 1, Staff 37 (Associate ED), and Staff 39 (MC Director) on 03/07/24. They acknowledged the findings.

C 260:  OAR 411-054-0036 (1-4) Service Plan: General 1. DHS-RN and ALD will complete all service plans to reflect any changes and clear directions for staff through TSPs, orders, diagnosis, and significant change in conditions.  All service plans will be printed, signed, and placed in charts with staff copies within access to all care staff in the "service plan binder". Resident 1: Service plan is up to date, reflective of changes, and provides clear direction for resident care. Updated service plan available to staff. Resident 15: Service plan has been updated and provides clear direction for resident care. Updated service plan available to staff. 2. Training will be provided to ALD, HSA, DHS-RN or designee in person centered care planning and chart reviews. 3. Quarterly and as significant changes occur 4. ED, DHS-RN, ALD, and designee

Based on interview and record review, it was determined the facility failed to ensure resident service plans were accurate, provided clear direction to staff regarding the delivery of services, and were reviewed and updated after a change of condition for 1 of 2 sampled residents (#18). This is a repeat citation. Findings include, but are not limited to: Resident 18 moved into the facility in 11/2022 with diagnoses including aortic valve stenosis. The "service plan binder" direct care staff used to access the resident service plans was reviewed on 05/13/24.  Resident 18's service plan in the binder was dated 04/15/24. Review of the 04/15/24 service plan available to staff, interim service plans (ISPs), home health notes and interviews with Staff 17 (Med Tech) and Staff 12 (Caregiver/Med Tech) indicated the service plan did not include current information, instructions for staff, or ISPs in the following areas: * Treatments and interventions for Stage II pressure ulcers; * Use of a pressure relief cushion; * Home Health nursing, occupational, and physical therapy services; * Fall prevention interventions and fall risk; and * Assistance required for incontinence care and toileting. The need to ensure service plans were updated to reflect current status, were readily available to staff and provided clear direction regarding the delivery of services was discussed with Staff 37 (Executive Director), Staff 38 (RN), and Staff 43 (Director of Assisted Living) on 05/15/2024. They acknowledged the findings.

1. Resident 18's service plan have been updated to ensure it is reflective of their conditions and services. Caregiver instructions have been added for Resident 18's service plan to reflect routine as it pertains to outside providers, any interventions in place, and specific instructions as related to certain ADLs. For outside providers, additions include who is providing the services, how often they visit the community, what they do when they visit the community, what direct care staff should be doing between visits, and how to contact the outside agency if there are questions to be asked. All resident service plans will be audited using this knowledge and updated as needed. 2. We will correct this system by ensuring that we include all aspects of the resident's care in their service plan, including those through outside providers. All service plan updates will be added to the ISP binder for staff review and should be initialed and dated by all staff members. These will stay in place until the issue resolves or will be added to the permanent service plan if this is the resident's new baseline during their quarterly service plan review. 3. This new system will be evaluated quarterly. Following our weekly quality assurance meetings, if there are any changes to a resident's care that affects their service plan, an ISP will be implemented. This will be done to ensure accuracy and timeliness as related to resident changes. 4. The Executive Director, Associate Executive Director, Assisted Living Director, Health Services Director, and Administrator or designee will be responsible for making sure these corrections are implemented and monitored.

5. Resident 6 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes and a history of a fractured right humerus. Review of the resident's current service plan dated 06/09/23, evaluation dated 07/17/23, and narrative charting dated 06/12/23 through 08/04/23 were reviewed. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution: * Return from a hospitalization; * Cigarette smell in the apartment with cigarette butts noted in the trash can; * Behaviors; * Rash in the groin area; * Outside provider services initiated for RN and PT; * Changes in pain medication; and * Increased risk for bruising/bleeding related to a high PT/INR (test that helps determine blood clotting time). The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (ED), Staff 2 (Associate ED) and Staff 3 (Wellness Nurse LPN) on 08/11/23 at 9:00 am. Staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate changes of condition, refer significant changes of condition to the facility nurse, determine actions or resident-specific interventions, document weekly progress noted until the condition resolved for 5 of 5 sampled residents (#s 1, 3, 4, 5 and 6) with changes of condition. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2022 with diagnoses including dementia and chronic obstructive pulmonary disease. Observations of the resident, interviews with staff and review of the resident's 07/29/23 service plan, including narrative charting notes from 06/03/23 through 08/03/23 identified the resident experienced multiple short-term changes of condition in the following areas: * Falls, rib injury, and pain; * Bruising on rib, breast, and arm; * Increased confusion, hallucinations, and wandering; and * New medications and medication changes. There was no documented evidence the facility consistently evaluated the resident, determined actions or interventions specific to each change of condition, updated the service plan as needed, or monitored and documented on the progress of the condition at least weekly until resolved. The need to ensure the facility evaluated, determined, and documented what actions or interventions were needed for changes of conditions and monitored until resolution was reviewed with Staff 2 (Associate ED), Staff 3 (Wellness Nurse LPN), and Staff 16 (Health Services Technician) on 08/11/23. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes and chronic pancreatitis. Observations of the resident, interviews with staff and review of the resident's 08/04/23 service plan, including narrative charting notes from 06/10/23 through 08/07/23 identified the resident experienced multiple short-term changes of condition in the following areas: * ER visit; * Skin infection; * New medications and treatment changes; * Falls with injury; * Disruptive and unsafe behaviors; * Alcohol intoxication; and * Episodes of diarrhea. There was no documented evidence the facility consistently evaluated the resident, determined actions or interventions specific to each change of condition, updated the service plan as needed, or monitored and documented on the progress of the condition at least weekly until resolved. The need to ensure the facility evaluated, determined, and documented what actions or interventions were needed for changes of conditions and monitored until resolution was reviewed with Staff 2 (Associate ED), Staff 3 (Wellness Nurse LPN), and Staff 16 (Health Services Technician) on 08/11/23. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 06/2022 with diagnoses including constipation, atrial fibrillation, and left diastolic heart failure. Observations of the resident, interviews with staff, review of the resident's service plan dated 06/29/23, interim service plans, and progress notes dated 04/20/23 through 08/05/23 were reviewed. a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly, and documentation of resolution: * 06/07/23 - Lower abdominal pain; * 06/13/23 - Crystals in urine; * 06/21/23 - Left middle toenail falling off; * 06/26/23 - Right lower leg pain, leg appears bigger than the left; * 06/27/23 - Scrotal bleeding, blood in brief; * 07/04/23 - Increased leg circumference; * 07/05/23 - Lesions on resident's forearm; * 08/02/23 - Big [toenail] coming off; and * 08/04/23 - Left buttock wound reopened. b. The following short-term changes of condition lacked documentation of progress noted at least weekly through resolution: * 05/04/23 - Left buttock wound; * 05/07/23 - No bowel movement; * 05/11/23 - Skin tear right upper thigh; and * 05/14/23 - Missed senna (for constipation) dosage. The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift and the changes of condition were monitored through resolution was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/10/23. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 09/2022 with diagnoses including atrial fibrillation, anticoagulation monitoring, chronic diastolic (congestive) heart failure, and macular degeneration. Review of clinical records, including the service plan dated 05/18/23, narrative charting notes from 05/08/23 through 08/08/23, and interviews with facility staff and the resident's son, revealed the following information: a. The following significant change of condition lacked documentation the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed: * 05/18/23 - Sacral skin wound stage three. b. The following short-term change of conditions lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved: * 05/22/23 - " ...Open sore and some redness on ...the bottom..."; * 05/29/23 - Cloudy urine; * 06/08/23 - Change in level of consciousness/confusion; * 06/23/23 - Bruising on bottom lip; * 06/24/23 - Refused all medications on 06/23/23 and 06/24/23; * 06/29/23 - Started new cough medicine; * 07/11/23 - Urgent care visit; * 07/11/23 - Started new antibiotic for skin infection; * 07/16/23 - Diarrhea, blood in stool; * 07/18/23 - Diarrhea; * 08/04/23 - New order for oxygen; and * 08/04/23 - New order for antibiotic ointment for skin lesion. The need to ensure the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed for a significant change of condition, and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (ED), Staff 2 (Associate ED) and Staff 3 (Wellness Nurse LPN) on 08/11/23 at 11:40 am. They acknowledged the findings. No further information was provided.

1. Alert charting funtion in electronic system (AL Advantage) feature utilized to alert staff on each shift to monitor change of condition timeframe as determined by Director of Health Services (DHS) and/or Wellness Nurse (WN). Med techs were provided in-service training on identifying short-term change of condition. DHS/LPN on call 24/7 for any notification of short term change of condition and will eveluate if the condition requires further action. Resident 4,5,1,3,6 service plans were reviewed have now been updated to reflect any current needs of the residents. All residents reviewed have been placed on skin tracking by licensed nurse for all current skin issues. 2. Med Techs were retrained on initiating alert charting for short term change of condition. Med Techs to complete an incident report for all new skin issues which will then be reviewed by DHS or Wellness Nurse who will monitor until resolved. Med Techs were retrained on how to create and interim service plan for specific change of condition in order to communicate specific instructions on what to monitor and who to notify for changes. All significant change of conditions will be reported to facility RN for a significant change of condition assessment and weekly progress notes will be completed by DHS/Wellness Nurse. Each alert charting period set to maximum hours and may be closed/discontinued only by DHS or WN. 3. Determined by status of change of condition monitoring. Once resolved, alert charting ends. 4. DHS, WN

2. Resident 10 was admitted to the facility in 04/2018 with diagnoses including acute gout attack, arthritis, and Diabetes Type II. Review of the clinical record revealed the following: * 10/23/23 - Rectal bleeding discovered and monitored until 11/26/23; and * 11/17/23 - A bruise on Resident 10's left hand discovered and monitored until 11/26/23. The short-term changes of condition were monitored until 11/26/23, then no further monitoring or resolution was noted. The need to ensure the facility monitored short-term changes of condition with weekly progress noted until resolution was shared with Staff 1 (ED) on 12/12/23. She acknowledged the findings. 3. Resident 12 was admitted to the facility on 08/18/23 with diagnoses including dementia, malnutrition, and perianal cyst. Review of the clinical record revealed the following:   A Hospice note dated 11/15/23, and charted on 11/21/23 as a late entry, noted "pt likely will develop worsening pressure injury" and "significant change in status? Yes." There was no documented evidence the change of condition noted by hospice was evaluated or interventions developed and shared with staff on each shift. The need to ensure the facility evaluated short-term changes of condition, developed and shared interventions with staff on each shift, and documented monitoring with at least weekly progress noted until resolution was shared with Staff 1 (ED) on 12/12/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate changes of condition, determine actions or resident-specific interventions, communicate action or intervention to staff on all shifts, and document weekly progress until the condition resolved for 3 of 4 sampled residents (#s 10, 12, and 14) with changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 14 was admitted to the facility in 05/2023 with diagnoses including osteoporosis. A review of the clinical record revealed the following: Resident 14 was placed on alert charting: * 10/03/23 for a decrease in prednisone from 40 mg to 20 mg and starting zinc 220 mg daily; * 10/07/23 for mood changes/depression; and * 11/03/23 for an increase in prednisone to 1.5 10 mg tablet daily. The facility failed to document on the progress of these changes at least weekly until resolved. The need to ensure the facility monitored short-term changes of condition with weekly progress noted until resolution was shared with Staff 1 (ED) on 12/12/23. She acknowledged the findings.

o C 270:  OAR 411-054-0040 (1-2) Change of Condition and Monitoring 1. The facility will maintain a monitoring and reporting system to be utilized 24 hrs a day.  This 24 hr book will ensure that changes of condition are identified, evaluated, interventions are developed and documented, and conditions monitored through resolution (at least weekly). 2. Staff will receive training on incidents and change in condition reporting by compliance date.  Staff will have received training on the use of the 24 hour book by the compliance date.  The staff will be trained on the use of ISPs and interventions for change in condition by the compliance date.  Staff will receive training on alert charting by the compliance date. 3. This process will be monitored on a daily basis through weekly QA clinical meeting to include ED, DHS, ALD, CFLD, and designee. 4. The ED will ensure that this process is completed/monitored.

3. Resident 4 was admitted to the facility in 11/2022 with diagnoses including dementia and chronic obstructive pulmonary disease. Review of Resident 4's clinical record, including hospice outside service notes and narrative charting notes from 06/03/23 through 08/03/23, identified the following: * On 05/02/23, the resident was admitted to hospice;  and * Between 06/03/23 and 08/03/23, staff noted the resident was experiencing increased confusion and weakness. During the survey on 08/08/23 through 08/11/23, staff interviews revealed, in the last three months, the resident was noted: * Needing more assistance with ADLs; * Eating less; * Sleeping more; * Decreased mobility; and * Increased confusion and hallucinations. The admission to hospice and decline in ADLs constituted a significant change in condition for which an assessment by the facility RN was required. There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition. On 08/10/23, Staff 16 (Health Services Technician) confirmed no RN assessment was completed for Resident 4's significant change condition. The facility RN Staff 9 (Director of Health Services) was not on-site during the survey and was unavailable to interview. The need to ensure the facility RN conducted an assessment when a resident experienced a significant change of condition, was discussed with Staff 2 (Associate ED), Staff 3 (Wellness Nurse LPN), and Staff 16 on 08/11/23. They acknowledged the findings. 4. Resident 5 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes and chronic pancreatitis. During the acuity interview on 08/08/23, staff identified Resident 5 with a pelvic fracture. A review of the resident's clinical record including narrative charting notes dated 06/10/23 through 08/07/23 identified the following: * On 07/30/23 at 5:53 am, staff documented Resident 5 was found on his/her floor in front of the doorway to his/her apartment. The resident reported s/he had fallen out of bed and that his/her hip hurt. Staff noted the resident was slurring his/her words and staff observed empty wine bottles in the resident's apartment. Resident 5 was refusing to have 911 called. Staff called the paramedics; however, the resident refused being sent out and signed a waiver refusing medical treatment. Later that same day at 10:00 pm Resident 5 was sent out to the ER due to complaining of hip pain; and * On 07/31/23, the resident returned from the ER with a diagnosis of a pelvic fracture. Observations and interviews with the resident and staff conducted on 08/09/23 and 08/10/23 showed the resident was dependent on staff for most ADLs, required total assistance with incontinent care and had challenging and disruptive behaviors. The resident was observed lying in his/her bed throughout the survey and reported to the surveyor s/he could not ambulate without assistance. The diagnosis of a pelvic fracture and decline in ADLs constituted a significant change in condition for which an assessment by the facility RN was required. There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition. On 08/11/23, Staff 2 (Associate ED) and Staff 3 (Wellness Nurse LPN) confirmed no RN assessment was completed for Resident 5's significant change condition. The facility RN Staff 9 (Director of Health Services) was not on-site during the survey and was unavailable to interview. The need to ensure the facility RN conducted an assessment when a resident experienced a significant change of condition, was discussed with Staff 2, Staff 3, and Staff 16 (Health Services Technician) on 08/11/23. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 06/2022 with diagnoses including generalized edema and left diastolic heart failure. Review of the clinical record and interviews with staff identified the following: * 06/14/23 - Resident 1 had a stage two wound on his/her bilateral upper buttocks which was identified by the HH RN; * 07/15/23 - The facility's Skin Integrity Monitoring Form completed by Staff 3 (Wellness Nurse LPN) indicated the "open area appears to be improved"; and * 07/27/23 - Outside Agency Documentation completed by HH RN indicated wound care continued to be provided. The stage two wound constituted a significant change in condition for which an assessment by the facility RN was required. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. During the survey, Staff 9 (Director of Health Services/RN) was unavailable for interview. During an interview on 08/10/23, Staff 3 confirmed there was no RN assessment completed. The need to ensure the facility RN conducted an assessment when a resident experienced a significant change of condition, and the assessment was completed timely, was reviewed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/10/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for 4 of 4 sampled residents (#1, 3, 4 and 5) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 09/2022 with diagnoses including atrial fibrillation, anticoagulation monitoring, chronic diastolic (congestive) heart failure, and macular degeneration. A review of the resident's clinical record between 05/08/23 and 08/08/23 identified the following: * An order from Resident 3's PCP dated 05/18/23 to approve home health orders to "evaluate and treat sacral skin wound stage 3"; and * Home health orders dated 05/18/23 for "wound management and instructions to patient/caregiver to perform wound care on non-visit days." The sacral skin wound stage three constituted a significant change in condition requiring a facility RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. On 08/10/23, the surveyor observed the sacral skin wound area during the resident's toileting, and it was noted skin integrity had been restored. Staff 9 (Director of Health Services), the facility RN, was not present and available during the survey. The need to ensure the RN at minimum assessed all residents with a significant change of condition was reviewed with Staff 1 (ED) Staff 2 (Associate ED), and Staff 3 (Wellness Nurse LPN) on 08/11/23 at 11:40 am. They acknowledged the findings. No further information was provided.

. During survey, RN was unavailable for interview and employement terminated. Facility immediately contracted with RN to provide RN assessment and monitoring resident condition as required by OAR 411-054-0045 (1)(a-f)(A)(C-F). Resident 3 sacral wound is resolved and no sig change needed Resident 1 has been placed on weekly skin monitoring, stage 2 pressure wound has recently reopened. Resident 4 notified RN and sig change is in process Resident sig change was completed by contract RN 2. Facility is recruiting staff RN to fill vacant Wellness Nurse position. DHS will monitor residents daily and notifiy contracted RN of any sig changes needed completed until facility recruited a permanent staff RN. Facility RN will then take over daily monitoring of resident conditions. 3. DHS will conduct daily monitoring of resident conditons until facility RN/wellness nurse position is fiiled. 4. DHS, AED, ED

Based on interview and record review, it was determined the facility failed to ensure an RN assessment had been completed for 1 of 3 sampled residents (#14) who had a significant change of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 14 was admitted to the facility in 05/2023 with diagnoses including atrial fibrillation and hypothyroidism. Review of the resident's 10/01/23 through 12/10/23 progress notes showed the following: * The resident was admitted to the hospital 12/02/23 and returned to the facility on 12/05/23 with a diagnosis of pneumonia. Resident 14 had a significant change of condition upon return from the hospital, as s/he could no longer ambulate without a wheelchair. Previously the resident could ambulate with a walker. There was no documented evidence the RN had completed an assessment. The need to have an RN assessment for a significant change of condition was reviewed with Staff 1 (ED) on 12/13/23. She acknowledged the findings.

o C 280:  OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services 1. Facility will ensure a thorough and accurate RN assessment is completed when resident's experience a significant change in condition 2. Clinical staff will receive training on the criteria for significant change in condition and policy regarding the role of the RN and any significant change in condition.   3. This process will be monitored on a weekly basis through QA clinical meeting to include RN, DHS, CFLD, ED and designee. 4. The RN/ED will ensure that this process is completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment had been completed for 1 of 1 sampled resident (#1) who had a significant change of condition. This is a repeat citation. Findings include, but are not limited to: Resident 1 moved into the facility in 06/2022 with diagnoses including atrial fibrillation. Review of the resident's 01/24/24 through 03/06/24 progress notes showed the following: * 01/24/24: "red, irritated bottom ... triad paste applied ...faxed doctor about resident's bottom"; * 01/25/24: "open sore on bottom" and placed on alert monitoring; * 02/03/24: late entry for 01/29/24, Staff 39 (Contract RN) documented "skin breakdown between buttocks. Multiple small open areas noted ... slight pain and discomfort relieved with application of Triad paste, awaiting providence HH visit, will continue to monitor."; and * 02/28/24: outside provider note: "wound care to R buttocks.Pl: 2 distinct wounds: #1 more lateral ...#2 superior medial near gluteal crease..." On 03/06/24, an RN assessment for the wounds was requested. During an interview on 03/07/24, Staff 1 (ED) and Staff 38 (RN) stated an RN assessment of the wounds that included findings, resident status and interventions made as a result of the assessment was not completed. The need to ensure an RN assessment, which included findings, resident status and interventions made as a result of the assessment, for significant changes of condition was reviewed with Staff 1 and Staff 38 on 03/07/24. They acknowledged the findings.

C 280:  OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services 1. Facility will ensure a thorough and accurate RN assessment is completed when resident's experience a significant change in condition. Resident 1: RN assessment complete including significant change of condition documentation. 2. Community DHS-RN, HSA, ALD, and designee will receive training on the criteria for significant change in condition and policy regarding the role of the RN and any significant change in condition.   3. This process will be monitored on a daily basis through a daily clinical meeting to include DHS-RN, ALD, HSA, ED and designee. 4. The DHS-RN/ED will ensure that this process is completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (#6) who received insulin injections by unlicensed facility staff. Resident 6 was at risk for harm related to potential medical complications from the lack of an RN assessment of the resident's condition, unlicensed staff training and supervision to ensure safety and accuracy of insulin administration. Findings include, but are not limited to:   Resident 6 was admitted to the facility in 06/2023 with diagnoses including diabetes. Review of the 07/15/23 through 08/07/23 MAR noted the resident received routine insulin every evening at bedtime. The MAR noted Staff 20 (MT), Staff 22 (CG) and Staff 8 (MT) administered insulin to the resident during the month of August. During an interview with Staff 1 (ED), Staff 2 (Associate ED) and Staff 3 (Wellness Nurse LPN) on 08/10/23 at 12:48 pm, they stated the assisted living community had four residents that received insulin and the facility RN had recently completed delegation. Staff 9 (Director of Health Services), the facility RN, was not present and available during the survey. Review of the delegation binder for Resident 6 revealed no documented evidence the resident's condition was stable and predictable or determination of frequency resident should be reassessed, including rationale. There was no documented evidence any of the non-licensed staff had been delegated by an RN including: * Rationale why the task could be safely delegated; * Skills, abilities and willingness of non-licensed staff to complete the task; * Task was taught to the non-licensed staff and they were competent to safely perform task; * Written instructions available including risks, side effects, response, and risk factors; * Non-licensed staff were taught the task was client specific and not transferable; * Determination of frequency the non-licensed staff should be supervised and reevaluated, including rationale; and * RN takes responsibility for delegating task and ensures supervision will occur for as long as RN was supervising performance. On 08/10/23, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1, 2, and 3. They acknowledged the above findings. The Surveyor requested an immediate plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules. On 08/10/23 at 5:00 pm, a plan to address the delegation issue which included licensed staff administering insulin until delegation was completed was accepted and the situation was abated.

1. During survey, RN was unavailable for interview and employement terminated. Facility immediately contracted with RN to provide RN assessment and monitoring resident condition as required by OAR 411-054-0045 (1)(a-f)(A)(C-F). Resident 6 RN assessment for delegation was completed by contract RN and med techs were appropriately delegated to give insulin to resident 6. All insulin dependant residents were properly assessed by contract RN and ensured that only appropriately delegated Med techs will be administering insulin. 2. Facility is recruiting staff RN to fill vacant Wellness Nurse position.Contract RN has taken over delegations. RN to ensure the delegations are performed timely per regulation (initial, 60 day, 90-180 day) All delegations will be monitored at least quarterly and audited by the ED at least quarterly. 3. ED will conduct quarterly audits to ensure that the delegations are being completed timely by the RN 4. DHS, AED, ED

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules for 1 of 1 sampled resident (# 7) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to: During the acuity interview on 12/11/23, Resident 7 was identified to be administered insulin injections by non-licensed staff. Resident 7's delegation records, dated 10/01/23 through 11/01/23, and MARs, dated 10/01/23 through 12/11/23, were reviewed. The documents revealed four staff members, who were not delegated, had administered insulin to Resident 7. The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED) on 12/13/23. She acknowledged the findings.

o C 282:  OAR 411-054-0045 1. The facility will ensure delegation and supervision of special tasks of nursing care is completed in accordance with OSBN rules. 2. RN delegation book will include rationale as to why the resident can be considered stable and predictable, why task can be safely delegated, frequency of reassessment, initial and redelegation of staff, and the skills and abilities of the caregiver through observation and demonstration of competence. 3. This process will be monitored on a weekly basis through January, and then on a monthly basis through the quarter and then quarterly through QA systems. 4. ED, RN or designee is responsible for ensuring this is completed timely and monitored appropriately.

2 . Resident 4 was admitted to the facility in November 2022 with diagnoses including chronic obstructive pulmonary disease and dementia. During the acuity interview on 08/08/23, Staff 3 (Wellness Nurse LPN)  indicated Resident 4 received hospice services. The "Outside Agency Documentation" visit notes dated 05/02/23 through 07/24/23 were reviewed and identified the following: 06/24/23 - HH RN documented "apply ice to left rib as to palliate discomfort" and marked yes on the form for any significant changes in status and documented "new left rib pain after fall" and to call with any concerns or symptom needs. 06/26/23 - HH RN recommended " ice and/or heat to ribs" and marked yes on the form for any significant changes in status and documented "bruising post fall and pain, low oxygen stats, worsening short term memory loss." 07/11/23 - Hospice Chaplin wrote "offers to resident and their spouse opening apartment door to help create a sense of space, resident feeling very confined." There was no documented evidence the notes left by hospice had been reviewed by the facility or that the information had been communicated to staff. In an interview on 08/11/23, Staff 3 stated the "Outside Services Documentation" visit notes were supposed to be reviewed by the RN. No other information was provided. The facility RN Staff 9 (Director of Health Services) was not on-site during the survey and was unavailable to interview. The need to ensure coordination between the facility and outside service providers was reviewed with Staff 2 (Associate ED), Staff 3, and Staff 16 (Health Services Technician) on 08/11/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care, for 2 of 4 sampled residents (#s 3 and 4) whose records were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 09/2022 with diagnoses including atrial fibrillation, anticoagulation monitoring, chronic diastolic (congestive) heart failure, and macular degeneration. Review of clinical records, including the service plan dated 05/18/23, narrative charting notes from 05/08/23 through 08/08/23, and interview with Witness 1 (family), revealed the following information: * An order from Resident 3's PCP dated 05/18/23 to approve HH orders to evaluate and treat sacral skin wound "stage 3";   * HH orders dated 05/18/23 for "wound management and instructions to patient/caregiver to perform wound care on non-visit days..."; * Narrative charting notes on 05/23/23 by Staff 9 (Director of Health Services) stated, "HH PT notes reviewed. [S/he] is on service for gait and transfer training and respiratory training..."; * Narrative charting notes on 05/31/23 by Staff 9 stated, "HH visit note from 5/25 reviewed..."; and * Narrative charting notes on 06/12/23 by Staff 9 stated, "Resident was discharged from HH nursing services today." During the interview on 08/10/23 at 9:42 am, Staff 3 (Wellness Nurse LPN), stated HH records were stored in Staff 9's office. However, facility staff were unable to provide copies of the records during the survey. Staff 9, the facility RN, was not present or available during the survey. Witness 1 (Family) stated during an interview on 08/11/23 at 9:40 am, "I bought an inflatable waffle seat cushion because PT [from HH agency] recommended it. It helped the bed sore to heal faster." He confirmed no HH written recommendations or discharge instructions were left in the HH service folder. The need to have policies to ensure that outside service providers left written information in the facility that addressed on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 on 08/11/23 at 11:40 am. They acknowledged the findings. No further information was provided.

1. Ensure providers are informed of facility requirement for written documentation of provider's visit be filed with staff prior to exiting building. Resident 3 and Resident 4 outside provider services were reviewed and updated in service plan and evaluation. The name/service of the outside provider and contact information will be entered to the service plan and all outside provider forms will be reviewed by DHS for coordination of care. 2. Upon registration at arrival, provider will be given document with instructions to complete and retun prior to exiting the building. All provider forms/documentation will be reviewed by DHS after submission and entered into resident chart by DHS/WN/Health Services Assistant. DHS will ensure all recommendations will be impletented timely through an ISP 3. At each provider visit. 4. Concierge staff, DHS, WN, HSA.

Based on interview and record review, it was determined the facility failed to ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure staff were informed of new interventions, the service plan was adjusted as necessary, and services were implemented for 1 of 1 sampled resident (#12) who received outside services. This is a repeat citation. Findings include, but are not limited to: Resident 12's current service plan dated 08/08/23, outside provider notes dated 10/10/23 through 12/11/23, and MARs dated 10/10/23 through 12/11/23 noted the following: * 10/20/23 hospice note "wearing the same clothes at each visit, unsure if patient bathes, severe memory impairment"; * 10/20/23 hospice note "concerns about hygiene and concerns about safety - ambulates without supervision"; and * 10/23/23 hospice note "New order for diet change" to mechanical soft. An RN note dated 10/25/23 stated "no new orders" and "no further concerns noted or reported," however, a diet change had been ordered and concerns about hygiene and safety were reported five days earlier. * 11/15/23 hospice note "patient will likely develop worsening pressure injury" and "Any significant changes in status? Yes". The note was not reviewed until six days later on 11/21/23 as a late entry. There was no response documented to the hospice note indicating a change of condition and risk for worsening pressure injury. * 11/24/23 hospice note ordered "DC'ing [discontinuing] mepilex"; however, the note was not reviewed until 11/27/23. Review of the MAR showed the mepilex had not been discontinued and was still active on the 12/11/23 MAR. There was no documented evidence the service plan was adjusted as necessary in response to the outside provider concerns, recommendations, and orders. The need to ensure the facility management or licensed nurse was notified of the services provided by the outside provider to coordinate care, ensure the service plan was adjusted as necessary, and services were implemented was discussed with Staff 1 (ED) on 12/13/23. She acknowledged the findings.

o C 290:  OAR 411-054-0045(2) Res Hlth Srvc:  On & Off-Site Health Srvc 1. Facility will ensure all outside agency documentation is completed for visits and will be reviewed for appropriate follow-up.  Follow-up and appropriate documentation will be completed. 2. ALD or designee will ensure all outside providers complete visit documentation.  Community RN, DHS, ALD or designee will review forms on a daily basis for appropriate follow-up and update the service plan accordingly. 3. Daily and as needed 4. ED, RN, DHS, ALD, HAS, or designee

3. Resident 5 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes, chronic pancreatitis, and depression. a. Physician orders and MARs, reviewed from 07/01/23 through 08/08/23, showed the resident was self-administering his/her medications prior to 08/01/23. Resident 5's MAR between 08/01/23 and 08/08/23 identified the following medication and treatment orders were not carried out as prescribed: * Diclofenac 1% gel for pain, apply to affected areas four times a day; * Duloxetine 60 mg one capsule daily (for depression); * Loperamide 25 mg one tablet two times daily (for treatment of diarrhea); * Omperazole 20 mg one capsule daily 30 minutes before a meal (for heartburn); and * Vitamin D3 one capsule daily. Reasons listed on the MAR for not administering the medications included "we do not have all meds," "waiting for pharmacy," and "not available." b. Resident 5's MAR from 08/01/23 through 8/08/23 showed the facility was applying Clotrimazole 1% cream topically twice daily without a signed physician order. The need to ensure orders were carried out as prescribed and that the facility had signed orders in the resident's facility record for all medications and treatments being administered by the facility was discussed with Staff 2 (Associate ED), Staff 3 (Wellness Nurse LPN), and Staff 16 (Health Services Technician) on 08/11/23. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 09/2022 with diagnoses including atrial fibrillation, anticoagulation monitoring, chronic diastolic (congestive) heart failure, and macular degeneration. Resident 3's current facility records and MARs from 07/01/23 to 08/08/23 were reviewed. Resident 3's MAR included an order to "[administer] Furosemide 20 mg [diuretic] 1 tablet by mouth every day as needed for edema. Take 1 tablet daily for 2 days if weight gain is more than 2 lbs in 2 days or 5 lbs in over a week." On 05/19/23, Staff 3 (Wellness Nurse LPN) notified the resident's PCP of the agreement between the facility and Witness 1 (family) for the latter to "monitor daily weight, daily BP and O2 sats for the resident to reduce the level of care costs." PCP signed the notification on 05/22/23. Review of weights from the log recorded by the Witness 1 showed the following: * 07/21/23 weight of 129.5 pounds; and * 07/23/23 weight of 133.0 pounds, a gain of 3.5 pounds from the weight recorded two days prior.   There was no documented evidence Furosemide 20 mg was administered as ordered. The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 on 08/11/23 at 11:40 am. They acknowledged the findings. No further information was provided.

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 3 of 6 sampled residents (#s 3, 5, and 6) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes, cellulitis of right lower limb, and right humerus fracture. Resident 6's MARs, dated 07/01/23 through 08/08/23 and physician orders were reviewed and revealed the following: Resident 6 had an order to check blood sugars three times a day, dated 07/25/23. No documented evidence was found that the order was updated and the facility continued to check CBGs one time a day. In an interview with Staff 3 on 08/11/23 at 1:00 pm, she acknowledged that the order was received but not updated on the MAR. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 on 08/11/23. They acknowledged the findings.

1.Med tech retraining provided on 1st , 2nd and 3rd check system for all medication orders which will ensure that all medications are checked 3 times for accuracy by Med techs and DHS/wellness nurse. Staff training and education provided for entering treatment orders such as checking CBG, manually to QuickMAR system. Resident 6, Resident 3, Resident 5 MAR and physician orders were reviewed for accuracy. All incorrect/duplicate orders were corrected and updated in MAR. 2.All prescription medications are entered to QuickMAR by pharmacy. Med techs retrained on checking for accuracy in verbiage, time, dose, and frequency. Med techs were also trained on checking for duplicate orders when confirming medication orders on QuickMAR. Lead Med Tech will audit for accuracy and documentation. 3. Daily review. Weekly audit. 4. Lead Med Tech, Health Services Assistant,  Wellness Nurse, DHS.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when residents refused consent to orders for 2 of 5 sampled residents (#s 1 and 6), who had documented medication and treatment refusals. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 06/2022 with diagnoses including constipation. The resident's MAR and TAR, dated 07/01/23 through 08/08/23, were reviewed and revealed facility staff documented Resident 1 refused the following orders: * Acetaminophen (for pain) on one occasion; * Diclofenac (for pain) on six occasions; * Miconazole nitrate 2% cream (for antifungal) on eight occasions; * Polyethylene glycol (for constipation) on one occasion; * Senna (for constipation) on one occasion; and * Triad hydrophilic wound paste (for wound care) on six occasions. On 08/09/23 at 10:09 am, Staff 3 (Wellness Nurse LPN) confirmed medication and treatment refusals were to be faxed to the practitioner and placed in the Provider Fax Communication binder. There was no documented evidence in the binder the practitioner was notified of the multiple medication and treatment refusals. On 08/10/23, the need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (ED), Staff 2 (Associate ED) and Staff 3.  They acknowledged the findings, and no additional documentation was provided. 2. Resident 6 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes, cellulitis of right lower limb, and right humerus fracture. Resident 6's MARs, dated 07/01/23 through 08/08/23 and physician orders were reviewed and revealed facility staff documented Resident 6 refused the following orders: * Polyethylene glycol (for bowel care) on three occasions; * Senna (for bowel care) on four occasions; * Acetaminophen (for pain) on one occasion; * Supplemental beverage, sugar free on eight occasions; * Fluticasone nasal spray (for nasal congestion) on two occasions; and * Wound care to left hand on three occasions. On 08/10/23 at 10:05 am, Staff 19 (MT) reported that  medication and treatment refusals were to be faxed to the physician and placed in the Physician Communication binder. There was no documented evidence in the binder the practitioner was notified of the multiple medication and treatment refusals. On 08/11/23, the need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (ED), Staff 2 (Associate ED) and Staff 3 (Wellness Nurse LPN).  They acknowledged the findings, and no additional documentation was provided.

1. Retraining of facility care staff to comply with OAR 411 -054-0055 (1)(j-k) Systems Resident Right to Refuse. Resident 1 and Resident 6 refusals were reviewed and PCP was notified of refusals. 2. Ensure facility care staff have unincumbered access to refusal documentation, physician notification information, and directive for notification.   3. Weekly audit. DHS will conduct weekly audits to ensure all Providers are notified of refusals. Also sent clarification to all Providers on how often they would like to be notified for missed meds/refusals and will be added to the MAR accordinly. 4. Lead Med Tech, Health Services Assistant, QA Team

2. Resident 1 was admitted to the facility in 06/2022 with diagnoses including constipation and atrial fibrillation. Resident 1's signed physician orders and 07/01/23 through 08/08/23 MAR/TAR were reviewed during the survey and revealed the following: a. The following medications lacked documented reasons for use: * Diclofenac 1%; * Melatonin 1 mg; * Miconazole nitrate 2% cream; * Polyethylene glycol; * Potassium chloride ER 10 meq; * Pradaxa 150 mg; * Senna/docusate 8.6-50 mg; * Trazodone 50 mg; * Triad hydrophilic wound paste 71 gram; * Nystatin 100,000 U/G powder; and * Moi-stir spray/pump. b. The following medications lacked resident specific parameters or instructions for PRN bowel medications: * Sodium phosphate enema; and * Bisacodyl 10 mg suppository. During an interview on 08/09/23 at 12:45 pm, Staff 11 (MT) confirmed there were no reasons for use or resident specific parameters for the medications on the electronic version of the MAR/TAR. The need to ensure all medications on the MAR indicated reasons for use and all PRN medications had resident specific parameters was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/10/23. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 09/2022 with diagnoses including atrial fibrillation, anticoagulation monitoring, chronic diastolic (congestive) heart failure, and macular degeneration. Resident 3's MARs from 07/01/23 through 08/08/23 and physician orders were reviewed, and revealed the following: a. The following medications lacked documented reasons for use: * Furosemide; * Levothyroxine; * Lisinopril; * Memantine; * Oyst Calcium + D 500g/200 U; * Pantoprazole; * Warfarin; and * Zioptan ophthalmic solution. b. The following PRN medications lacked resident specific parameters, including sequential order of use:   * Benzonatate 100 mg (for cough); and * Guaifen DM 100-10 mg/5ml syrup (for cough). The need to ensure MARs for each resident that the facility administered medications to included reason for use, and resident specific parameters and instructions for PRN medications was reviewed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (Wellness Nurse LPN) on 08/11/23 at 11:40 am. They acknowledged the findings. No further information was provided. Surveyor: Bowen, Lindsay 4. Resident 4 was admitted to the facility in November 2022 with diagnoses including dementia and chronic obstructive pulmonary disease. a. Resident 4's MARs from 07/01/23 through 08/08/23 were reviewed, and noted the following medications lacked reasons for use: * Acetaminophen 500 mg; * Amlodipine 50 mg; * Aspirin 81 mg; * Haloperidol 2 mg/ml; * Ipratropium-Albuterol 0.5-2.5 mg/3 ml; * Lisinopril 10 mg; * Lumigan 0.01% drops; and * Timolol maleate 0.5%. b. Resident 4 had an order for continuous oxygen at 3.5 liters per minute. There was an oxygen reminder listed on the MAR instructing staff that O2 should always be set at 3.5 liters per minute. There were no specific instructions on the MAR to staff on how to safely operate the oxygen concentrator or how to maintain and clean the device. The need to ensure all orders on the MAR included reasons for use and specific instructions for staff was discussed with Staff 2 (Associate ED), Staff 3 (Wellness Nurse LPN) and Staff 16 (Health Services Technician) on 08/11/23. They acknowledged the findings. 5. Resident 5 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes and chronic pancreatitis. a. Resident 5's MARs from 07/01/23 through 08/08/23 were reviewed, and noted the following medications lacked reasons for use: * Creon 12-38-60K; * Duloxextine 60 mg; * Glipizide 5 mg; * Levothyroxine 50 mcg; * Loperamide 2 mg; * Mybetriq 50 mg; and * Omeprazole 20 mg. b. Resident 5 had an order for Diclofenac 1% gel for pain, apply to affected areas four times a day. There were no medication specific instructions to staff on where the affected areas were located. The need to ensure all orders on the MAR included reasons for use and medication specific instructions for staff was discussed with Staff 2 (Associate ED), Staff 3 (Wellness Nurse LPN), and Staff 16 (Health Services Technician) on 08/11/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included reason for use, medication specific instructions and included resident-specific parameters for PRN medications for 5 of 6 sampled residents (#s 1, 3, 4, 5, and 6) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 06/2023 with diagnoses including Type 2 diabetes, cellulitis of right lower limb, and right humerus fracture. Resident 6's signed physician orders and 07/01/23 through 08/08/23 MAR/TAR were reviewed during the survey and revealed the following: a. The following medications lacked documented reasons for use: * Warfarin. b. Resident 6 had an order listed on the MAR for Lantus 100-U/ML pen 8 units subcutaneously every night at bedtime. Resident's CBGs were being checked at the time. The facility had physician instructions for a hypoglycemia protocol but lacked resident specific CBG parameters for hyperglycemic readings. In an interview with Staff 19 (MT) on 08/10/23 she acknowledged that the resident did not have CBG parameters for notifying the physician when elevated. c. Resident 6 had an order for wound care to the left hand to cleanse wound and apply triple antibiotic and bandage, initiated on 07/20/23. On 07/21/23, there was documentation that the area was healed but staff continued to document that care was provided on 12 more occasions. In an interview with Staff 3 (Wellness Nurse LPN) on 08/11/23, she stated the wound was healed, but was not aware the order was still on the August MAR. The need to ensure MARs for each resident that the facility administered medications to included reason for use and resident specific parameters was reviewed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 3 (Wellness Nurse LPN) on 08/11/23 at 8:45 am. They acknowledged the findings. No further information was provided.

1. Facility to ensure resident MAR meets the requirement as stated in OAR 411-054-005 (2) Systems: Medication Administration. Facility staff audit and update MAR. Resident 6, Resident 1, Resident 3, Resident 4, Resident 5 MARs were reviewed and indication of use for all medications were updated. Resident 6 hyperglycemia parameters and instructions to notify RN/PCP was added. Resident 6 Warfarin reason for use was updated. Resident 6 wound care order was discontinued. 2. Lead Med Tech will ensure MAR is accurate and up to date with medication information, reasons for use, and specific instructions for administration. 3. Weekly audit and quarterly with 90 day physician orders 4. Health Services Assistant, Wellness Nurse, DHS.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to: The facility's ABST was reviewed on 08/09/23 and discussed with Staff 1 (ED) and Staff 2 (Associate ED). They reported the ABST was populated by the Resident Assessment, which was driven by the service plan for each resident. There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using. The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 1 and Staff 2 on 08/10/23. They acknowledged the findings. Staff 1 was referred to the Department's ABST Policy Analyst.

1. Facility to pursue further revision to AL Advantage ABST tool for the purposes of meeting the OAR 411-054-0037 (1-8) Acuity Based Staffing Tool. 22 ADLS to be listed as dictated by OAR. 2. Facility consultant firm to pursue corrections to ABST. 3. Before new resident move-in, within 30 days, with any sig change but no less than quarterly. 4. Executive Director, Regional Director.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly-hired staff (#s 8, 10, and 18) completed all required pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to: On 08/09/23 at 11:25 am, Staff 8 (MT), Staff 10 (CG), and Staff 18's (CG) training records were reviewed. During an interview with Staff 16 (Health Services Technician) and Staff 17 (Lead MT), the following was identified: Staff 8 (MT) was hired on 05/03/23, Staff 10 (CG) was hired on 05/25/23, and Staff 18 (CG) was hired on 04/20/23.  There was no documented evidence the pre-service orientation had been completed prior to performing job duties in the following areas: * Residents' rights and values of CBC care; * Abuse and reporting requirements; * Infectious Disease Prevention training;   * Fire safety and emergency procedures; and * Pre-service dementia care training. The need to ensure all newly-hired staff completed pre-service orientation training prior to beginning their job responsibilities was discussed on 08/10/23 with Staff 1 (ED), Staff 2 (Associate ED), and Staff 16. They acknowledged the findings.

1. Facility immediately audited employee files for pre-service orientation & training. Provided orientation and training as well as documentation where necessary utilizing Oregon Care Partners resource, and approved food handlers training organization. 2. Updated process and procedure developed and documented to ensure each new employee will be evaluated and cross referenced for pre-service orientation and training upon hire before first floor/direct care shift. 3. Each new hire audited during orientation period.   4. Department managers, AED.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 26, 29, 33, and 35) completed all required pre-service orientation prior to beginning their job responsibilities and 2 of 3 newly-hired direct care staff (#s 29 and 33) completed all required pre-service dementia training prior to providing direct care to residents. This is a repeat citation. Findings include, but are not limited to: Staff training records, reviewed on 12/12/23 with Staff 34 (Business Office Manager), identified the following: 1. There was no documented evidence Staff 26 (CG), Staff 29 (CG), Staff 33 (CG), and Staff 35 (Concierge), hired 10/18/23, 10/17/23, 10/30/23, and 10/23/23, respectively, completed one or more of the following required pre-service orientation training topics: * Resident rights and values of CBC care; * Abuse reporting requirements; * Infectious Disease Prevention; and * Fire safety and emergency procedures. 2. There was no documented evidence Staff 29 and Staff 33 completed the following pre-service dementia training: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach. The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities was discussed with Staff 1 (ED) on 12/13/23. She acknowledged the findings, and no additional documentation was provided.

o C 370:  OAR 411-054-0070(3-4) Staffing Requirements and Training:  Caregiver Requirements 1. Audit of staff training records will be completed for pre-service orientation training and pre-service dementia training requirements.  Missing training items to be completed.   2. Training to be provided to BOM, DHS, ALD, HSA on proper onboarding processes and training requirements. 3. Weekly 4. BOM/ED

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired direct care staff (#s 7, 8, 10, and 18) completed demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to: On 08/09/23 at 11:25 am, training records were reviewed with Staff 16 (Health Services Technician) and Staff 17 (Lead MT). There was no documented evidence competency was demonstrated in changes associated with normal aging and First Aid/Abdominal Thrust for the following staff: * Staff 7 (MT), hired 02/15/23; * Staff 8 (MT), hired 05/03/23; * Staff 10 (CG), hired 05/25/23; and * Staff 18 (CG), hired 04/20/23. The need to ensure all newly hired staff had competency demonstrated in all areas required within 30 days of hire was discussed on 08/10/23 with Staff 1 (ED), Staff 2 (Associate ED), and Staff 16. They acknowledged the findings.

1. Immediately audited employee files for completeness. Hold in-service training and competency assessments; document. 2. Facility updated new hire 30-day competency policy and procedure to meet the requirement. 3. At 30-days for each new hire. 4. Hiring manager, DHS, Health Services Assitant, AED.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 26, 29, and 33) demonstrated satisfactory performance in their assigned duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Staff training records, reviewed on 12/12/23 with Staff 34 (Business Office Manager), identified the following: Staff 26 (CG), Staff 29 (CG), and Staff 33 (CG) were hired on 10/18/23, 10/17/23, and 10/30/23, respectively. There was no documented evidence Staff 26, Staff 29, and Staff 33 demonstrated competency in their job duties within 30 days of hire in one or more of the following areas: * Changes associated with normal aging; and * First Aid/abdominal thrust. The need to ensure staff had demonstrated competency in all job duties within 30 days of hire was reviewed with Staff 1 (ED) on 12/13/23. She acknowledged the findings, and no additional documentation was provided.

o C 372:  OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff 1. Audit of staff training records will be completed for training, demonstrated competencies and abdominal thrust requirements.  Missing training items to be completed.   2. Training to be provided to BOM, DHS, ALD, HSA on proper onboarding processes and training requirements. 3. Weekly 4. BOM/ED

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (# 40) demonstrated satisfactory performance in assigned duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to: Staff training records, reviewed on 03/06/24 with Staff 1 (ED), identified the following: There was no documented evidence Staff 40 (CG), hired 01/22/24, demonstrated competency within 30 days of hire in first aid and abdominal thrust. The need to ensure staff had demonstrated competency in all job duties within 30 days of hire was reviewed with Staff 1, Staff 37 (Associate ED), and Staff 39 (MCC Director) on 03/07/24. They acknowledged the findings, and no additional documentation was provided.

C 372:  OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff 1. Audit of staff training records will be completed for training and demonstrated competencies.  Missing training documentation/competencies will be completed.   2. Training to be provided to DHS-RN, ALD, HSA on proper onboarding processes and training requirements. 3. Weekly 4. BOM/ED

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 veteran direct care staff (#s 12 and 13) completed a minimum of 12 hours of in-service training annually, including six hours on dementia care. Findings include, but are not limited to:   Review of the facility's training records on 08/10/23 revealed the following staff lacked documented evidence of six hours of annual in-service training related to provision of care in CBC and six hours related to dementia care for: *Staff 12 (MT), hired 08/29/17; and *Staff 13 (MT), hired 11/08/19. The need to ensure all staff had a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including dementia care topics was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 16. They acknowledged the findings.

1. Immediately audit facility staff training files. Provide training for all staff who do not meet requirement.   2. Develop schedule of annual trainings, track, and document staff participation. Remove non-compliant staff from schedule. 3. Monthly 4. DHS, AED, ED

Based on interview and record review, it was determined the facility failed to have a system in place to ensure all direct care staff completed a minimum of 12 hours of in-service training annually on topics related to the provision of care, including 6 hours of dementia training. This is a repeat citation. Findings include, but are not limited to: On 12/12/23 Staff 1 (ED) was asked to explain the facility's process for providing annual in-service training to staff. Staff 1 stated the facility's goal was to assign courses to staff through an online training program, and then the facility would monitor the courses completed by staff. Staff 1 reported this had not been completed yet. On 12/13/23, the need to ensure all annual training requirements were completed by care staff based on anniversary dates of hire was discussed with Staff 1. She acknowledged the findings, and no additional documentation was provided.

o C 374:  OAR 411-054-0070 (2-5)(5-8) Annual Training and Other Requirements 1. Audit of annual in-service training records will be completed.  Missing training items to be completed.   2. Training to be provided to BOM, DHS, ALD, HSA on annual staff training requirements and record keeping. 3. Monthly and as needed 4. ED, BOM, DHS, ALD or designee

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and recorded every other month, included required components on fire drill records, and provided fire and life safety instruction to staff on alternating months according to the Oregon Fire Code (OFC). Findings include, but are not limited to: On 08/09/23 at 10:00 am fire drill and fire and life safety training records for the previous six months were reviewed, and the following was identified: a. Fire drills and fire and life safety instruction were not consistently completed every other month during the six-month time frame reviewed. b. Fire drill records lacked the following components: - Problems encountered, comments relating to residents who resisted or failed to participate in the drills; - Number of occupants evacuated; and - Evidence alternate routes were used during fire drills. The requirements regarding fire drills and fire and life safety instruction for staff was discussed with Staff 1 (ED), Staff 2 (Associate ED) and Staff 5 (Director of Environmental Services) on 08/09/2023 at 2:15 pm. They acknowledged the findings.

1. Facility to ensure schedule and content of fire drills meets requirement. Facility will adequately document fire drills and associated activity which meets the requirement. Facility will ensure all staff are brought up to date on training.   2. Electronic reminder and documentation tool will be updated to ensure regulatory compliance. 3. monthly 4. Director of Environmental Services, AED, ED

Based on interview and record review, it was determined the facility failed to ensure residents were instructed annually about the facility's fire and life safety procedures according to the Oregon Fire Code (OFC). Findings include, but are not limited to: During a group interview on 08/08/23 at 1:30 pm, multiple non-sampled residents discussed concerns with fire drills and receiving fire and life safety instructions. Fire and life safety records were reviewed on 08/09/23 at 10:00 am and lacked documented evidence the facility was conducting fire and life safety instruction annually for residents. An interview on 08/09/23 at 2:15 pm, Staff 5 (Director of Environmental Services) stated the facility was not conducting fire and life safety instruction annually for residents. The need to ensure residents received fire and life safety training and re-instruction annually, was discussed with Staff 1 (ED), Staff 2 (Associate ED), and Staff 5 on 08/09/23 at 2:15 pm. They acknowledged the findings.

1. Facility to develop new resident Fire, Life, Safety orientation which meets the requirement. Facility staff will develop training and utilize monthly Town Hall meetings 2x each year to provide ongoing education, to be supplemented by documentation and followup for residents not in attendance. 2. Bi-annual audit of resident education cirriculum, training schedule and documentation. 3. 2x year 4. Director of Environmental Services, AED, ED

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and clothing. Findings include, but are not limited to: The facility laundry rooms were observed on 08/08/23 at 10:45 am and noted to have both residential type washers and one industrial type washer.   During interviews on 08/09/23, Staff 24 (CG) and Staff 12 (MT) stated the facility industrial type washer was "out of order" and the facility was using residential type washers on each floor to clean soiled linen and clothing. The residential washers did not have any means to ensure a minimum rinse temperature of 140 degrees Fahrenheit, and their laundry detergent did not have a chemical disinfectant component. The need to ensure soiled laundry was properly disinfected was discussed on 08/09/23 with Staff 1 (ED), Staff 2 (Associate ED), and Staff 5 (Director of Environmental Services). They acknowledged the findings.

1. Facility will supply disinfectant additive for use in laundry, to meet the requirement. 2. Facility staff will be trained on apprioriate use and storage of laundry disinfectant. 3. Weekly audit. 4. Director of Environmental Services

Based on interview and record review, it was determined the facility failed to ensure a resident who self-administered a medication had a physician's order and was evaluated at least quarterly to ensure the ability to safely self-administer medications for 1 of 1 sampled resident (#14). Findings include, but are not limited to: Resident 14 was admitted to the facility in 05/2023 with diagnoses including osteoporosis. A record review of Resident 14's 11/01/23 through 12/11/23 MARs had an order to take alendronate 70 mg one time daily. The MARs also stated "ok to leave 1 tablet at the patient bedside on Thursday evening for patient to self administer on Friday morning." There was no written physician's order with these instructions. There was no evaluation of the resident's ability to safely administer the alendronate and keep it in his/her room. In an interview on 12/13/23 at 1:00 pm, Staff 19 (MT) indicated she was unable to find an order for Resident 14 to self-administer his/her prescription or an evaluation of the resident's ability to self-administer medications. The need to complete evaluations of a resident's ability to self-administer medications at least quarterly was discussed with Staff 1 (ED) on 12/13/23. She acknowledged the findings.

o C 325:  OAR 411-054-0055 (5) Systems:  Self-Administration of Meds 1. Facility will complete evaluations for all residents that self-administer medications and ensure MD authorization is received and on file. 2. DHS, ALD, RN or designee will complete re-evaluations of resident's continued ability to self-administer quarterly and upon significant change in condition.  Service plans will be updated to reflect. 3. Quarterly and as significant changes occur 4. ED, DHS, ALD, RN or designee

Based on interview and record review, it was determined the facility failed to ensure residents who choose to self-administer their medications were evaluated quarterly to assure ability to safely self-administer medications for 1 of 2 sampled residents (#17) who self-administered medications. This is a repeat citation. Findings include, but are not limited to: Resident 17 was admitted to the facility in 02/2022 with diagnoses including hypertension and Parkinson's disease. The resident's 06/17/23 evaluation and physician orders were reviewed. The facility lacked documentation that the resident was evaluated quarterly for his/her ability to safely self-administer medications. The need to ensure residents were evaluated at least quarterly for their ability to safely self-administer medications was discussed with Staff 1 (Executive Director), Staff 37 (Associate ED), and Staff 39 (MCC Director) on 03/07/24. They acknowledged the findings.

C 325:  OAR 411-054-0055 (5) Systems:  Self-Administration of Meds 1. Community will complete evaluations for all residents that self-administer medications.   2. ALD, DHS-RN or designee will complete re-evaluations of resident's continued ability to self-administer quarterly and upon significant change in condition.  Service plans will be updated to reflect.  Community DHS-RN has received training on requirements for medication self-administration. 3. Quarterly and as significant changes occur 4. DHS-RN, ALD, ED or designee

Based on observation, interview, and record review, it was determined the facility failed to ensure their change of management survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C231, C260, C270, C280, C282, C290, C370, C372, and C374.

o C 455:  OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval 1. Facility will ensure the Plan of Correction is implemented 2. System reviewed by ED 3. Status checks will be done daily until substantial compliance is met 4. ED will ensure corrections are completed/monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 260 , C 280 , C 325 , and C 372 .

C 455:  OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval 1. Facility will ensure the Plan of Correction is implemented 2. System reviewed by ED 3. Status checks will be done daily until substantial compliance is met 4. ED will ensure corrections are completed/monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 260.

1. This facility will ensure that the Plan of Correction for C260 tag will be implemented. 2. Systems will be reviewed by Executive Director, Associate Executive Director, and Administrator. 3. Plan of correction checks will be done daily until substantial compliance is met. 4. Executive Director, Associate Executive Director, Assisted Living Director, Director of Health Services, Administrator or designee will ensure these corrections are implemented & monitored.

The findings of the re-licensure survey, conducted 08/08/23 through 08/11/23, 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 A situation was identified where there was a failure of the facility to comply with the Department's rules that was likely to cause residents serious harm. An immediate plan of correction was requested in the following area: OAR 411-054-0045 (1)(B) Delegation and Teaching. The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the first re-visit to the re-licensure survey of 08/11/23, conducted 12/11/23 through 12/13/23, 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 second re-visit to the re-licensure survey of 08/11/23, conducted 03/06/24 through 03/07/24, 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 third re-visit to the re-licensure survey of 08/11/23, conducted  through 05/13/24 through 05/15/24, 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 fourth re-visit to the re-licensure survey of 08/11/23, conducted on 07/17/24, 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.