Sheridan Assisted Living

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 07/15/25 at 10:50 am, the facility kitchen was observed to need cleaning the following areas: * Ceiling vents at entrance to kitchen – heavy layer of dust; * Front of dishwashing machine – drips/spills; * Wall above splash guard behind spray hose – caulking with black matter build up; * Exterior of garbage disposal – build up of food spills/drips; * Hood above dishwashing machine – build up of dust; * Microwave interior and exterior – food splatters/handle sticky; * Commercial can opener – blade finish worn off/housing with significant build up of black matter; * Waffle iron exterior – build up of dried food batter; and * Walk in refrigerator fan – build up of dust. Other areas of concern included: * Clean flatware stored with eating portion up creating potential for cross contamination; * Dishwashing machine leaking – tub below catching water from piping; * Two small refrigerators on counter in service line area without interior thermometers; and * Lack of facial hair restraints. The areas of concern were observed and discussed with Staff 1 (Dietary Serviced Director) and discussed with Staff 2 (Executive Administrator) on 07/15/25. The findings were acknowledged.

The facility acknowledges the cited deficiencies and is committed to correcting and maintaining compliance with all health and safety standards. A comprehensive action plan is outlined below. 1) Deep Cleaning and Maintenance - Completed on 7/20/2025 The following areas have been thoroughly cleaned and sanitized: • Ceiling vents at kitchen entrance • Front and hood of dishwashing machine • Wall above splash guard and caulking behind spray hose • Exterior of garbage disposal • Microwave (interior and exterior) • Commercial can opener (cleaned; replacement blade ordered) • Waffle iron disposed of and replaced • Walk-in refrigerator fan a) Clean Flatware Storage - Corrected by 07/16/25 *Flatware is now stored with eating portions down to prevent contamination. b) Dishwashing Machine Leak *Leak was assessed by maintenance and is in process of being repaired.To be monitored daily for signs of recurring leaks. c) Refrigerators Missing Thermometers - Corrected on 07/17/25 *Interior thermometers have been installed in both small refrigerators. d) Facial Hair Restraints - Implemented on 07/16/25 *All dietary staff with facial hair have been reminded to wear appropriate facial hair restraints while on duty. Supplies provided and staff re-trained. 2) The Dietary Services Manager (DSM) is responsible for overseeing the daily operations of the Dietary Services department, ensuring that all kitchen practices and protocols comply with the Food Sanitation Rules (OAR 333-150-0000), under the supervision of the Administrator. The DSM ensures that all cleaning tasks are completed, checklists are signed, and records are properly documented in the daily logs. The Administrator or their designee conducts daily check-ins with the DSM to discuss departmental needs, set goals, and provide oversight. During these check-ins, the Administrator verifies that the DSM is reviewing cleaning checklists and ensuring proper documentation. a) DSM is responsible for visual inspections during each meal service. b) Maintenance Director is responsible for maintenance log and follow-up inspection and continued monitoring. c) DSM verifies thermometers logged and checked twice daily. d) Administrator verifies staff grooming compliance checks added to kitchen audits. 3. The DSM, Maintenance Director, and Administrator are responsible for overseeing these processes on a daily basis. 4. The DSM and Maintenance Director ensures the above processes are occurring, with oversight from the 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 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the re-licensure survey, conducted 03/03/25 through 03/06/25, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations. Refer to the deficiencies identified in the report.

1. The Administrator or designee oversees the daily operations of the community. Please refer to citations C: 200, 231, 260, 262, 270, 280, 303, 305, 310, 361, 362, 363, 370, 372, 374, 420, 610, 613. 2. Please refer to citations C: 200, 231, 260, 262, 270, 280, 303, 305, 310, 361, 362, 363, 370, 372, 374, 420, 610, 613. 3. Daily, weekly, monthly. 4. The Administrator.

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

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 and interview, it was determined the facility failed to ensure the residents right to be given informed choice and opportunity to select food choices for 1 of 1 sampled resident (#4) who had a modified diet. Findings include, but are not limited to: Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The resident was identified in the acuity interview to receive a modified diet. Meal observations were completed and interviews with staff and the resident were conducted from 03/03/25 through 03/06/25, and identified the following: On 03/03/25, Resident 4 was observed to receive a bowl that contained cream colored textured food and stated s/he “[thought] it [was] chicken” and s/he was “tired of chicken” or “whatever this is.” On 03/04/25, Resident 4 stated s/he ordered “french toast” for breakfast, however staff told the resident they “couldn’t have french toast” and was served cream of wheat. The resident was served pureed chicken for lunch and stated s/he ordered “something else and this is what [s/he] got”. On 03/04/25, Staff 21 (Dietary Aide) stated the resident requested food s/he cannot have so staff prepare something else. On 03/05/25, Resident 4 stated s/he “[checked] multiple items on the menu” and “only [got] one thing”. Staff 21 confirmed the resident did not receive what s/he ordered for lunch and instead was provided pureed chicken. On 03/06/25, Resident 4 was served pureed barbeque chicken for lunch and was not given informed choice or opportunity to select his/her food choices. The need to ensure residents were given informed choice and opportunity to select food choices was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. An Individual Nutrition/Hydration Plan form has been developed for Resident 4. The Dietary Director interviewed the resident to identify the residents preferences. The dining staff and care staff have been in-serviced on what is a pureed diet. Consultant provided an example of pureed diet for training.The administrator has been observing meal service and the pureed food provided. The diet order is in place and posted in the kitchen. 2. All diet orders will be reviewed and verified. Dining staff and care staff training on the different types of diets and expectations. The diet resources have been placed in kitchen for easy reference. Diet training will happen with onboarding for dining staff and care staff. Dining manager is scheduled to do rounds to ensure the food is served as ordered. Feedback will be provided from residents individually, through food committee and town hall. 3. Daily, weekly, monthly. 4. Administrator and Dietary Services Director

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.

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

Based on interview and record review, it was determined the facility failed to promptly investigate incidents to rule out abuse or neglect and report incidents 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 (#4) who had a puree diet. Findings include, but are not limited to: Resident 4 moved into the facility in 11/2024 with diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. Additionally, the resident was admitted with a puree diet. The resident’s clinical record including, observation notes dated 12/03/24 through 03/03/25, and temporary service plans were reviewed. The following was identified: * 12/07/24 - “...resident was eating [solid food] in [his/her] room and [had] choking issues”; and * 12/29/24 - “resident was choking in the dining room cause the kitchen gave her mechanical soft instead of puree”. On 03/06/25 at 11:40 pm, Staff 3 (Wellness Director) stated there was no documented evidence either event was investigated to rule out abuse or neglect. On 03/06/25 at 12:27 pm, Staff 1 (ED) confirmed the events were not investigated to rule out abuse or neglect and the event on 12/07/24 was not reported to local SPD. Staff 1 provided documentation the event on 12/29/24 was reported on 03/05/25, after survey requested documentation. The need to promptly investigate injuries of unknown cause with all required components and report the incidents to the local SPD office if abuse or neglect could not be ruled out, was discussed with Staff 1, Staff 3, and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1.Resident 4 12/29/2024 incident has been investigated and reported to APS. The APS report was submitted during the survey on 3/5/2025. Refer to C200. The dining staff and care staff have also been in-serviced on reporting/indentifying abuse and neglect, how to respond to choking and abdominal thrust. 2. Refer to C200. Incidents reviewed daily by the clinical team during morning stand-up. Investigations completed within 24 hours of incident and reported to local SPD when unable to rule out abuse, neglect or injuries of unknown cause. Staff training completed on reporting/identifying abuse and neglect, how to respond to choking and abdominal thrust. 3. Daily, monthly. 4. Administrator, WD

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

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

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services, and the facility administrator was responsible for ensuring the implementation of services for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2020 with diagnoses including chronic diastolic (congestive) heart failure, malignant neoplasm of unspecified ovary, and shortness of breath. Additionally, the resident’s hospital discharge notes included a diagnosis of chronic obstructive pulmonary disease (COPD). Interviews with the resident and facility staff were conducted. The current service plan dated 01/24/25 was reviewed. Resident 1's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Instructions on edema management; * Smoking; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Oxygen equipment precautions, instructions for proper maintenance, and how to monitor for safety; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Instructions on proper maintenance of nebulizer used for breathing therapy; * Instructions for aspiration precautions and interventions while choking; * Number of staff needed to assist with emergency evacuations; * Instructions on to whom to report weight gain or loss; * Instructions on fall prevention; * Skin integrity and instructions on to whom to report skin impairments; * Incorrect reference to existence of a chemotherapy port; * Incorrect reference to not having a dog; and * Number of staff needed to assist with transfers to wheelchair. The facility stores resident care plans in an electronic database and makes available to staff a portion of the service plans, referred to by the facility as Active Cares, by storing them in a binder located in the staff break room. Therefore, Resident 1’s full current service plan was not included in the binder and not available to facility staff at the time of the survey. The need to ensure service plans were readily available to staff, reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including opioid dependence and major depressive disorder. The service plan dated 02/04/25, temporary service plans and observation notes dated 12/04/24 through 03/01/25 were reviewed. Interviews with care staff were completed. The resident's service plan was not reflective and/or failed to provide clear instruction to staff, and/or the facility administrator was responsible for ensuring the implementation of services in the following areas: * Oral care; * Behavioral monitoring; * Safety checks; and * Safety plan. The service plan instructed staff to provide behavior monitoring daily at 5:00 am, 1:00 pm and 9:00 pm. Review of the service plan “Task Administration Record” was completed from 12/01/24 through 02/28/25 and revealed behavior monitoring took place six times during the time period reviewed. In an interview with Staff 18 (MT) on 03/06/25, at 11:10 am, it was confirmed that the behavioral monitoring was not being done daily. The need to ensure service plans were reflective of the resident's care needs and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. The findings were acknowledged. 3. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. The service plan dated 02/28/25, temporary service plans and observation notes dated 12/04/24 through 03/01/25 were reviewed. Interviews with care staff were completed. The resident's service plan was not reflective, failed to provide clear instruction to staff, and/or the facility administrator was responsible for ensuring the implementation of services in the following areas: * Wound care and precautions; * Home health services; * Fall interventions; and * Catheter care. A progress note dated 12/25/24 documented “resident’s catheter bag was not emptied on day shift, resident told me day shift kept telling him/her they were busy and couldn’t empty it, or they would come back to empty it but never did”. Review of the service plan “Task Administration Record” for December 2024 indicated Resident 3’s catheter bag was to be emptied twice each shift, documented when completed, and if there was no urine output to report to the nurse. The task was left blank 89 times in December 2024. The need to ensure service plans provided clear instruction to staff and were followed was reviewed on 03/05/25 with Witness 1 (RN Consultant) and on 03/06/25 with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN). They acknowledged the findings. 4. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The current service plan dated 02/06/25 and temporary service plans were reviewed, observations were made, and interviews with the resident and facility staff were conducted. The following was identified: a. The resident’s current service plan, dated 02/06/25, was not available to staff. b. The resident’s service plan lacked resident specific instruction and/or was not reflective of the resident’s current status in the following areas: * Use of Hoyer including the risks, benefits, and safety instructions; * Use of hospital bed and side rails including the risks, benefits, and safety instructions; * Use of assistive devices including contracture cushion for left hand and leg brace; * Incontinent care including incontinent checks and resident specific instruction; * Bowel care instruction and monitoring; * Behavior interventions including frequency of checks; * Instruction relating to “promptly answer call lights”; * Resident specific bathing instruction including use of bed for bed baths; * Use of “puffy socks” and pillows while in wheelchair; * Instruction relating to taking all vitals twice daily; * Use of resident’s personal beverage cups and straws including cleaning instruction; and * Resident’s current smoking status. The need to ensure the resident’s service plan was available to staff, provided resident specific instruction, and was reflective of the resident’s current status, was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Resident 1 (CB) deceased as of 3/7/2025. Resident 2 (TD), 3 (SG) (completed) and 4 (CM) service plans will be updated to reflect resident's current status and needs, provide clear resident specific instructions to staff regarding delivery of services and implementation of services by alleged compliance date. Service plans placed in service plan binder, located in the employee breakroom and is available to staff. All other service plans are under review for accuracy and will be completed by the alleged compliance date. The binder also includes any pertinent instructions from hospital, home health, hospice, behavioral support, and community nurse. Care staff and Med Techs in-serviced on following care plans, EMAR and proper documentation. 2. All service plans are printed, kept in a service plan binder and availble to staff. Service plans are printed any time a TSP, Signficant change of condition, or any other change is made to the service plan. An acknowledgement form for staff to sign will be kept with service plans. RCC and WD review dashboard to EMAR daily to ensure proper documentation and care plans being followed. 3. Daily, weekly, monthly. 4. Administrator, WD, RCC

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

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

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who was familiar with, or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to: Resident 1, 2, 3 and 4's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. No further information was provided.

1. Refer to C260. Service plans will be developed and reviewed for residents 2, 3, and 4 by a Service Planning Team that consists of the resident, legal representative (if applicable) any person of the resident's choice, Administrator or designee and one other staff person familiar with services provided to the resident by alleged compliance date. 2. Going over upcoming service plan review and due date report from ECP dashboard during daily stand-up clinical meeting. A tracking sheet of service conferences will be maintained. Caseworkers will receive monthly notifications about upcoming service conferences and are encouraged to attend if possible. 3. Daily, weekly, monthly. 4. Administrator, WD, RCC

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

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

Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2020 with diagnoses including chronic diastolic (congestive) heart failure, malignant neoplasm of unspecified ovary, and shortness of breath. Additionally, the resident’s hospital discharge notes included a diagnosis of chronic obstructive pulmonary disease (COPD). Clinical records, including the current service plan, TARs from 12/01/24 through 02/28/25, observation notes from 12/03/24 through 03/03/25 were reviewed, and interviews with the resident and facility staff were conducted. The following short-term changes of condition 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/or documented weekly progress until the condition resolved: * 12/06/24: return to the facility after ER visit related to exacerbation of chronic obstructive pulmonary disease (COPD); * 01/08/25: return to the facility after oncology visit and started new medication Cyclophosphamide 50mg (for malignant neoplasm); * 01/16/25: return to the facility after ER visit related to chest pain and shortness of breath; * 01/19/25: choking episode; * 02/08/25: blood pressure 80/53 mm/Hg (outside normal parameters); * 02/10/25: blood pressure 87/52 mm/Hg (outside normal parameters); * 02/15/25: smoking in the room; * 02/17/25: blood pressure 67/36 mm/Hg (outside normal parameters); * 02/19/25: no bowel movement for three consecutive days; * 02/21/25: blood pressure 84/51 mm/Hg (outside normal parameters); * 02/23/25: returned from ER with diagnosis of brain transient ischemic attack (TIA) and COPD exacerbation; and * 02/26/25: blood pressure 86/49 mm/Hg (outside normal parameters). The need to ensure the facility 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 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 12/2021 with diagnoses including opioid dependence and major depressive disorder. The resident’s clinical record, including the current service plan dated 02/04/25, observation notes dated 12/01/24 through 03/01/25, alert charting notes dated 12/16/24 through 02/25/25, Task Administration Record dated 12/01/24 through 02/28/25, temporary service plans were reviewed, and facility staff were interviewed. The following short-term changes of condition 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/or documented weekly progress until the condition resolved: * 12/16/24: experienced a sudden loss; * 01/14/25: new medication (docusate); * 01/20/25: missed 8 am medications; * 01/26/25: unwitnessed fall; * 02/04/25: resident to resident altercation; * 02/21/25: smoking in apartment; and * 02/24/25: missed 12 pm medications. The need to ensure the facility determined and documented resident-specific actions or interventions needed for changes of condition, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. The findings were acknowledged. 3. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. Clinical records, including the current service plan, TARs from 12/01/24 through 02/28/25, home health notes, observation notes from 12/03/24 through 03/03/25 were reviewed, and interviews with the resident and facility staff were conducted. The following short-term changes of condition 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/or documented weekly progress until the condition resolved. * 12/24/24: discovery of open wound; * 12/29/24: discovery of four inch open wound and ulceration at suprapubic catheter site; * 01/09/25: discovery of a wound on head; and * 01/25/25: discovery of a wound on leg. On 02/28/25, an RN assessed Resident 3’s skin and identified six wounds, and additional wounds covered with dressings. On 03/04/25, Witness 1 (RN Consultant) reviewed Resident 3’s medical record, and was not able to find documented evidence the wounds had been evaluated when discovered or had individual weekly monitoring until resolution. In interview on 03/05/25, Staff 3 (Wellness Director) acknowledged there was not consistent documented monitoring of the wounds prior to the RN assessment on 02/28/25, and the wounds were now being treated and monitored. The need to ensure the facility determined and documented resident-specific actions or interventions needed for changes of condition, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved was reviewed on 03/05/25 with Witness 1 (RN Consultant), and on 03/06/25 with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN). They acknowledged the findings. 4. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The resident’s clinical record, including the current service plan dated 02/06/25, observation notes dated 12/03/24 through 03/03/25, and interim service plans (ISPs) were reviewed. The following was identified: The following changes of condition lacked documentation the change of condition was identified, included resident-specific actions or interventions, and/or was monitored consistent with his/her evaluated needs through resolution: * 12/07/24: Choked on cereal in room; * 12/28/24: Missed medication; * 12/29/24: Choked in dining room, was provided incorrect texture diet; * 12/29/24: Multiple missed medications; * 01/02/25: Float heels, use pillow while in wheelchair; * 02/02/25: Painful urination; * 02/02/25: Start of antibiotics for infection; * 02/06/25: Skin condition in peri area; * 02/09/25: New redness inner thighs; * 02/26/25: Return from hospital new diagnosis; * 02/28/25: Multiple new medications; and * 03/01/25: Start taking a full set of vitals twice daily. The need to ensure residents who experienced changes of condition were monitored consistent with their evaluated needs through resolution and resident specific interventions were determined and implemented was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Resident 1 (CB) deceased as of 3/7/2025. Service plans and TSP's will be reviewed and updated for residents 2, 3, and 4 including any COC by alleged compliance date. Alert monitoring tracking sheet also implemented. 2. Med Tech's and Care staff have been in-serviced on the use of approved Temporary Service Plan (TSP) form and when to notify RCC and Nurse using the Nurse reporting guidline form. Med Tech's in-serviced on alert charting following the Alert Charting Guidelines. WD and RCC review ECP recent notes daily and the alert monitoring tracking sheet. WD and RN keep a white board of all skin concerns and provide weekly skin/wound monitoring. Med Tech's and care staff in-serviced on when and how to report any unusual or sudden changes in residents physical or mental condition to nurse to ensure timely assessment and intervention. RN to complete Significant change of condition assessment as required per policy and OAR. 3. Daily, weekly, monthly. 4. Administrator, RN, WD, RCC

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

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

Based on interview and record review, it was determined the facility failed to ensure an RN completed an assessment which documented findings, resident status, and interventions made as a result of the assessment for 2 of 3 sampled resident (#s 1 and 3) who experienced significant changes of condition related to loss/gain of weight. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2020 with diagnoses including chronic diastolic (congestive) heart failure, malignant neoplasm of unspecified ovary, and shortness of breath. Additionally, the resident’s hospital discharge notes included a diagnosis of chronic obstructive pulmonary disease (COPD). Clinical records, including the current service plan, dated 01/24/25, TARs from 12/01/24 through 02/28/25, and physician orders were reviewed. According to the resident's TARs, the resident's weight was scheduled to be taken on the third Wednesday of each month. The following weights were recorded by the facility: * 09/18/24 – 106.5 pounds; * No weight was recorded in 10/2024; * 11/26/24 – 118.0 pounds; * 12/30/24 – 118.5 pounds; * 01/15/25 – 119.0 pounds; * 01/19/25 – 0 pounds; and * 02/19/25 – 119.0 pounds. The resident experienced a 12.0 pound weight gain, or 10.12% of his/her total body weight, in three months (09/18/24 through 12/30/24). This represented a significant change of condition. There was no documented evidence the facility RN conducted assessments which included documentation of findings, resident status, and interventions made as a result of the assessments. The resident refused to be weighed and ate independently in his/her room. The need to ensure an RN assessment was completed for all residents who experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. 2. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. Clinical records, including the current service plan, TARs from 12/01/24 through 02/28/25, observation notes from 12/03/24 through 03/03/25 were reviewed, and interviews with the resident and facility staff were conducted. The following changes of condition were identified: a. The following weights were recorded by the facility: * 11/26/24 - 370 lbs; * 12/30/24 - 375 lbs; * 01/15/25 - 356 lbs =19 pound or 5% weight loss; and * 02/26/25 - 380 lbs = 24 pound or 6.75% weight gain. The resident experienced a 19 pound weight loss, or 5% of his/her total body weight, in 15 days (12/30/24 through 01/15/25), and a 24 pound gain, or 6.75% weight gain in one month (01/15/25 through 02/26/25). A meal observation was completed at 12:45 on 03/04/25, Resident 3 ate independently, and completed close to 100% of the meal. A second meal observation was completed on 03/05/25, Resident 3 ate approximately 75% of the meal independently. The most recent weight available for Resident 3 was taken on 02/26/25 and recorded as 380 lbs. There was no documented evaluation of the weight changes. The unexplained weight changes constituted significant changes of condition. There was no documented evidence the facility RN assessed the weight changes, including documentation of findings, resident status, and interventions made as a result of the assessments. b. On 01/13/25 Resident 3 was admitted to the hospital. Observation notes dated 01/14/25 documented: “mobility needs have changed... one person assist with all transfers and wheelchair necessity not walker”. Resident 3 returned to the facility on 01/15/25 with five medication changes, using a wheelchair instead of a walker, and requiring a one person assist with ADLs they had been previously independent with. The changes constituted a major deviation from the most recent evaluation that affected multiple areas of functioning and were not expected to be short term. There was no documented evidence the facility RN assessed the changes, including documentation of findings, resident status, and interventions made as a result of the assessments. c. On 02/13/25 Resident 3 was hospitalized. An observation note dated 02/17/25 documented “Change of Condition Assessment needed by RN due to coming back with oxygen orders of 2 liter continuous” and while at the hospital “had 10 liters of fluid removed and IV antibiotics”. A change of condition evaluation was completed by Staff 25 (RN) three days later, on 2/20/25, and documented Resident 3 had not had any hospital admissions in the past year. The need to ensure a timely and accurate RN assessment was completed for all residents who experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 3:28 pm. They acknowledged the findings.

1. RN completed COC evaluation and updated service plan for resident 3. 2. RN to be available on site per new position at 40hrs per week and available by phone after hours. New RN will be trained for timely and accurate review of weight monitoring in EHR system, and the new RN will be signed up to attend the OHCA Role of the Nurse class if not previously completed in the last 365 days. New WD/LPN will be trained on when to report potential COC to RN for assessment. Nurse (LPN or RN) to review all return paperwork from hospital visits (ER) or hospital admissions to determine appropriate montioring, interventions or need of COC assessment by RN for return to facility. White board monitoring system for residents who have had a recent COC to continue montioring and assessment of interventions effectiveness and return to baseline. 3. Daily, weekly, monthly. 4. Administrator, RN, WD, RCC

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

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

Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 3 of 5 sampled residents (#s 3, 4, and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. Physician orders and MARs, reviewed from 02/01/25 through 03/03/25, revealed the following medications were being administered by the facility: * Furosemide 20 mg tab (diuretic); and * Supplemental oxygen (continuous). In interview on 03/05/25, Witness 1 (RN Consultant) was unable to locate a signed order for the medications. During an interview on 03/06/25 at 11:00 am, Staff 3 (Wellness Director) was not able to locate a signed order for the medications. In interview on 03/06/25, Staff 3 stated if the signed orders could not be located, new copies of the orders would be obtained. The lack of an order for the medications was reviewed 03/06/25 with Staff 1 (ED), Staff 3, and Staff 25 (RN). They acknowledged the findings. 2. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The resident’s record was reviewed and interviews with staff were conducted and identified the resident did not have current signed physician orders. On 03/04/25 at 11:17 am, Resident 4’s signed physician orders were requested, and Staff 5 (RCC) stated the resident was in-between physicians and the facility did not have current signed orders. On 03/06/25 at 1:26 pm, Staff 3 (Wellness Director) confirmed the resident did not have current signed physician orders. The need to ensure signed physician orders were documented in the resident's facility record was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 09/2017 with diagnoses including type 2 diabetes mellitus. Facility staff administered insulin to the resident three times daily. a. Review of Resident 5's medical record, current physician orders, dated 11/15/24, and MAR from 02/01/25 through 02/28/25 revealed Humalog suspension 100 unit/ml (to control blood glucose level) was ordered to “…inject 6 units subcutaneously two times daily at lunch and dinner. Hold if CBG is less than 80 or if resident is not eating meal.” In an interview on 03/05/25 at 12:40 pm, the resident stated s/he “usually” eats meals in the room and staff administers insulin injections prior to eating meals. The timing of administration of insulin injections was confirmed by review of the facility Med Pass history record. The insulin injections were administered prior to meal delivery times as observed by the survey team during the survey visit. During the interview on 03/05/25 at 1:07 pm, Staff 18 (MT) stated the facility does not keep track of timing or amount of food intake. b. Blood sugar checks (CBG's) were ordered before lunch and dinner (for diabetes). The physician and RN were to be notified of any CBG below 70 or above 400. There was no documented evidence the facility notified the physician of blood sugars above 400 on 17 occasions. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings.

1. The following (a-h) have been completed. a. Complete EMAR audit to be completed by RN. Review for appropriate orders, indication, directions, interventions and administration steps for multiple orders with same indication to be evaluated. b. Nursing to review for oxygen use in facility with correlating MD order and EMAR directions. c. 90 day orders faxed to all providers for review and signatures. Tracking sheet for processing of 90 day orders maintained. Signed orders then faxed to pharmacy for update. This shall be completed on a 90 day basis by LPN, RCC or designee. d. Complete review of med room processes and box system reimplemented. Filing system reviewed for accuracy and timliness. Accurate purging system implemented to assure orders processed and filed timely. e. RCC training completed by RN for appropriate steps on processing orders, verifying accuracy and pharmacy medication check-in review 3/21/25. f. Current signed physician orders received for resident 4. g. Communication with PCP for directions on resident 5. h. Humalog directions/notifications clarified. PCP states only to notify of CBG that is above 500 or below 70. RN implemented required Question attached to CBG order for MT to indicate if PCP was notfified via Fax or call regarding above PCP parameters. Hold orders for "not eating" removed. 2. The above systems are implemented. 3 check system in place for all orders. Dashboard monitoring daily. 90 Day physician orders sent out and tracked back by RCC. Then given to the nurse for review. 3. Daily, weekly, monthly. 4. Administrator, RN, WD, RCC

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

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

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 3 of 4 sampled residents (#s 1, 3, and 4) who had documented medication and/or treatment refusals. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The resident's February MAR dated 02/01/25 to 02/28/25 and “Physician Order Sheet” dated 02/15/25 was reviewed and identified Resident 4 refused his/her scheduled Polyethylene glycol powder (for constipation) on 25 occasions. On 03/05/25 at 9:57 am, Staff 19 (MT) confirmed the lack of prescriber notification. The need to ensure the physician or other practitioner was notified when a resident refused consent to orders was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 03/2020 with diagnoses including chronic diastolic (congestive) heart failure, malignant neoplasm of unspecified ovary, and shortness of breath. Additionally, the resident’s hospital discharge notes included a diagnosis of chronic obstructive pulmonary disease (COPD). Resident 1's MARs from 02/01/25 through 02/28/25 and corresponding Med Pass History from 02/01/25 through 03/02/25 were reviewed. The resident's records showed the following medication and treatment refusals: * Nicotine transdermal patch (for nicotine dependence) on 20 occasions; * Trelegy Ellipta (breathing treatment) on two occasions; * Ipratropium/Albuterol (breathing treatment) on two occasions; and * Calmoceptine ointment (for skin care) on 23 occasions. There was no documented evidence the facility notified the physician or other practitioner each time the resident refused to consent to the orders. The need to ensure the facility notified the physician or other practitioner of medication and treatment refusals was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. 3. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. Resident 3's MARs from 02/01/25 through 02/28/25 and corresponding Med Pass History from 02/01/25 through 03/02/25 were reviewed. The resident's records showed the following medication and treatment refusals: * Mupirocin 2% ointment (for skin care) on 19 occasions; and * Zinc Oxide 40% cream (for skin care) on 21 occasions. There was no documented evidence the facility notified the physician or other practitioner each time the resident refused to consent to the orders. The need to ensure the facility notified the physician or other practitioner of medication and treatment refusals was reviewed on 03/05/25 with Witness 1 (RN Consultant) and on 03/06/25 with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN). They acknowledged the findings.

1. Med Techs re-instructed on daily notifications of medications refused, unless otherwise noted by the PCP. Faxes were sent to PCP's to clarify their preference of refusal notifications and if other than daily, this will be added to EMAR to prompt for notification. Company form for refusals was re-implemented and Med Techs trained on it's use 3/20/25 by RCC and RN. 2. For residents with frequent refusals- parameters for notification are requested from provider. For consistent refusals of certain medications, a request for provider review of appropriateness of continued order are sent. If refusals are deemed to be behavioral in nature, a consideration for Behavioral Support is made. 3. Daily, weekly, monthly 4. Administrator, WD, RCC

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

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters and contained reasons for use for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including opioid dependance and major depressive disorder. Resident 2's MARs from 02/01/25 through 02/28/25, corresponding Med Pass History from 02/01/25 through 03/02/25, and physician orders were reviewed and revealed the following: a. The following medications lacked documented reasons for use: * Sucralfate 1 gm (for ulcers); * Donepezil 10 mg (for cognition); * Memantine HCL 10 mg (for memory); * Polyethelene glycol 17 gm (for constipation); * Secura protective 10% cream 1 gm (for skin rash); and * Metamucil 3.4 gm (for constipation). The need to ensure MARs included reasons for use was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. The findings were acknowledged. b. Resident 2 was prescribed docusate sodium, Metamucil, and polyethylene glycol for constipation. There were no parameters listed on the MAR for the PRN bowel medications instructing staff which should be used first. In an interview with Staff 18 (MT) on 03/06/25, at 11:10 am, it was confirmed that the electronic MAR did not contain any additional information for staff as to which PRN bowel medication to use first. The need to ensure MARs included resident-specific parameters for all PRN medications was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. The findings were acknowledged. 2. Resident 1 was admitted to the facility in 03/2020 with diagnoses including chronic diastolic (congestive) heart failure, malignant neoplasm of unspecified ovary, and shortness of breath. Additionally, the resident’s hospital discharge notes included a diagnosis of chronic obstructive pulmonary disease (COPD). Resident 1's MARs from 02/01/25 through 02/28/25, corresponding Med Pass History from 02/01/25 through 03/02/25, physician orders were reviewed and revealed the following medications lacked documented reasons for use: * Pregabalin 50mg (for nerve pain); * Midodrine 5mg (for lower blood pressure); * Ipratropium/Albuterol 0.5-2.5mg (for difficulty breathing); * Omeprazole 20mg (for gastro-esophageal reflux); * Ropinirole 1mg (for restless leg syndrome); * Trelegy Ellipta 100-62.5-25 mcg (for COPD); * Cyclophosphamide 50mg (for malignant neoplasm); * Furosemide 40mg (diuretic); * Prednisone 50mg (anti-inflammatory); * Ketotifen 0.025% (for dry eyes); and * Betameth Dip Aug 0.05% (for rash). The need to ensure MARs for each resident that the facility administers medications to include reason for use was reviewed with Staff 1 (ED), Staff 25 (RN), and Staff 3 (Wellness Director) on 03/06/25 at 1:28 pm. They acknowledged the findings. 3. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. Resident 3's MARs from 02/01/25 through 02/28/25, corresponding Med Pass History from 02/01/25 through 03/02/25, and physician orders were reviewed and revealed the following medications lacked documented reasons for use: * Pregabalin 150 mg (anticonvulsant); * Aspirin 81 mg (analgesic); * Metoprolol 25 mg (blood pressure); * Mupirocin ointment (skin care); * Sertraline 100 mg (anti-depressant); * Pantoprazole 20 mg (proton pump inhibitor); * Desitin 40% paste (skin care); * Ferrous Sulfate (iron supplement); * Amiodarone 200 mg (cardiac Rythm); * Levofloxacin (anti-biotic); and * Furosemide 20 mg (diuretic). The need to ensure MARs for each resident the facility administered medications to included reason for use was reviewed on 03/05/25 with Witness 1 (RN Consultant) and on 03/06/25 with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN). They acknowledged the findings. 4. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. The resident's February MAR dated 02/01/25 to 02/28/25 and “Physician Order Sheet” dated 02/15/25 were reviewed and identified the following: Resident 4 was prescribed senna, polyethylene glycol powder, lactulose, sodium phosphate enema, and bisacodyl suppository for constipation. There were no parameters listed on the MAR for the PRN bowel medication that instructed staff what to administer first and in what order. The need to ensure MARs included resident-specific parameters for all PRN medications was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. EMAR audit to be completed for residents 2, 3, and 4 by RN by alleged compliance date. Review for appropriate orders, indications, directions, interventions and administration steps for multiple orders with same indication to be evaluated. 2. Full EMAR audit reviewing appropriate orders, indications, directions, interventions and administration steps are accurate for all residents will be done by alleged compliance date. MT/RCC trained on proper pharmacy check-in and appropriate review of orders as a part of the three check process. Medications dashboard report review as part of daily clinical meeting. 3. Daily, weekly, monthly. 4. Administrator, RN, WD, RCC

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted.

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 and discussed by phone with Staff 26 (Vice President of Health Services) on 03/05/25 at 12:25 pm. The facility had implemented the Department’s ABST tool. The following was identified: * Seven former residents were entered into the ABST tool; * Five unsampled residents were not entered into the ABST tool; and * One sampled Specific Needs Contract resident (#4) had not been entered into the tool. The need to implement an ABST which met the regulation was discussed with Staff 26 (Vice President of Health Services) on 03/05/26 at 12:25 pm, and Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. They acknowledged the findings.

1. ABST fully updated on 3/12/25 removing any former residents and adding any current residents that were not entered yet. The remainder of the residents were reviewed and updated using caregiver reports on multiple shifts and while reviewing service plans in conjunction. Schedule and staffing have been updated to meet the needs in relation to ABST. RCC has the duty of maintaining the ABST with oversight of nurse and Administrator. 2. The ABST is updated promptly as changes occur ensuring reflecting current needs. The Administrator will assure that the RCC takes company training in relation to the ABST. New RCC and WD will be trained on the ABST. 3. Daily, weekly, monthly. 4. Administrator, WD, RCC

OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Address and document all individual ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete each care element for each resident. (D) Ensure the ABST can present the total time, in minutes, required to meet the scheduled needs for all residents, 24 hours a day, seven days a week, preferably per shift, per day. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the ABST Proprietary Department Review Request (PDRR) Form, including but not limited to the following: (A) All facilities which currently have implemented a proprietary ABST must submit a PDRR Form no later than August 31, 2024. Facilities which do not submit a request on or before August 31, 2024, will be subject to corrective action as outlined in paragraph (9) of this rule. (B) Completed ABST PDRR Form. (C) Sample ABST report displaying all the ABST care elements listed in paragraph (3) of this rule, and the estimated staff time needed to complete each care element, shown per day, in minutes. Although not required, it is preferred that staff time be shown per shift, per day, in minutes. (D) The facility’s ABST policy required under OAR 411-054-0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement. The summary statement must be available upon request by the Department. An ABST summary statement must contain a general guide of how the ABST functions, as outlined on the PDRR form. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the design of its proprietary ABST that impacts the ABST’s functionality and if such changes would make the information submitted in support of its approval inaccurate or invalid, the facility must re-submit the ABST PDRR Form as described in this rule to the Department for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted.

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 interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff provided to each resident as outlined in each individual service plan for 2 of 4 sampled residents (#s 3 and 4) whose ABST was reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the facility in 11/2024 with diagnosis including chronic obstructive pulmonary disease (COPD), respiratory failure, spastic hemiplegia, and dysphagia. On 03/05/25, the facilities ABST was reviewed and identified Resident 4 had not been entered into the ABST. Therefore, there was no documented evidence the facility accurately captured care time and/or care elements that staff provided to the resident. The need to accurately capture care time and care elements on the resident's ABST was discussed with Staff 1 (ED), Staff 3, and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings. Resident 3 was admitted in 09/2024 with diagnosis including diabetes, cardiomegaly, and kidney disease. 2. On 03/05/25, the facilities ABST was reviewed and identified Resident 3’s ABST had not been updated since 11/2024 and was not updated with a significant change in condition on 02/28/25. Resident 3’s service plan showed staff assistance was required in the following areas, but was not accounted for on the ABST: * Transferring in or out of bed or chair; * Dressing and undressing; and * Grooming such as nail care and brushing hair. The need to accurately capture care time and care elements on the resident's ABST was discussed with Staff 1 (ED), Staff 3, and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Resident 3 was updated on the ABST specifc to the items mentioned in the SOD. Resident 4 is under our specific needs contract and does not get entered into ABST. The remainder of the residents were reviewed and updated using caregiver reports on multiple shifts while reviewing service plans in conjunction. Schedule and staffing have been updated to meet the needs in relation to ABST. 2. The new RCC will be trained on the ABST and will update daily as needed with move ins, move outs, or changes in care needs. 3. Daily, weekly, monthly. 4. Administrator, WD, RCC

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.

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

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated no less than quarterly for 2 of 4 (#2 and 4) sampled resident’s, multiple unsampled residents and/or with a significant change of condition for 2 of 3 residents with significant change of condition (#3 and 4). Findings include, but are not limited to: During the acuity interview at 9:52 am on 03/03/25, Staff 5 (RCC) confirmed the facility census was at 47 residents. The facility’s ABST data and posted staffing plan were reviewed at 9:50 am on 03/05/25 and revealed the following: a. One sampled resident (#4) and five unsampled residents had no ABST data. b. Seven residents who no longer resided at the facility were listed in the ABST data. c. Resident 2 had no documented evidence the ABST data had been updated quarterly. d. Resident 3 experienced a significant change of condition on 03/01/25 and there was no documented evidence the ABST data had been updated. e. Resident 4 experienced a significant change of condition on 02/26/25 and there was no documented evidence the ABST data had been updated. During an interview by phone on 03/05/25 at 12:25 pm, Staff 26 (Vice President of Health Services) stated the facility staff had been trained on the ABST and she “turned it over” to the facility and they were responsible for updating the ABST data at the same time the service plan was being updated and/or with significant change of condition. Staff 26 acknowledged the ABST findings. No additional documentation was provided. The need to ensure residents’ ABST was updated no less than quarterly and/or with significant change of condition was discussed with Staff 26 on 03/05/25 at 12:25 pm and Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 3:15 pm. They acknowledged the findings.

1. Refer to C362. All residents were updated on the ABST as well as specifc to the items mentioned in the SOD. The remainder of the residents were reviewed and updated using caregiver reports on multiple shifts and while reviewing service plans in conjunction. Schedule and staffing have been updated to meet the needs in relation to ABST. 2. The new RCC will be trained on the ABST and will update daily as needed with move ins, move outs, or changes in care needs. 3. Daily, weekly, monthly. 4. Administrator, WD, RCC

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

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

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired caregivers (#s 8 and 13) completed all required pre-service orientation training. Findings include, but are not limited to: Staff training records were reviewed on 03/04/25 at 1:00 pm with Staff 4 (Business Office Manager) and the following was identified: There was no documented evidence Staff 8 (CG hired on 11/07/24) and Staff 13 (CG hired on 12/1/24) completed the following required pre-service orientation topics prior to beginning their job responsibilities: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Written job description; and * Pre-service dementia training. There was no documented evidence Staff 13 (CG hired on 12/1/24) completed the required pre-service infectious disease prevention. The requirements for documented pre-service orientation and training for all employees were reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/6/25 at 3 pm. They acknowledged the findings.

1. Staff #8 has completed the missing pre-service orientation topics Staff #13 no longer employed. Completed a training audit to assure that all staff are trained per policy and OAR. All staff trainings to be completed by the alleged compliance date. 2. A training tracker spreadsheet has been implemented to ensure training is completed and recorded timely per OARs. Relias and Oregon Care Partners approved classes are utilized for compliance followed by company approved orientation and competencies done for each employee. 3.Daily, weekly, monthly. 4. Administrator, BOM

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

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

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 9, 11, and 17) demonstrated satisfactory performance in all assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 03/04/25 at 1:00 pm with Staff 4 (Business Office Manager) and the following was identified: There was no documented evidence staff demonstrated satisfactory performance within 30 days of hire of the following required elements: * Staff 17 (MT) hired on 1/28/25 and Staff 11 (CG) hired on 1/20/25 were missing documentation of the required “Changes associated with normal aging”; and * Staff 9 (CG hired on 1/3/25) and Staff 11 (CG hired on 1/20/25) did not have documentation of having demonstrated competency in First aid and Abdominal thrust. The requirements for documented pre-service orientation and training for employees were reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 3/6/25 at 3 pm. They acknowledged the findings.

1. Employee # 9, 11, and 17 are in process of completing all required trainings associated with the 30-day training. A complete training audit under review to assure that all staff are trained per policy and OAR. All staff to be completed by the alleged compliance date. 2.Refer to C370. Designated staff trainers perform competency checks on their department staff to observe demonstrated performance skills. 3. Daily, weekly, monthly. 4. Administrator, BOM

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

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

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 long-term staff (#14) completed 12 hours of annual in-service training, including at least six hours of dementia care, and failed to complete Home and Community Based Services training and LGBTQIA2+ inclusion training as required. Findings include, but are not limited to: Staff training records were reviewed on 03/04/25 at 1:00 pm with Staff 4 (Business Office Manager) and the following was identified: a. There was no documented evidence Staff 14 (CG hired on 05/21/22) completed at least 12 hours of training based on their anniversary date of hire related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics. The need to ensure and document that long-term direct care staff completed the required number of hours of annual in-service training and annual infectious disease training was discussed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 3/6/25 at 3 pm. They acknowledged the findings.

1. Staff member #14 has completed over 33hrs of annual in-service training related to the provision of care in CBC 10 of which are related to dementia care. HCBS and LGBTQIA2+ training to be completed by alleged compliance date. 2. Refer to C370. Annual training plan in place for all direct care staff. 3. Daily, weekly, monthly. 4. Administrator, BOM

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

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

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed between 09/2024 and 03/2025, revealed the following: a. The facility lacked documented evidence fire drills were conducted and documented every other month, with all required components. b. The facility lacked documented evidence fire and life safety training instruction was provided to staff on alternating months from fire drills. On 03/04/25 at 12:01 pm, Staff 2 (Facility Service Director) confirmed the lack of documented evidence of fire drills and fire and life safety training for staff. The need to ensure fire drills and fire and life safety training was provided and documented as required was reviewed with Staff 1 (ED), Staff 3 (Wellness Director), and Staff 25 (RN) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Effective immediately, the Maintenance Director will be conducting and documenting fire drills every other month with all required components. The Maintenace Director will also be responsible for fire and life safety training instruction alternating months from fire drills at the monthly all staff meeting. Orientation checklist has fire safety and fire locations performed by the Maintenance Director for all new staff. 2. Fire Drills and Fire and Life Safety training will alternate monthly and be completed by the end of each month and documentation will be kept together in a binder located in the BOM office. 3. Monthly 4. Administrator, Maintenance Director

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

OAR 411-054-0300 (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: On 03/04/25 at 12:34 pm, during a walk-through of the facility with Staff 2 (Facility Service Director) and Staff 24 (Facility Service Aide) the following was identified: a. The pathway along the front of the facility had multiple areas with broken material that created uneven gaps on the pathway, measured up to one and a half inches wide. This created potential fall hazards to the residents. b. There were multiple drop-offs measured up to four inches from the concrete to the ground, identified around the exterior perimeter pathways of the facility and in the interior courtyard along the concrete patio and courtyard doors. This created potential fall hazards to the residents. The need to ensure all exterior pathways were maintained in good repair was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Maintenance Director in process of repairing the broken material, uneven gaps and drop-offs on pathways along the front of the community, interior courtyard along the concrete patio, courtyard doors, and other exterior pathways by adding additional dirt, gravel and multi-bark to the mentioned areas to ensure all unsafe areas are eliminated. 2. Repair log implemented. Maintenance Director keeps track of needed upkeep, cleaning, repairs and completions. 3. Daily, weekly, monthly. 4. Administrator, Maintenance Director

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.

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

Based on observation and interview, it was determined the facility failed to ensure all materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: On 03/04/25 and 03/06/25, during a walk-through of the facility with Staff 2 (Facility Service Director) and Staff 24 (Facility Service Aide) the following was identified: a. The exterior of the facility had multiple tarps covering areas identified by the facility which required repair on the roof. The tarps were located in the interior courtyard and along the back side of the facility. b. Interior areas of the facility, found not clean and/or in good repair: * Multiple doors and door frames including the public restroom doors, exit doors, private dining room door, resident laundry room door, and room numbers 101, 104, 105, 107, 108, 110, 111, 118, 119, 124, 126, 129, 134, 135, 136, 137, 138, 142, 146, 151, and 153; * Two resident room windows had heavy condensation located on the left side of the interior courtyard; * Front desk area had gouged and missing material; * Hole in the ceiling located near room 131; * The packaged terminal air conditioner unit located near room 118 had a cover that was falling off and not secure; * Broken dryer handle in the resident laundry room; * Activity room door had a metal divider that was bent and damaged; and * Wooden furniture in the lobby and dining room, including a desk, coffee table, and chest. On 03/06/25 at 10:20 am, Staff 2 and Staff 24 confirmed they were aware of areas identified. The need to ensure all materials and surfaces were kept clean and in good repair was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director) on 03/06/25 at 1:27 pm. They acknowledged the findings.

1. Roof has been patched and repaired, all areas are water tight, and tarps have been removed. The Maintenance Director has begun working on all survey identified interior areas in need of cleaning, repair and new paint. Doors and frames are in process of being evaluated and repaired/painted. 2. Repair log implemented. Maintenenace Director keeps track of needed upkeep, cleaning, repairs and completions. 3. Daily, weekly, monthly. 4. Administrator, Maintenance Director

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

Based on observation, interview, and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility's failure to implement a smoking policy was substantiated for 1 of 1 sampled resident (# 11). This posed an immediate jeopardy situation that could threaten the health, safety, and welfare of residents. Findings include, but are not limited to: During separate interviews on 01/28/25 and 01/29/25, Staff 8 (Med Tech), Staff 11 (Caregiver), and Staff 14 (Caregiver) stated Resident 11 was smoking cigarettes in his/her, and they had notified management. On 01/28/25, at approximately 10:30 am, an ashtray with ash in it and a strong odor of cigarette smoke was observed in Resident 11's room. On 01/28/25, the facility provided the Department with quarterly smoking assessments for residents identified as smokers. A smoking assessment for Resident 11 was not included. A risk agreement for Resident 11, dated 01/30/24, indicated s/he had been smoking in his/her room and care partners were to assist Resident 11 outside if s/he wanted to smoke. The risk agreement indicated it was to be reviewed on 02/30/24. There was no documented evidence the risk agreement had been reviewed. Chart notes for Resident 11, dated 04/20/24, indicated staff had reported Resident 11 smoking in his/her room. A "Smoking Safety Plan" for Resident 11, undated, indicated "lighters, matches, and cigarettes should be securely stored by staff and only made available during supervised smoking time." On 01/28/25, Staff 3 (Executive Director) stated residents were "not suppose" to smoke in their rooms but s/he had been told they do. S/he further stated the facility had not removed lighters or cigarettes from Resident 11's room. On 01/28/25 at approximately 7:30 pm, the facility submitted a written plan of correction indicating the facility was instituting safety checks four times a shift to ensure Resident 11 was not smoking in his/her room, and posted a room inspection check-off sheet on Resident 11's door for staff to document they had performed the checks. The plan of correction further indicated service plans would be made available to staff. On 01/29/25, at approximately 3:06 pm, only three signatures were observed on the check-off sheet for day shift, which ended at 2:30 pm. On 01/29/25, at approximately 3:14 pm, Resident 11 stated s/he had smoked in his/her room that day. On 01/29/25, at approximately 3:20 pm, Staff 15 (Caregiver) stated s/he was unaware of any new temporary service plans increased monitoring for any residents. On 01/29/25, at approximately 3:20 pm, Staff 12 (Med Tech) stated there was no new temporary service plan for Resident 11. On 01/28/25, Staff 6 (Med Tech) stated care staff do not have access to resident service plans if they are not in the service plan binder in the break room. On 01/29/25, no temporary service plan was observed for Resident 11 in the break room. The facility's failure to implement a smoking policy was substantiated. This posed an immediate jeopardy situation that could threaten the health, safety, and welfare of residents. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4 (Wellness Director, LPN), and Staff 5 (Resident Care Coordinator) on 01/31/25. The Department received and accepted a written plan of correction on 01/28/25 at approximately 7:30 pm.

Based on interview and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility's failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse was substantiated for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: An incident report, dated 05/03/24, indicated Resident 2 had suffered an unwitnessed fall with injury and was unable to tell staff what had happened. There was no documented evidence the facility had investigated or reported the unwitnessed fall with injury to the local Seniors and People with Disabilities (SPD) office. On 01/31/25, Staff 4 (Wellness Director, LPN) stated the incident had not been investigated by the facility. The facility's failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4, and Staff 5 (Resident Care Coordinator) on 01/31/25. Verbal plan of correction: The employees responsible for investigating and reporting the incident were no longer employed by the facility. Executive Director and Wellness Director to review incident reports daily, investigate, and report to the local SPD if necessary.

Based on interview and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility's failure to ensure the implementation of services was substantiated for 2 of 4 sampled residents (#s 1 and 4). Findings include, but are not limited to: On 01/29/25, Staff 11 (Caregiver) stated the facility tracked resident showers by initialing the facility's shower schedule when showers were completed. S/he further stated staff were to indicate refusals on the shower schedule, and if there was no initial, care staff had forgotten to sign the sheet or the resident had not received a shower. 1. Resident 1's service plan, dated 01/06/25, indicated s/he was to receive assistance with showers. It did not indicate when or how often Resident 1 was to receive assistance with showers. On 01/31/25, Resident 1 stated s/he was to receive assistance with showers twice a week and had not received a shower "in weeks."  S/He further stated s/he had not left the facility during that time. The facility's swing shift shower schedule, dated 12/13/24 through 01/19/25, indicated: · Resident 1 was to receive showers on Tuesdays and Saturdays; · Resident 1 had been marked as "out" on 12/31/24, 01/07/25, and 01/14/25; · There were no staff initials for Resident 1's scheduled showers on 12/17/24, 12/21/24, 01/04/25, or 01/11/25; and · There were no swing shifts shower schedules past 01/19/25. 2. Resident 4's service plan, dated 01/10/25, indicated s/he was to receive full assistance with showers, and staff were to offer Resident 4 showers daily. On 01/29/25, Resident 4 declined to be interviewed. The facility's swing shift shower schedule, dated 12/13/24 through 01/19/25, indicated: · Resident 4 was to receive showers on Mondays and Wednesdays; and · There were no staff initials for Resident 4's scheduled showers on 12/18/25, 12/30/25, 01/01/25, 01/08/25, 01/13/25, and 01/15/25. The facility's failure to ensure the implementation of services was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4 (Wellness Director, LPN), and Staff 5 (Resident Care Coordinator) on 01/31/25. Verbal plan of correction: Verbal POC: Facility to review shower schedule, ensure all residents are on the shower schedule, and Wellness Director will immediately begin reviewing shower schedules daily.

Based on interview and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (# 9). Findings include, but are not limited to: On 01/29/25, Resident 9 stated s/he had not received her inhaler for a week. A physician order for Resident 9, dated 06/13/24, indicated s/he was to receive Trelegy-Ellipta 100mcg-62.5mcg-25mcg (inhaler) once a day. Resident 9's MAR, dated 01/01/25 through 01/29/25, indicated s/he had not received his/her Trelegy-Ellipta 100mcg-62.5mcg-25mcg from 01/24/25 through 01/27/25. Notes indicated the facility was "waiting on refill." On 01/29/25, Staff 4 (Wellness Director, LPN) stated s/he was unaware Resident 9 had been missing medication and the facility was supposed to order medications for residents seven days before the medication ran out. The facility's failure to carry out medication orders as prescribed was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4, and Staff 5 (Resident Care Coordinator) on 01/31/25. Verbal plan of correction: Exception list for missed medications to be reviewed daily. Med techs will be retrained to ensure med techs are reordering medications 7 days in advance.

Based on observation, interview and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility ' s failure to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident and adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department was substantiated for 3 of 3 sampled residents (#s 1, 4, and 10). Findings include, but are not limited to: The facility ' s Personal/Professional Services Contract, dated 10/08/24, indicated the facility was to provide staff solely responsible for residents on specific needs contracts: · Three caregivers and one med tech on day shift; · Three caregivers and one med tech on swing shift; and · Two caregivers and one med tech on night shift. The facility ' s posted staffing plan indicated totals of: · Three caregivers and two med techs on day shift; · Two caregivers and one med tech on swing shift; and · Two caregivers and one med tech on night shift. The facility ' s staff schedule, dated 01/19/25 through 01/31/25 indicated: · " SN "  for staff members responsible for specific needs residents and  " ALF "  for staff members responsible for all other residents; · The facility scheduled one caregiver and one med tech on night shift, delineated as  " SN; "  and · One direct care staff delineated as  " ALF. " The facility had one resident who required two-person transfer assistance and was not on a specific needs contract. The facility would be unable to provide assistance during an evacuation with only one direct care staff assigned to non-specific needs residents. Staff timecards indicated the facility was not staffed to meet the fire safety evacuation standards as required on 10/10/24, 10/14/24, 11/01/24, 11/04/24, 11/19/24, 11/27/24, 12/01/24, 12/06/24, 12/16/24, 12/17/24, and 01/01/25. On 01/29/25, Staff 11 (Caregiver) stated: · S/He was  " not sure "  what the difference was between  " SN "  and  " ALF "  on the schedule and management had never told care staff; · Staff were  " lucky "  if they were able to get resident ' s laundry done; · The facility tracked resident showers by initialing the facility ' s shower schedule when showers were completed; and · Staff were to indicate refusals on the shower schedule, and if there was no initial, care staff had forgotten to sign the sheet or the resident had not received a shower. Resident 1 ' s service plan, dated 01/06/25, indicated s/he was to receive assistance with showers. It did not indicate when or how often Resident 1 was to receive assistance with showers. On 01/31/25, Resident 1 stated s/he was to receive assistance with showers twice a week and had not received a shower  " in weeks. "  S/He further stated s/he had not left the facility during that time. The facility ' s swing shift shower schedule, dated 12/13/24 through 01/19/25, indicated: · Resident 1 was to receive showers on Tuesdays and Saturdays; · Resident 1 had been marked as  " out "  on 12/31/24, 01/07/25, and 01/14/25; · There were no staff initials for Resident 1 ' s scheduled showers on 12/17/24, 12/21/24, 01/04/25, or 01/11/25; and · There were no swing shifts shower schedules past 01/19/25. Resident 4 ' s service plan, dated 01/10/25, indicated s/he was to receive full assistance with showers, and staff were to offer Resident 4 showers daily. On 01/29/25, Resident 4 declined to be interviewed. The facility ' s swing shift shower schedule, dated 12/13/24 through 01/19/25, indicated: · Resident 4 was to receive showers on Mondays and Wednesdays; and · There were no staff initials for Resident 4 ' s scheduled showers on 12/18/25, 12/30/25, 01/01/25, 01/08/25, 01/13/25, and 01/15/25. On 01/29/25, Resident 10 stated s/he had been  " stuck in bed yesterday "  and had asked staff for assistance at around 9:30 am or 10:00 am but  " there was always some reason they had to do something. "  S/He further stated staff had assisted him/her out of bed at approximately 3:00 pm. Resident 6 stated some staff could get her out of bed by themselves, but others say they need two.   On 01/29/25, Staff 11 stated staff on day shift had been too busy to help Resident 10 out of bed as s/he was a two-person transfer assist. Resident 10 ' s service plan, dated 01/14/25, indicated s/he required assistance from one staff member to transfer in and out of bed, effective on 01/11/24. The facility ' s failure to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident and adequate direct care staff present at all times to meet the fire safety evacuation standards as required by the fire authority or the Department was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4 (Wellness Director, LPN), and Staff 5 (Resident Care Coordinator) on 01/31/25. Verbal plan of correction: Facility to use their Acuity-Based Staffing Tool specific needs staffing requirements, and fire and life safety standards to create schedules going forward and will no longer share staff between recipients of the specific needs contracts and other residents.

Based on interview and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25 the facility ' s failure to fully implement and update an acuity-based staffing tool was substantiated. Findings include, but are not limited to: The facility had implemented the ODHS ABST. The census was 51. The facility had a specific needs contract, dated 10/08/24, with ten residents serviced by the contract. The specific needs contract indicated: · Day shift, 6:00 am-2:00pm, three caregivers and one med tech. · Swing shift, 2:00pm-10:30pm, three caregivers and one med tech. · Night shift, 10:00pm-6:30pm, two caregiver and one med tech. The facility ' s posted staffing plan indicated: · Day shift, 6:00 am-2:00pm, three caregivers and two med techs. · Swing shift, 2:00pm-10:30pm, two caregivers and one med tech. · Night shift, 10:00pm-6:30pm, two caregivers and one med tech. The facility ' s posted staffing plan failed to account for the staffing requirements of the specific needs contract. The facility ' s master staff schedule indicated: · " SN "  for staff members responsible for specific needs residents and  " ALF "  for staff members responsible for all other residents; · The facility scheduled one caregiver and one med tech on night shift, delineated as  " SN; "  and · One direct care staff delineated as  " ALF. " On 01/29/25, Staff 11 (Caregiver) stated s/he was  " not sure "  what the difference was between  " SN "  and  " ALF "  on the schedule and management had never told care staff. The facility had one resident who required two-person transfer assistance and was not on a specific needs contract. The facility would be unable to provide assistance during an evacuation with only one direct care staff assigned to non-specific needs residents. A review of the facility ' s schedule for night shift, dated 01/19/25 through 01/31/25 revealed the facility was not staffing to meet the combined needs of residents serviced by the specific needs contract or the assisted living residents. It was determined the facility did not fully implement and update an acuity-based staffing tool. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4 (Wellness Director, LPN), and Staff 5 (Resident Care Coordinator) on 01/31/25.

Based on observation, interview, and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility ' s failure to provide pre-service fire safety and emergency procedure training to employees was substantiated for 3 of 3 sampled direct care staff (#s 12, 24, and 25). Findings include, but are not limited to: The facility ' s staff roster indicated: · Staff 12 ' s (Med Tech) hire date was 11/13/24; · Staff 24 ' s (Med Tech) hire date was 11/26/24; and · Staff 25 ' s (Med Tech) hire date was 12/27/24. The facility ' s pre-service training documentation failed to indicate Staff 12, 24, and 25 had completed required pre-service fire and life safety training. The facility staff schedule, dated 01/19/25 through 01/31/25, indicated Staff 8, 12, 24, and 25 were scheduled to provide care to residents. Staff 12 was observed providing care to residents during the site visit. On 01/28/25, Staff 5 (Resident Care Coordinator) stated  " we don ' t have individual training [records] for everyone. " The facility ' s failure to provide pre-service fire safety and emergency procedure training to employees was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4 (Wellness Director, LPN), and Staff 5 on 01/31/25.

Based on observation and interview, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility's failure to ensure the interior of the facility must be free from unpleasant odors was substantiated. Findings include, but are not limited to: On 01/28/25, 01/29/25, and 01/31/25 facility hallways were observed to smell strongly of cigarette smoke and bodily odors. On 01/29/25, Staff 4 (Wellness Director, LPN), stated the hallways smelled of cigarette smoke and bodily odors. The facility's failure to ensure the interior of the facility must be free from unpleasant odors was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4, and Staff 5 (Resident Care Coordinator) on 01/31/25. Verbal plan of correction: Facility to initiate housekeeping refusal logs. Executive Director will be responsible for weekly review of housekeeping logs. The facility will implement plans for residents with a pattern of refusal and enact behavioral support systems if necessary. Care staff will be directed to notify management of unpleasant odors. If cigarette smoke is recognized, facility will intervene immediately.

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 05/29/24 at 11:10 am, the facility kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, debris, dust, grease, black, brown and/or white matter was observed on, under, below and/or behind the following: * Lower shelves of counter top refrigerator and juice dispenser, toaster counter, steam table and steamer; * Hood vents above grill/stove; * Sides of grill/stove and oven doors; * Warmer drawer front on steam table; * Commercial mixer splash guard; * Drain under single sink prep counter; * Ceiling vents between stove/grill and steam table, above kitchen entrance door and dishwashing area; * Exterior of microwave; * Floor under toaster counter and behind and under stove/grill/steamer; and * Floor under dishwashing area. The areas which required cleaning were observed and discussed with Staff 1 (Dietary Services Manager) and discussed with Staff 2 (Executive Director) on 05/29/24. The findings were acknowledged.

The Administrator or Designee will over see dailiy operations of the kitchen to ensure quality of cleanliness. Facility Administrator and or Dietary Manager will do daily cleaning task inspections. The Administrator implemented daily, weekly and monthly cleaning check off list for all kitchen staff Kitchen staff prepare 3 meals a day with a soup of the day with snacks available to all resiednts apon request. Snacks consist of sandwitches, fruits and vegetables seven days a week. Dietary Manager has a food committee once a month to ion encourage involvement from the residents to develop menus of the residents liking. Dietary Manager provides menus to be accessible to the residents one week in advance. Maintenance or designee cleans vents, between stove /grill and steam table, above kitchen entance door and dishwashing area monthly or as needed.

The findings of the kitchen inspection, conducted 05/29/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the re-visit to the kitchen inspection of 05/29/24, conducted 08/05/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 01/31/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality care and services were provided. Findings include, but are not limited to: The licensee is responsible for the operation of the facility and the quality of services rendered in the facility, including the supervision and training of staff. During the change of ownership survey, conducted 10/31/22 through 11/04/22, administrative oversight to ensure adequate resident care and services, including the development, implementation and monitoring of systems for responding to resident changes of condition and for updating resident service plans with new care instructions, was found to be ineffective based on the severity and number of citations. Refer to deficiencies in this report.

Based on interview and record review, it was determined the facility failed to ensure background checks were submitted to the Department for criminal fitness determination for 6 of 6 newly hired employees (#s 3, 18, 19, 20, 21 and 22) in accordance with OAR chapter 407-007-0200 to 407-007-0370, and 407-007-0600 to 0640 and were not being actively supervised at all times by an individual who had been approved without restrictions pursuant to OAR 407-007-0065. Findings include, but are not limited to: In an interview with Staff 1 (Administrator) and Staff 4 (Business Office Manager) on 11/03/22 at 9:20 am, it was revealed that six recently hired staff members (#s 3, 18, 19, 20, 21 and 22) had not had a background check submitted prior to beginning employment and were not being actively supervised at all times by an individual who had been approved without restrictions pursuant to OAR 407-007-0065. After the interview, the background checks were submitted to the Department for fitness determination for the newly hired employees. A plan was provided to the survey team on 11/04/22 at 10:30 am by Staff 1 ensuring direct supervision of those staff members who had background checks submitted until final fitness determination was obtained. The need to ensure the facility had submitted background checks to the Department for a criminal fitness determination for all newly hired employees and received approval to work prior to working unsupervised was discussed with Staff 1, Staff 4 and Staff 8 (Administrative Assistant) on 11/05/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: During a group interview, conducted on 11/02/22 with eleven unsampled residents, multiple complaints or concerns were brought up. The complaints included: * There were not enough activities or scheduled activities often did not occur; * The facility van's plates had expired so there were no scheduled outings; * Residents didn't feel there were any qualified staff available if they had a medical emergency; * Staff didn't always knock on the resident's door or wait until the resident invited the staff in; * Multiple issues with meals: food wasn't cooked properly, vegetables were overcooked, the variety/menu was limited, portions were too small; and * Residents sometimes went without scheduled medications because the facility failed to re-order prescriptions timely. When asked, the residents stated they did not feel the facility addressed their concerns and made changes to resolve complaints. One resident stated s/he typically got the response, "We're working on it." The residents reported they had ceased having resident council meetings because of low turnout and interest. In an interview on 11/04/22, Staff 1 (Administrator) acknowledged she was aware residents had a lot of complaints. She stated she felt like even when the facility attempted to resolve resident complaints, the residents were not satisfied and found more things to complain about. She explained that the facility has a "Grievance Form", but residents refuse to fill it out. She also said that rather than approaching her or the Ombudsman with concerns, many residents just called Adult Protective Services. She acknowledged she did not currently have a procedure for documenting resident complaints and how the facility attempted to resolve the complaints.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes and resident satisfaction. Findings include, but are not limited to: During the survey, conducted 10/31/22 through 11/04/22, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective. Staff 1 (Administrator) and Staff 8 (Administrative Assistant) was asked about the facility's quality improvement program on 11/04/22 at 10:20 am. During the interview, Staff 1 stated the facility did not currently have a Quality Improvement Program. The need to ensure the facility had an effective method to evaluate services, resident outcomes and resident satisfaction was discussed. They acknowledged the findings. Refer to the deficiencies in the report.

Based on observation, interview and record review, it was determined the facility failed to ensure 1 of 1 sampled resident who was bedbound (#5) was treated with dignity and respect. Findings include, but are not limited to: Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain. During the entrance conference on 10/31/22, staff reported the resident had a recent overall decline in health, had been hospitalized and was now bedbound. The record indicated Resident 5 was hospitalized from 09/30/22 through 10/05/22 for exacerbation of seizure activity. Prior to the hospital stay, the resident's 05/13/22 service plan and interviews with staff indicated the resident was independent for most ADLs including transfers, mobility and toileting. Upon return to the facility, the resident had a Foley catheter, and was unable to bear weight, requiring multiple staff and a Hoyer lift for transfers in and out of bed. In an interview on 11/01/22 at 1:30 pm, the Resident 5 stated s/he felt "neglected" because s/he wanted to be assisted out of bed and use his/her manual wheelchair for mobility in his/her apartment and in the building. The resident stated that care staff reported they were not able to safely lift and transfer him/her out of bed and into the wheelchair. The resident stated s/he had been restricted to his/her bed since returning to the facility on 10/05/22. In interviews on 11/03/22, Staff 12 (CG) and Staff 15 (CG) confirmed it took two to three staff just to reposition the resident due to the resident's weight, and the facility was unable to physically transfer the resident out of bed. The resident's status and care needs were discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. Staff 1 acknowledged the facility had not been able to transfer the resident out of bed per the resident's preference and request. Staff 1 stated corporate policy prohibited the facility from utilizing a Hoyer Lift to transfer the resident. The surveyors informed Staff 1 and Staff 8 that because they had accepted Resident 5 back to the facility following the hospitalization, the facility was responsible to meet the resident's care needs and preferences, and failure to do so was a violation of the resident's right to be treated with dignity and respect. Staff 1 and 8 acknowledged the findings. Upon exiting the building on 11/04/22 at 4:45 pm, a caregiver was observed pushing Resident 5 outside the building in his/her wheelchair. The resident told this surveyor "I feel so much better being out of bed."

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: a. Observation of the kitchen on 10/31/22 at 10:05 am revealed an accumulation of food spills, splatters, loose food debris, dirt and/or dust on or underneath the following: * Cupboards under juice station; * Small refrigerator near juice station; * Juice dispenser; * Coffee machine; * Ice machine; * Cupboards under steam table; * Cupboards across from steam table * Steam table shelving; * Steam table sides; * Industrial toaster; * Shelving below toaster; * Ovens; * Stove; * Ventilation hood; * Steamer; * Industrial mixer; * Prep sink counter and shelving; * Clean dish shelving; * Push carts; * Flooring of the walk-in refrigerator; * Cooling racks; * Warewasher; * Garbage disposal mechanism; * Walls throughout the kitchen; * Flooring and baseboards throughout the kitchen; * Floor drains throughout the kitchen; and * Doors throughout the kitchen. b. The following kitchen items needed repair: * Laminate on the shelving surrounding the steam table had scrapes and/or gouges with bare wood exposed rendering the surfaces uncleanable; and * Clean dish shelving had scrapes and/or gouges with bare wood exposed rendering the surfaces uncleanable. c. The following food items were not stored in a manner to prevent rodent or pest infestation: * Cornstarch in pantry; * Noodles in pantry; * Flour near prep area; * Sugar near prep area; and * Cooking oil under steam table. d. Garbage cans throughout the kitchen were left uncovered when not in use. The areas that required cleaning and repair were observed and discussed with Staff 1 (Administrator) on 10/31/22 at 11:22 am. She acknowledged the findings. Staff 1 was asked to begin cleaning immediately. Upon re-inspection of the kitchen on 11/01/22, surfaces throughout the kitchen were clean.

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, and physical, mental, and psychosocial needs. Findings include, but are not limited to: The facility provided the survey team with the monthly activity calendar for November 2022. Each day, the calendar indicated multiple activities were scheduled from 9:30 am until 3:00 pm. Activities included: * Morning workout or morning walk; * Painting; * Games; * BINGO; * Relax with friends; * Trivia; and * Movie night. On 11/01/22 and 11/02/22, residents organized and led their own BINGO activity. On 11/03/22, Staff 6 (Activity Director) led a BINGO activity from 9:30 am until approximately 11:00 am in which nine residents attended and participated. None of the other scheduled activities were observed to occur during the survey. During a group interview, conducted by the survey team on 11/02/22, multiple unsampled residents reported: * There weren't many activities; * Activities often were canceled; * They didn't feel some activities were age-appropriate; * Fitness activities didn't occur and they wished the facility had exercise equipment; * There weren't activities developed specifically for the male residents; and * The facility van's license plates had not been renewed so the facility could not offer outings as activities for the residents. The lack of a daily program of social and recreational activities was discussed with Staff 1 (Administrator), Staff 8 (Administrative Assistant) and Staff 6 on 11/04/22. They acknowledged the facility was not providing activities that were scheduled and needed to improve the current activity program.

Based on interview and record review, it was determined the facility failed to ensure resident evaluations were completed before the resident moved into the facility, at least quarterly and following a significant change of condition, that initial evaluations addressed all required elements and that evaluations were reflective of the resident's current status, for 3 of 5 sampled residents (#s 3, 4 and 5) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications. a. In an interview on 11/04/22, Staff 1 (Administrator) acknowledged she did not begin entering Resident 3's initial evaluation information into the facility electronic documentation system until three days after the resident was admitted and did not complete the evaluation until 18 days after admission. b. The initial evaluation failed to address the following elements with sufficient information to develop an initial service plan: * Customary routines: sleeping, eating, bathing; * Interests, hobbies, social and leisure activities; * Spiritual, cultural preferences and traditions; * Mental health: history of treatment and effective non-pharmacological interventions; * Pain: description and non-pharmaceutical interventions; * Fluid preferences; * Emergency evacuation ability; * Complex medication regimen; * History of dehydration or unexplained weight loss or gain; * Elopement history or risk; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature. The need to ensure the initial evaluation addressed all elements and was completed prior to the resident's admission was reviewed with Staff 1 and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the deficiencies. 2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, COPD, seizures, diabetes mellitus - type 2, neuropathy and pain. The record indicated Resident 5 was hospitalized from 09/30/22 through 10/05/22 for exacerbation of seizure activity. Prior to the hospital stay, the resident's 05/13/22 service plan and interviews with staff indicated the resident was independent for most ADLs including transfers, mobility and toileting. Upon return to the facility, the resident had a Foley catheter, and was unable to bear weight, requiring multiple staff and a Hoyer lift for transfers in and out of bed. The resident experienced a significant change of condition in status and care needs following the hospitalization. The resident's evaluation was not updated for staff to reflect the changes in status and care needs until 10/24/22 - 19 days after the changes occurred. The need to ensure resident evaluations were updated timely following a significant change of condition was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the evaluation was not updated timely. 3. Resident 4 was admitted to the facility in 10/2020 with diagnoses including arthritis and gait disorder. The resident's record indicated that s/he received wound care from an outpatient provider on 08/04/22 who documented the presence of wounds on both the left foot and right toe. Review of the resident's progress notes, dated 07/31/22 through 10/30/22, revealed no documented evaluation of the wound on the resident's right toe. The resident experienced a significant change of condition following the identification of a right toe wound. The resident's service plan, dated 08/20/22, was not updated with changes to the resident's care needs. The need to ensure evaluations were completed timely following a significant change of condition was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 1:00 pm. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 01/2021. a. During the acuity interview on 10/31/22, facility staff stated current service plans available to staff were located in a binder at the front desk. Review of the binder revealed Resident 6's service plan, available to staff, was dated 10/12/21 (a year old). In an interview with Staff 1 (Administrator) on 10/31/22, she acknowledged the service plan available to staff was not current. She stated the most recent service plan had to be printed from her computer. A copy of the recent service plan, dated 09/19/22, was printed and given to the surveyor. b. Interviews with care staff, observations and an interview with Resident 6, and review of the clinical record revealed the service plan, dated 09/19/22, was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas: * Skin wounds; * Application of lotion; * Use of a fall mat; * Dressing assistance; * Personal hygiene/grooming assistance; * Continence care; * Bathing assistance; * Daily housekeeping services; * Oxygen flow rate; and * Activity participation/socialization. The need to ensure the current service plan was available to staff, was reflective of Resident 6's care needs, and provided clear direction was discussed with Staff 1 and Staff 8 (Administrative Assistant) during an interview on 11/04/22. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were completed before move-in and following quarterly evaluations and significant changes of condition, were reflective of the resident's current status, included a written description of the services to be provided and were readily available to staff, for 6 of 6 sampled residents (#s 1, 2, 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 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications. Review of the record indicated Resident 3's service plan was not completed until 18 days after s/he was admitted to the facility. The need to ensure resident service plans were completed prior to move-in was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, COPD, seizures, diabetes mellitus - type 2, neuropathy and pain. The record indicated Resident 5 experienced a significant change of condition that affected his/her status and care needs upon returning from a hospitalization on 10/05/22. The resident's service plan was not updated to reflect the changes in status and care needs until 10/24/22 - 19 days after the changes occurred. Refer to C 252, example 2. 3. Resident 4 was admitted to the facility in 10/2020 with diagnoses including arthritis. The resident's current service plan dated 08/20/22 was reviewed, observations were made, and interviews were conducted between 10/31/22 and 11/04/22. Resident 4's service plan was not reflective, did not provide clear instruction to staff and/or was not followed in the following areas: * Transfer status; * Fall interventions; * Toileting status; * Skin wounds; and * Alcohol consumption including the need for increased safety checks. The need to ensure service plans were reflective of the identified needs of the resident, provided clear direction to staff, and were followed by staff was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 1:00 pm. They acknowledged the findings. 5. Resident 1 and Resident 2 were admitted to the facility in 09/2017. Service plans for Resident 1 and Resident 2, available for review to this surveyor and to the staff, were dated 02/15/22. On 11/02/22, updated service plans for Resident 1 and Resident 2, dated 10/31/22, were provided to this surveyor by Staff 1 (Administrator). The need to ensure service plans were completed quarterly after the resident moved into the facility was discussed with Staff 1 and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, at least one other staff person who was familiar with or who was going to provide services to the resident for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6). As applicable, the Service Planning Team must also include local APD or AAA Case Managers and family invited by the resident, and a licensed nurse if the resident shall need or is receiving nursing services or experienced a significant change of condition. Findings include, but are not limited to: Current service plans for Residents 1, 2, 3, 4, 5 and 6 were reviewed during the survey. The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

3. Resident 6 was admitted in 01/2021 and had a history of falls, skin breakdown and congestive heart failure. During the entrance conference on 10/31/22, staff reported the resident had a recent significant overall decline in health and weight loss. The clinical record, progress notes, hospital discharge summaries, and facility weights were reviewed from 04/2022 through 10/31/22, and an interview with the resident on 10/31/22 revealed the following: a. Resident 6, who was alert and oriented, was interviewed on 10/31/22. During the interview, s/he said s/he eats in his/her room, had a poor appetite, often refused meals, and had lost weight. On 08/13/22, a staff MT documented in progress notes that the resident had "unplanned weight loss suspected ...loss of appetite ..." On 08/26/22, a progress note written by Staff 24 (former LPN) indicated the resident had "not been eating well and has been losing weight ..." Facility weight records and hospital discharge summaries revealed the following weights: * 04/26/22: 159.8 lbs. * 05/12/22: 147.9 lbs. * 08/26/22: 124.0 lbs. * 09/23/22: 135.8 lbs. * 10/21/22: 139.1 lbs. Staff obtained the resident's weight on 11/02/22. Resident 6 weighed 140 lbs. Resident 6 weighed 159.8 pounds in 04/2022. On 10/21/22, the resident's weight dropped to 139.1 pounds, which was a loss of 20.7 pounds or 12.9% loss in six months which constituted a severe loss and significant change in condition. There was no evidence the facility evaluated the weight loss, referred the significant change to the facility RN, or updated the service plan. b. A progress note, written by an MT on 08/13/22, indicated the resident had "shown the following signs of a significant change in condition: uncontrolled pain, fast decline in activities of daily living, unplanned weight loss suspected, level of consciousness change, loss of appetite. Has been put on alert for change in condition." The facility failed to refer to the facility RN for assessment and update the service plan to reflect the change in condition. c. Resident 6 fell five times between 08/01/22 and 10/12/22. Review of the record revealed no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved. Additionally, the facility failed to consistently evaluate if service-planned interventions were implemented, were effective, or if new interventions were needed. d. Between 09/01/22 and 10/03/22, Resident 6 was sent to the hospital on four occasions and returned with diagnoses including, but not limited to: foot cellulitis, head trauma, foot pain, pneumonia and decreased level of consciousness. The facility initiated short-term monitoring. However, ongoing monitoring did not continue until resolution for the short-term changes in condition. The need to ensure the facility monitored and documented on the progress of short-term changes in condition at least weekly until resolved, determined if fall interventions were implemented, effective or if new interventions were needed, ensured significant changes of condition were evaluated, referred to the facility RN for assessment, and the service plan updated was shared with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 10:20 am. They acknowledged the findings. No further information was provided. 2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain. During the entrance conference on 10/31/22, staff reported the resident had a recent overall decline in health, had been hospitalized and was now bedbound. The clinical record, progress notes and hospital and PCP visit summaries from 08/01/22 through 10/31/22 were reviewed. Facility staff and the resident were interviewed. The following deficiencies were identified: a. Between 08/11/22 and 10/18/22, the resident had nine falls in his/her apartment. There was no documented evidence the facility: * Reviewed each fall to determine whether service-planned fall interventions were being followed, were effective or whether different or additional interventions needed to be implemented to prevent further falls; and * Ensured staff instructions or interventions were resident-specific and made part of the resident record with weekly progress noted until the condition resolved. b. The resident sustained several minor injuries from the falls including bruising and skin tears. * There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed for the resident; and * The facility failed to monitor the injuries with weekly progress noted until the conditions resolved. c. The resident was hospitalized three times for reports of chest pains or exacerbation of respiratory conditions. * For two of the incidents, there was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed for the resident and monitored the resident with weekly progress noted until the conditions resolved; and * The facility failed to make staff instructions or interventions part of the resident record. d. Resident 5 was hospitalized from 09/30/22 through 10/05/22 for exacerbation of seizure activity. Prior to the hospital stay, the resident's 05/13/22 service plan and interviews with staff indicated the resident was independent for most ADLs including transfers, mobility and toileting. Upon return to the facility, the resident had a Foley catheter, and was unable to bear weight, requiring multiple staff and a Hoyer lift for transfers in and out of bed. The change in status and care needs following the hospitalization represented a significant change of condition. Though the facility nurse documented some of the resident's changes, the facility failed to update the resident's service plan with specific instructions for staff as to how to meet Resident 5's care needs regarding transfers, mobility, toileting, catheter care and other ADLs. The need for the facility to develop and implement an effective system for responding to resident changes of condition that included review of service-planned interventions, development, documentation and communication of instructions for staff that were made part of the resident's record and monitoring of conditions until resolved, was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift, weekly progress documented until the condition resolved and/or the facility failed to refer significant changes of condition to the facility RN for 3 of 3 sampled residents (#s 4, 5 and 6) who had changes of condition. Resident 4 did not receive consistent and ordered wound care and the resident's wound worsened and caused distress to the resident. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 10/2020 with diagnoses including gait disorder and lichen planus (inflammation of the skin). During the entrance conference interview on 10/31/22, Resident 4 was identified as receiving home health services for lower leg edema.   Resident 4 was interviewed on 11/01/22 at 9:35 am and reported to have wounds on both his/her left and right feet. The wounds were visualized at that time with the resident's permission. The left foot had approximately a quarter-sized wound on the left side. The right foot had a visible wound on the second toe with a crusty black coating. Neither wound was bandaged. The resident reported the facility did not check on his/her wounds regularly, s/he was not receiving home health services, and the wound clinic frequently canceled appointments due to lack of staff. a. Resident 4's medical records were examined. The first documentation of a right toe wound occurred on 08/04/22 following an outpatient wound care visit. The clinic identified the location of the wound as the right lateral side of the second toe with orders to "change dressing every other day or as needed for excessive drainage," "cleanse wounds on dressing days with soap and water," "apply Collagen dressing to wound bed as directed," and "Band-Aid applied over Prisma layer."   The service plan, dated 08/20/22, progress notes, dated 07/31/22 through 10/30/22, and MARs, dated 08/2022 through 10/2022, were reviewed and there was no monitoring of the wound, no documentation of when it originated or when the RN was made aware of it. On 11/02/22 at 9:20 am, the resident's wounds were observed with Staff 2 (RN - Wellness Director) and an RN surveyor. Staff 2 documented the assessment on 11/02/22 and indicated the resident had an open 2 cm x 3 cm wound on top and proximally surrounding the right second and third toe with mild clear-yellow discharge. At 11:09 am on 11/02/22, Staff 2 reported she was not previously aware of the resident's right toe ulcers and her first assessment of the resident's lower extremity wounds was completed by direction of this surveyor on 11/02/22. She also stated there was no documentation by the facility of the resident's right toe wounds, and Staff 11 (CG) completed all basic wound treatments for the resident and home health completed all other wound care. Staff 2 was unaware the resident's wound care clinic appointments had been canceled by the clinic due to lack of staff. When questioned about her job duties, Staff 2 then stated she was hired to complete delegation tasks only and she was made aware of other nursing issues when caregiving staff or residents told her of problems directly. The facility's policy was reviewed on 11/04/22. According to the policies and procedures, a "Nursing Comprehensive Evaluation" must be completed by an RN following a significant change of condition. Regarding coordination of care, the RN was responsible to discuss options to address resident's needs with the resident when services could not be provided by the community. Moreover, the RN was responsible for coordination of care and required documentation. On 11/02/22 at 11:30 am, Staff 11 reported she completed basic wound care for the resident at least every other shift she worked. This included the use of cleanser, antibiotic ointment and covering with a Band-Aid. She went on to state she did not document any wound care she completed, and any concerns about the resident's wounds were reported to the RN or RCC. There was no documented evidence the facility was providing the wound care ordered by the outpatient wound clinic. Resident 4 was seen on 11/02/22 at his/her primary care physician's office with instructions to start antibiotics for the toe ulcer, directions for wound cleaning and instructions to return to the office for a follow-up visit in one week. An immediate plan of action to address the resident's wound care, until home health services began, was requested of the facility and approved by this surveyor on 11/04/22. The facility failed to identify and evaluate the resident's right toe ulcer, refer to the facility RN following a significant change of condition, determine and document interventions regarding the ulcer, communicate the interventions to staff and monitor the resident according to his/her evaluated needs. The resident's right second toe wound worsened to include the third toe. b. During an interview with Resident 4 on 11/01/22, s/he reported a wound on the left foot. Resident 4's progress notes, dated 07/31/22 through 10/30/22 were reviewed for changes of condition related to the left foot wound and revealed the following information:   * 08/03/22 - "Remove from Alert Charting...Residents [sic] [left] foot ulcer is being monitored in house by this nurse and treated by this nurse in between [his/her] trips to off-site wound care...Residents [sic] wound continues to improve ..."; * 08/26/22 - "Residents [sic] wound care was canceled again today...at this time this nurse is following orders from the wound care facility"; * 09/27/22 - "Resident was getting upset, because [s/he] wanted to see a doctor or a nurse to do wound care on [his/her] feet...[s/he] requested to go to the ER [emergency room]"; and * 10/19/22 - "Resident came back from ...ER with diagnosis of Neuropathy and Chronic foot ulcer ..." On 11/02/22 at 11:30 am, Staff 11 reported she completed basic wound care for the resident at least every other shift she worked, but she did not document any wound care she completed. There was no documented evidence the facility identified resident specific interventions regarding the left foot wound, communicated the interventions to all staff and then monitored the resident according to his/her evaluated needs. c. Resident 4's progress notes, dated 07/31/22 through 10/30/22, service plan, dated 08/20/22, and ISP, dated 08/19/22 were reviewed and revealed the following: The following short-term changes of condition lacked evidence resident-specific actions or interventions were determined, documented and communicated to staff: * 08/20/22 - Fall with injury; and * 10/22/22 - Non-injury fall. The following short-term changes of condition lacked documented evidence the resident's determined actions or interventions were monitored through resolution: * 08/11/22 - New prescription for meloxicam (for arthritis) and Tylenol #3 (for pain); * 08/20/22 - Fall with injury; * 09/15/22 - New prescription for amlodipine (for high blood pressure) and the discontinuation of sertraline (for depression), Zofran (for nausea) and Tylenol PRN (for pain); and * 10/22/22 - Non-injury fall. The need to ensure changes of condition were identified, reported to RN if determined to be a significant change of condition, interventions determined, documented and communicated to staff with monitoring occurring per the residents' evaluated needs was discussed with Staff 1 (Administrator) and Staff 8 (Receptionist) on 11/04/22 at 1:00 pm. The findings were acknowledged, and no additional documentation was provided.

3. Resident 6 was admitted in 01/2021 and had a history of skin breakdown and poor appetite. a. Facility progress notes, weight records, MARs and the current service plan, reviewed from 04/2022 through 10/31/22, revealed the following: Resident 6 weighed 159.8 pounds in 04/26/22. On 10/21/22, the resident's weight dropped to 139.1 pounds, which was a loss of 20.7 pounds or 12.9% loss in six months which constituted a severe loss and significant change in condition. There was no documented facility RN assessment to address the weight loss. Refer to C 270, example 3a. b. On 08/13/22, a facility MT documented in progress notes that the resident had "shown the following signs of a significant change in condition: uncontrolled pain, fast decline in activities of daily living, unplanned weight loss suspected, level of consciousness change, loss of appetite. Has been put on alert for change in condition." There was no documented evidence the facility RN conducted an assessment. During an interview on 11/02/22 at 12:15 pm, Staff 2 (RN - Wellness Director) acknowledged the lack of documented RN assessments for the significant changes in condition. The need to ensure documented RN assessments for significant changes in condition was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 10:20 am. They acknowledged the findings. No further information was provided. 2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain. During the entrance conference on 10/31/22, staff reported the resident had a recent overall decline in health, had been hospitalized and was now bedbound. The clinical record, progress notes and hospital and PCP visit summaries from 08/01/22 through 10/31/22 were reviewed. Facility staff and the resident were interviewed. Resident 5 was hospitalized from 09/30/22 through 10/05/22 for exacerbation of seizure activity. Prior to the hospital stay, the resident's 05/13/22 service plan and interviews with staff indicated the resident was independent for most ADLs including transfers, mobility and toileting. Upon return to the facility, the resident had a Foley catheter, and was unable to bear weight, requiring multiple staff and a Hoyer lift for transfers in and out of bed. The change in status and care needs following the hospitalization represented a significant change of condition. There was no documented evidence the facility RN completed an assessment of the resident which documented findings, resident status, and interventions made as a result of this assessment. The need to ensure the facility RN completed an assessment of a resident with a significant change of condition was reviewed with Staff 2 (RN - Wellness Director) on 11/02/22 and with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged no assessment had been completed by the facility RN as required.

Based on observation, interview and record review, it was determined the facility failed to ensure health services were provided according to the facility's policy and per the resident condition, including ensuring the RN performed an assessment and interventions were developed based on the condition of the resident, and/or providing facility-arranged temporary or intermittent nursing services when services were not available through a third-party provider, for 3 of 3 sampled residents (#s 4, 5 and 6) who experienced significant changes of condition. Resident 4 experienced worsening wounds on the right foot. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 10/2020 with diagnoses including gait disorder and lichen planus (irritation of the skin). Progress notes, dated 05/09/22 through 10/30/22, and MARs, dated 08/2022 through 10/2022, were reviewed. Observations and interviews with staff were completed between 10/31/22 and 11/04/22 and revealed the following: Resident 4 had open wounds on the left foot and the right second and third toes which indicated a significant change of condition and required an RN assessment. There was no documented evidence the wounds were assessed by the facility RN with resident specific interventions created related to the change of condition. Additionally, there was no evidence the facility provided temporary nursing services when the resident's care needs could not be met through other third party providers. This resulted in worsening right toe wounds. The need to ensure documented RN assessments were completed and intermittent nursing services were provided when not available through a third-party provider was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 1:00 pm. They acknowledged the findings and no further information was provided. Refer to C 270, example 1a and 1b.

2. Resident 6 was admitted in 01/2021 and had a history of skin breakdown and weight loss. During the entrance conference interview on 10/31/22, staff indicated Resident 6 had lost weight and currently had skin breakdown that was being treated by home health nursing services. a. On 10/31/22 at 1:40 pm, the surveyor observed that Resident 6's left lower leg was wrapped with bandages. S/he explained the wound was bandaged by "home care." During the interview, an RN from home health arrived to perform wound care. The resident's clinical record revealed the resident sustained a laceration to his/her left lower leg on 06/23/22. Home health was initiated in 07/2022 and continued as of the survey. However, there was no on-going documentation left by home health, no wound care instructions in the event staff needed to provide supplemental care as needed, and no evidence the facility implemented recommendations that were provided by home health. In an interview on 11/03/22 at 9:50 am, Staff 11 (MT) said she was unsure what to do if she needed to change the dressing on the resident's leg. She reviewed the MAR and stated it lacked wound care instructions in the event the bandages needed to be changed/re-applied. b. On 10/18/22, home health documented on a facility "Outside Provider Coordination" form that staff should "please give snacks throughout day, trying to increase calorie intake." The document had staff initials, dated 10/25/22, that the recommendation had been reviewed. However, there was no evidence in the resident's record the recommendation had been communicated to staff and implemented. The need to ensure the facility obtained information from outside providers and ensure recommendations were communicated to staff and/or implemented was discussed with Staff 1 (Administrator), Staff 2 (RN - Wellness Director), Staff 3 (Med Room Manager), and Staff 8 (Administrative Assistant) during interviews on 11/02/22, 11/03/22 and 11/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers, ensure outside providers left written information in the facility that addressed on-site services being provided, and reviewed and updated the resident's service plan with new interventions, for 2 of 2 sampled residents (#s 5 and 6) who received home health services. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain. The record indicated Resident 5 received Physical Therapy services in the facility from 07/14/22 until approximately 09/26/22. * Review of "Outside Provider Coordination" notes indicated the facility did not review the information provided by PT until 10/09/22. * On 09/21/22, PT documented, "[Patient] has small wound on [left] heel please monitor daily." There was no documented evidence the facility monitored the wound as instructed by PT. The need to ensure outside provider information was reviewed timely and instructions/interventions added to the resident's service plan and implemented was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure adequate professional oversight of the medication administration system. Findings include, but are not limited to: During the change of ownership survey , conducted 10/31/22 through 11/04/22, administrative oversight was found to be ineffective based on deficiencies in the following areas: C 303: Systems: Medication and Treatment Orders; C 305: Systems: Resident Right to Refuse;   C 310: Systems: Medication Administration; C 325: Systems: Self-Administration of Meds; and C 330: Systems: Psychotropic Medications. Failure to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 11/04/22.

4.  Resident 6 was admitted in 01/2021 with diagnoses which included heart disease, COPD and constipation. Physician orders and MARs, reviewed from 10/01/22 through 10/31/22, revealed the following orders were not followed: * Clopidogrel 75 mg one tablet daily (for heart disease) was not administered on one occasion because it was "unavailable"; * Guaifenesin 1200 mg one tablet twice daily (for congestion) was not given on two occasions because it was "unavailable"; and   * Miralax (for constipation) 17 grams daily was not documented as given on 10/28/22. On 11/03/22 at 9:45 am, the surveyor and 11 (MT) observed/checked the MARs and medication supply. Staff 11 was unable to verify if the above orders had been followed. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 10:20 am. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to carry out medication and treatment orders as prescribed and ensure written, signed physician orders were documented in the resident's chart for medications and treatments the facility was responsible to administer, for 4 of 5 sampled residents (#s 1, 4, 5 and 6) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain. a. Review of Resident 5's chart and 10/01/22 through 10/31/22 MAR indicated the following medications were being administered without a signed written physician's order in the resident's record: * Morphine (for pain and difficulty breathing) TID; * Basaglar Quickpen (insulin for diabetes mellitus) 30 units at bedtime; * Basaglar Quickpen 40 units at 5:00 pm; * Keflex (an antibiotic) for 7 or 10 days BID or TID; * Cipro (an antibiotic) for 10 days BID; * Incruse Ellipta inhaler (for respiratory conditions) 1 puff daily; * PRN Haldol (for psychosis); * PRN lorazepam (for anxiety or agitation); * PRN morphine (for pain or breathing difficulty); * PRN tizanidine (for back spasms); * PRN Zofran (for nausea/vomiting); * PRN loparamide (for diarrhea); * PRN Bisacodyl suppository (for constipation); and * PRN Senna (for constipation). b. The facility ceased administering the following medications without a signed, written physician's order to discontinue the medications in the resident's record: * Amiodarone(for heart health); * Aspirin (for heart health); * Basaglar Quickpen (insulin for diabetes mellitus) 40 units daily; * Carvedilol (for high blood pressure and heart failure); * Eliquis (a blood thinner); * Flonase (for seasonal allergies); * Glipizide (for diabetes mellitus); * Pantoprazole (for acid reflux); * Pregabalin (for seizures); * Simvastatin (to lower cholesterol); * Spironolactone (for high blood pressure and heart failure); * Victoza (to lower blood sugar); and * Benadryl (for allergy and itch relief). c. The resident was prescribed torsimide (for removing excess fluid) 100 mg every day and an additional 50 mg every other day. The order was transcribed inaccurately on the MAR. In an interview on 11/04/22, Staff 10 (MT) stated she could not confirm that staff were administering the medication as ordered. The facility's failure to have signed, written physician orders in the resident's chart for all medications and treatments it was responsible to administer, and orders to discontinue medications and treatments, was reviewed with Staff 3 (Med Room Manager) on 11/02/22 and with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They were unable to provide copies of the orders. 2. Resident 4 was admitted to the facility in 10/2020 with diagnoses including hypertension and lichen planus (irritation of the skin). Resident 4's physician's orders, complete MAR, dated 10/01/22 through 10/30/22, and partial MARs, dated 08/2022 through 09/2022, were reviewed and revealed the following: a. The MAR was blank for the following medications or treatments: * 10/05/22 - Amlodipine 5 mg (for hypertension); * 10/28/22 - Clotrimazole 1% cream (for rash); and * 10/28/22 - Eucerin Advanced Repair Cream (for rash). On 11/01/22 at 2:47 pm, the surveyor and Staff 3 (Med Room Manager) observed/checked the MARs and medication supply. Staff 3 was unable to verify if the above orders had been followed. b. Resident 4 had a physician's order, dated 05/07/22, for amlodipine 5 mg - one tablet daily (for high blood pressure). The facility documented the medication as given twice daily on the following dates: * 08/01/22 - 08/31/22; * 09/01/22 - 09/07/22; * 09/10/22; * 09/12/22 - 09/13/22; * 09/17/22 - 09/18/22; * 09/20/22 - 09/26/22; * 09/28/22 - 09/29/22; and * 10/03/22 - 10/04/22. c. Resident 4 had a physician's order to administer Acetaminophen 500 mg - two tablets by mouth every four hours as needed for fever greater than 100.1 degrees F. On 10/04/22, the resident received the PRN Acetaminophen with documentation indicating it was administered for pain. The need to ensure medications were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 09/2017 with diagnoses including Diabetes Mellitus Type 2. Review of the MAR dated 10/01/22 through 10/31/22 and signed physician orders dated 03/10/22 noted the following: * Physician's orders requested the facility provide CBG reporting to the PCP monthly; and * Physician's orders also requested that the facility notify the provider any time Resident 1's CBG was 500 or greater. a. During an interview on 11/01/22 at 1:40 pm with Staff 11 (MT) it was confirmed the request for the facility to provide CBG reporting to the PCP monthly was not listed on the MAR and had not been completed as of the time of this survey. b. Based on record review, the facility did not document and could not confirm whether the provider was notified on two occasions that Resident 1's CBG was 500 or greater for the following dates: * 10/05/22 CBG was noted to be 511; and * 10/11/22 CBG was noted to be 500. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

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 5 sampled residents (#s 3, 7, and 10) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 03/2022 with diagnoses which included anxiety disorder, polyneuropathy, chronic obstructive pulmonary disease, and rheumatoid arthritis. The resident had an order for Azithromycin 250 mg tablet one time per day for prophylaxis. Resident 3's MAR, reviewed from 07/01/23 - 07/26/23, revealed the medication was not administered on 07/14/23, 07/15/23, and 07/16/23. During an interview on 07/26/23, with Staff 2 (RN Wellness Director), she reported the agency MT thought the medication had not been ordered in time and that the facility was out of the medication for those three days. She reported the medication was found on an alternate medication cart and administration of the medication was started again on 07/17/23. Findings were reviewed with Staff 24 (Administrator), Staff 2, Staff 26 (LPN Consultant) and Staff 27 (Regional RN) on 07/26/23. They acknowledged the findings. 2. Resident 10 was admitted to the facility in 06/2018 with diagnoses which included anemia. The resident had a physician order on 05/15/23 for ferrous sulfate 325 mg tablet, one tablet to be given by mouth twice daily. Resident 10's MAR, reviewed from 05/01/23 - 07/26/23, revealed the instructions for twice daily administration had been updated, but the medication was only administered once per day, resulting in the resident receiving half of the prescribed daily amount of the medication from 05/16/23 - 07/26/23. In an interview with Staff 2, Staff 26, and Staff 27 on 07/26/23, they acknowledged the finding and were unable to provide additional information. The need to ensure all medications were available and administered as prescribed was reviewed with Staff 2, Staff 26, and Staff 27 on 07/26/23. They acknowledged the findings. 3. Resident 7 was admitted to the facility in November 2021 with diagnoses including cerebral vascular disease and history of transient cerebral ischemic attack (TIA). A review of the resident's current signed physician orders, 05/01/23 through 05/31/23 MAR, temporary service plans and alert charting notes from 04/25/23 through 07/24/23 identified the following medications were not administered as prescribed: * Aspirin, one tablet daily, was not administered from 05/06/23 through 05/11/23; and * Trazodone, one tablet daily, was not administered from 05/05/23 through 05/07/23. The need to ensure medications were administered as prescribed was discussed with Staff 24 (Administrator), Staff 26 (LPN Consultant) and Staff 27 (Regional RN) on 07/26/23. They acknowledged the findings.

1. Resident #3 is receiving all medications as ordered. Resident #10 has had the orderd corrected and is receiving medication as ordered. Resident #7 is receiving medication as ordered. 2. 90 Day orders will be done quarterly by the RN and sent to providers. All new orders, changes, or DC orders will be managed by nursing. Manual imputation of orders will be limited to nursing and only for urgent orders.  Otherwise orders will be entered by the pharmacy and approved in the EHR through the pharmacy link section by nursing or the RCC. Re-training done with RCC and Community Nurse on process to assure scheduled times match order. 3. Quarterly MAR audit while preparing 90 physician orders. Daily review of Exception report in EHR to identify MAR discrepancies or exceptions for quality assurance. RCC performing weekly ordering until scheduled transition to Cycle Fill in September. 4. Community Nurse & ED

4. Resident 6 was admitted in 01/2021 with diagnoses which included heart disease, COPD and constipation. Resident 6's MARs were reviewed for the time period of 10/01/22 through 10/31/22. Staff documented Resident 6 refused: * Bezetri inhaler (for COPD) on two occasions; * Lasix (diuretic) on one occasion; * Oxycodone (for pain) on one occasion; * Guaifenesin (for congestion) on two occasions; and * Miralax powder (for constipation) on 16 occasions. There was no documented evidence the facility notified Resident 6's physician/practitioner of the refusals. In an interview on 11/04/22, Staff 1 (Administrator) and Staff 8 (Administrative Assistant) acknowledged there was no documented evidence the facility had notified the physician/practitioner of the refusals. No further information was provided.

Based on interview and record review, it was determined the facility failed to have a system to ensure the physician or other practitioner was notified if a resident refused consent to an order, for 4 of 4 sampled residents (#s 3, 4, 5 and 6) who had documented medication or treatment refusals. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications. The MAR, reviewed from 10/01/22 through 10/31/22, indicated Resident 3 refused an order to apply a lidocaine patch for 12 hours daily from 10/01/22 through 10/4/22. There was no documented evidence the facility notified the resident's primary care physician of the refusals. The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the facility had not notified the provider of the refusals. 2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain. The MAR, reviewed from 10/01/22 through 10/31/22, indicated Resident 5 refused multiple prescribed medications on multiple occasions including Eliquis (blood thinner), Lyrica (for diabetic nerve pain), Coreg (for high blood pressure and heart disease), Keppra (for seizures), Buspar (for anxiety), Zoloft (for depression) and several different inhaler/nebulizers (to treat respiratory conditions). There was no documented evidence the facility notified the resident's primary care physician of the refusals. The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the facility had not notified the provider of the refusals. 3. Resident 4 was admitted in 10/2020 with diagnoses which included hypertension and lichen planus (irritation of the skin). Resident 4's MARs, dated 10/01/22 through 10/30/22, were reviewed. Staff documented Resident 4 refused: * Amlodipine (for high blood pressure) on one occasion; * Clotrimazole (for rash) on 30 occasions; * Eucerin (for rash) on 19 occasions; * Ketoconazole (for fungal infections) on six occasions; and * Acetaminophen (for pain) on six occasions There was no documented evidence the facility notified Resident 4's physician of the refusals. The need to ensure the physician was notified of medication or treatment refusals was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22 at 1:00 pm. They acknowledged the findings, and no additional information was provided.

4. Resident 6 was admitted in 01/2021 with diagnoses which included hypertension, CHF and COPD. Residents 6's MARs were reviewed from 10/01/22 through 10/31/22 and the following was noted: * Reasons for use was not indicated for all medications. On 11/04/22, the need for the facility to ensure MARs were accurate was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant). They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications and treatments ordered by a legal prescriber and administered by the facility, for 4 of 4 sampled residents (#s 3, 4, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications. Resident 3's 10/01/22 through 10/31/22 MAR was reviewed. The following deficiencies were identified: * Multiple medications lacked a reason for use or diagnosis; * Multiple exceptions lacked an explanation of why the medication was not administered as ordered; * Multiple PRN pain medications (Tylenol, lidocaine patch and naproxen) lacked parameters for unlicensed staff as to when to administer each medication; and * Multiple PRN medications to treat shortness of breath (albuterol inhaler, combivent inhaler) lacked parameters for unlicensed staff as to when to administer each medication. The need to ensure MARs were complete and accurate, and included parameters for PRN medications, was discussed with Staff 3 (Med Room Manager) on 11/01/22 and with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD), seizures, diabetes mellitus - type 2, neuropathy and pain. Resident 5's 10/01/22 through 10/31/22 MAR was reviewed. The following deficiencies were identified: * Multiple medications lacked a reason for use or diagnosis; * Multiple exceptions lacked an explanation of why the medication was not administered as ordered; * Multiple PRN pain medications (Tylenol, morphine) lacked parameters for unlicensed staff as to when to administer each medication; and * Multiple PRN medications to treat shortness of breath (albuteral inhaler, Advair inhaler) lacked parameters for unlicensed staff as to when to administer each medication; and * Multiple PRN medications to treat constipation (Bisacodyl suppository, Senna tablets) lacked parameters for unlicensed staff as to when to administer each medication. The need to ensure MARs were complete and accurate, and included parameters for PRN medications, was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings. 3. Resident 4 was admitted to the facility in 10/2020 with diagnoses which included hypertension and lichen planus (irritation of the skin). Resident 4's MARs, dated 10/01/22 through 10/30/22, were reviewed and the following was revealed: a. The following medications lacked a reason for use or diagnosis: * Amlodipine (for high blood pressure); * Ketoconazole (for fungal infections); * Acetaminophen (for pain); * Meloxicam (for arthritis); * Cephalexin (antibiotic); * Bactrim (antibiotic); * Triamcinolone (for rash); and * Tamsulosin (for enlarged prostate). b. Tylenol #3 (for pain) was administered on 10/27/22 according to the narcotic log and medication card; however, it was not indicated as administered on the MAR. c. Cephalexin 500 mg (antibiotic) - Resident 4 was ordered to be given four capsules a day for seven days with the medication completed on 10/11/22. The MAR indicated it was administered nine additional times after 10/11/22. On 11/01/22 at 2:47 pm, the surveyor and Staff 3 (Med Room Manager) observed/checked the MARs and medication supply. Staff 3 and Staff 11 (MT) confirmed the resident had completed the course of antibiotics and the additional medications were not administered. d. The following medications lacked specific instructions to unlicensed staff: * Clotrimazole (for rash); * Eucerin (for rash); and * Triamcinalone (for rash). The need to ensure MARs were accurate, included reasons for use and medication specific instructions was discussed with Staff 1 (Administrator) and Staff 8 (administrative Assistant). They acknowledged the findings.

2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications. Interviews with Staff 10 (MT) and Resident 3 on 11/04/22 indicated Resident 3 self-administered multiple prescribed inhalers and nebulizer medications. * The facility could not provide written, signed physician's orders for the resident to self-administer the medications; and * The facility had evaluated the resident's ability to safely administer the medications on 6/11/22 but had not re-evaluated the resident quarterly as required. The need to ensure the facility obtained written, signed orders for the resident to self-administer prescribed medications and evaluated the resident's ability to safely self-administer medications quarterly was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who self-administered their medications were evaluated at least quarterly, to assure ability to safely self-administer medication, for 2 of 2 sampled residents (#s 2 and 3). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility 09/2017 with diagnoses including hyperlipidemia. Interviews with Resident 2 on 10/31/22, and Staff 11 (MT) and Staff 17 (MT) on 11/01/22 confirmed the resident administered his/her medications. Review of the resident's medical records revealed at the time of the survey the last self-medication evaluation had been completed on 05/23/22. A current evaluation was requested and completed by Staff 1 (Administrator) on 11/02/22. The need to ensure residents who self-administered their medications were evaluated at least quarterly, to assure ability to safely self-administer medications was discussed with Staff 1 and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the specific reasons for use for PRN psychotropic medications were included on the MAR and non-pharmacological interventions had been documented as attempted and ineffective prior to administering the medication, for 2 of 2 sampled residents (#s 3 and 5) who were prescribed and were administered PRN psychotropic medications. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, chronic pain syndrome and long-term use of opiate analgesic medications. Review of the record indicated Resident 3 had orders for, and was administered, PRN Atarax (for anxiety) on 13 occasions from 10/01/22 through 10/31/22. The following deficiencies were identified: * There were no specific reasons for use documented on the MAR which described how Resident 3 exhibited "anxiety"; * There were no non-pharmacological interventions listed for staff to attempt prior to considering administering the medication; and * The facility failed to document non-pharmacological interventions were attempted and were ineffective prior to administering the medication. The need to ensure there were specific reasons for use and non-drug interventions were attempted and ineffective prior to administering a PRN psychotropic medication was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the deficiencies. 2. Resident 5 was admitted to the facility in 03/2016 with diagnoses including congestive heart failure, cardiomyopathy, COPD, seizures, diabetes mellitus - type 2, neuropathy and pain. Review of the record indicated Resident 5 had orders for PRN Haldol for "severe psychosis" and PRN lorazepam for "anxiety or agitation." The MAR indicated the resident was administered the lorazepam on 12 occasions from 10/01/22 through 10/31/22. The following deficiencies were identified: * There were no specific reasons for use documented on the MAR which described how Resident 3 exhibited "severe psychosis" or "anxiety or agitation"; * There were no non-pharmacological interventions listed for staff to attempt prior to considering administering the medications; and * The facility failed to document non-pharmacological interventions were attempted and were ineffective prior to administering the medications. The need to ensure there were specific reasons for use and non-drug interventions were attempted and ineffective prior to administering a PRN psychotropic medication was reviewed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the deficiencies.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation was completed and documented for 4 of 4 newly-hired staff (#s 10, 14, 17 and 18) and infectious disease prevention training was completed for 1 of 2 veteran staff (#6). Findings include, but are not limited to: On 11/03/22 and 11/04/22 training records were reviewed with Staff 4 (Business Office Manager). The following deficiencies were identified: a. Staff 10 (CG) was hired on 06/15/22 and had not completed pre-service training in the following areas required of all employees: * Resident rights and values of CBC care; * Infectious disease prevention training; and * Fire safety and emergency procedures. b. Staff 14 (Cook) was hired on 07/05/22 and had not completed pre-service training in the following areas prior to performing any job duties: * Resident rights and values of CBC care;   * Infectious Disease Prevention; and * Fire safety and emergency procedures. c. Staff 17 (MT) was hired on 09/20/22 and had not completed pre-service training in the following areas required of all employees: * Resident rights and values of CBC care; * Abuse reporting requirements; * Infectious Disease Prevention training; * Fire safety and emergency procedures; and * Pre-service dementia training. d. Staff 18 (CG) was hired on 09/21/22 and had not completed pre-service training in the following areas required of all employees: * Resident rights and values of CBC care; * Abuse reporting requirements; * Infections disease prevention training; * Fire safety and emergency procedures; and * Pre-service dementia training. e. Staff 6 (Activity Director) was hired on 05/01/22 and had not completed infectious disease prevention training by 07/01/2022. The need to ensure all newly hired staff completed pre-service orientation training prior to providing care and services independently, and veteran staff completed infectious disease prevention was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 10, 16 and 23) demonstrated competency in all required areas within 30 days of hire. Review of the facility's training records on 11/03/22 and 11/04/22 revealed the following: a. Staff 10 (CG) was hired 06/15/22 and did not have documented evidence of competency demonstrated in the following areas: * Providing assistance with ADLs; and * Changes associated with normal aging. b. Staff 16 (CG) was hired 06/13/22 and did not have documented evidence of competency demonstrated in the following areas: * Providing assistance with ADLs; * General food safety, serving and sanitation; and * First Aid/Abdominal Thrust. c. Staff 23 (CG) was hired 06/06/22 and did not have documented evidence of competency demonstrated in the following areas: * Providing assistance with ADLs; * General food safety, serving and sanitation; and * First Aid/Abdominal Thrust. The need to ensure all newly hired staff had competency demonstrated in all areas required within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 veteran direct care staff (#s 11, 12 and 15) 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 11/03/22 and 11/04/22 revealed the following: *Staff 11 (MT) hired 05/14/20 did not have documented evidence of six hours of annual in-service training related to provision of care in CBC; and *Staff 12 (CG) hired 04/01/09 and Staff 15 (CG) hired 12/14/20, did not have documented evidence of six hours of annual in-service training related to provision of care in CBC and six hours related to dementia care. 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 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22.  They acknowledged the findings.

Based on interview and record review, it was determined that the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records from 05/2022 through 10/2022 were reviewed. The fire drill records did not consistently include documentation of the following required components: * Escape route used; * Evacuation time-period needed; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills. On 11/01/22 an interview with Staff 5 (Facility Services Director) revealed the facility was not relocating or evacuating residents as part of the fire drill process. The need to ensure the facility conducted and documented fire drills according to the OFC was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22.  They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting spaces inside or outside the building in the event of an actual fire at least annually. Findings include, but are not limited to: On 11/01/22, Staff 5 (Facility Services Director) was asked to explain the process of providing resident instruction on general safety procedures upon admission and re-instruction annually.  Staff 5 stated fire drill and safety procedures were reviewed with residents upon admission, however re-instruction was not provided annually. The need to ensure residents were instructed on general safety procedures and re-instructed at least annually was discussed with Staff 1 (Administrator) and Staff 8 (Administrative Assistant) on 11/04/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents was kept clean, in good repair, and free from odors. Findings include, but are not limited to: Observations of the facility on 10/31/22 and 11/01/22 revealed the following: * Resident rooms 103, 111, 112, 115, 118, 121, 125, 126, 129, 133, 134, 136, 138, 139, 142, 144, 151 and 153 had scraped doors and/or jambs; * The front entrance doors had scraped paint in several areas; * Sitting benches in the hallways had numerous stains on their fabric seats; * Hallway exit doors throughout the facility had scraped paint on doors and/or jambs, and spiders/webs/dirt/debris around the door frames. Wall heating units adjacent to exit doors had an accumulation spills/splatters on the exteriors and dirt/debris underneath them; * Windows/sills located next to Rooms 133 and 142 had an accumulation of dead bugs, dirt and debris; * The resident laundry room had laminate missing from edge of the folding counter, the floor had an accumulation of dirt, lint and debris along the perimeter and around appliances, and the door had scraped paint in several areas; * The activity room door had scraped paint in several areas; * Two common hallway bathrooms had urine odors and discolored caulking around toilet bases; * The employee laundry room had scraped paint on the door and jamb, laminate missing from the edge of the folding counter, a floor basin had an accumulation of black matter and debris, the window sill had peeling paint, and flooring surrounding the floor drain was cracked and peeling away from the drain; * Several dining chairs had scraped legs, the beverage counter was missing laminate from the edge, the beverage sink had brown matter in the basin and around the faucet, and several windowsills had scraped paint; * Pervasive odors were noted in halls and common areas during the survey; and * The exterior walking path to the side and rear of the building had an approximate 2-4-inch drop between the sidewalk and planting bed. Additionally, ground lighting along the path was broken in several areas. The surveyor toured the environment with Staff 1 (Administrator) and Staff 5 (Facility Services Director) on 11/01/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 303.

1. NA 2. See POC for 303 3. See POC for 303 4. Community Nurse and ED

The findings of the change of ownership survey conducted 10/31/22 through 11/04/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the re-licensure survey of 11/04/22, conducted 07/25/23 through 07/26/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities. 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 2nd revisit to the re-licensure survey of 11/04/22, conducted 09/21/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/18/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/18/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/18/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/18/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 8/18/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation, interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for 1 of 5 sampled residents (# 1) who experienced short term changes of condition related to skin and behavior.  Findings include, but are not limited to: Resident 1 was admitted to the facility in 2019 with diagnoses including depression. Progress notes reviewed from 7/1/21 through 8/2/21 noted the following: a. On 7/1/21, Resident 1 was noted to have a "new sore" on the front of the left shin.  HH was noting treatment to the area weekly through 7/16/21.  There was no documented evidence the facility documented contributing factors to the development of the skin change and there were no actions or interventions determined or communicated to staff including a treatment record. During an observation on 8/4/21 at 10:00 am, Resident 1's lower left leg was exposed and there were no sores or treatment applied to the shin. * On 7/21/21, the resident was noted to have a "large quarter size blood blister...(R) side of great toe".  On 7/23/21 the blister "popped" staff administered first aid.  Resident 1's toe was monitored and on 8/3/21 the facility RN assessed the area and applied a clean dressing. On 8/3/21 at 10:07 am, Resident 1's left lower foot was observed to have a dressing in place. Resident 1 had a change of condition related to a blister on the toe and there was no documented evidence reviewing contributing factors to the toe injury and no actions or interventions determined or communicated to staff including treatment instructions. b. Resident 1's current service plan and evaluation noted a history of behaviors including agitation, anxiety, depression and a history of suicidal ideation. The service plan identified multiple non-drug interventions to use when behaviors were present. Progress noted dated 7/28/21 and 7/29/21 noted the resident had increased confusion, was hallucinating and was not recognizing staff.  On 7/29/21, the resident was placed on alert charting related to a new PRN medication for behaviors. Resident 1 experienced a change of condition related to behaviors. There was no documented evidence the facility evaluated the resident to determine contributing factors prior to acquiring an PRN medication for behaviors. The medication was administered one time from 7/29/21 until the time of the survey 8/3/21. Resident 1 experienced changes of condition related to skin and behavior. There was no documented evidence the changes were evaluated to determine causal factors contributing to skin injuries and behavior change. There were no actions or interventions identified to treat the resident's skin. The changes of condition were discussed with Staff 3 (RN) and Staff 17 (Regional Operations Director) on 8/3/21 and 8/4/21 respectively. Staff acknowledged the findings.

a. Resident 1 wound: on 8/3/21 the community RN wrote a note characterizing the wound, developed a treatment plan and communicated the plan to staff in an Interim Service Plan, put treatment instructions on the MAR, and interviewed the resident as to the cause of the injury. The wound was placed on the skin log so that it can be followed up on at least weekly until it is healed. b. Resident 1 behavior: resident was seen by her PCP on 8/6/21 and the psychotropic medication was changed from PRN to a low dose once daily at bedtime. RN completed a significant change of condition assessment regarding the two issues: mental health/behavior changes and skin injury. Staff have been trained about new interventions that have resulted from this assessment which includes an updated service plan. Corrective actions: 1. There has been all staff training on identifying and reporting resident changes of condition utilizing the change of condition guidelines. In addition, the med room manager and other clinical staff have been trained in the actions required to thoroughly evaluate both short-term and long- term changes of condition, how to prepare appropriate interventions, and how to document the evaluations and interventions. New hire nurses and clinical staff will also receive this training. 2.The clinical team, the Executive Director (ED) and the Assistant Executive Director (AED) will conduct a meeting once a week to review the 24-hour log notes, recent behavior changes, new skin problems, etc. and to determine appropriate evaluation and treatment based on the change of condition guidelines. 3. Effectiveness of interventions will be evaluated at the daily standup meeting. 4. A review of all resident progress notes will be completed to ensure that there are no missing changes of condition that have not been properly followed up on. 5. The ED and AED will provide oversight to ensure that the evaluations and documentation are completed and that interventions are implemented and monitored.

2. a. Resident 1's 7/1/21 through 7/31/21 MAR was reviewed and noted the following: *Furosemide (for water retention) and Potassium (supplement) to be administered PRN. There were no clear instructions to staff regarding when the furosemide and potassium should be administered and for what symptoms. b.  Resident 3's 7/1/21 through 7/31/21 MAR was reviewed and noted the following: *Bumetanide (used for edema) PRN for excessive swelling. There were no clear instructions to staff regarding what excessive swelling was and when to administer the medication. Resident 1 and 3's MARs and PRN medication used for water retention and swelling without clear instructions for administration was reviewed with Staff 3 (RN) and Staff 17 (Regional Operations Director) on 8/3 and 8/4/21 respectively.  Staff acknowledged the lack of parameters for the PRN medications.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, provided clear instruction and parameters for administration of PRN medications for 4 of 5 sampled residents (#s 1, 2, 3 and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Review of Resident 2's MAR dated 7/1/21 - 7/31/21 identified the following: * The physician ordered Lexapro 20 mg, which was transcribed incorrectly to the MAR on 7/1/21. The need to ensure an accurate MAR was kept of all medications administered by the facility was discussed with Staff 3 (RN) and Staff 17 (Regional Operations Director) on 8/4/21. They acknowledged the findings. 3. Resident 5 was admitted to the facility in January 2021 with diagnoses including diabetes. The resident's 7/01/21 through 7/31/21 MAR and current physician orders were reviewed and revealed the following: The physician orders noted the resident was to receive sliding scale insulin three times daily. On 7/5/21, 7/12/21, and 7/28/21, Resident 5's sliding scale insulin was incorrect and there were 58 occasions in July 2021 the resident received the wrong dose of insulin. The facility failed to have an accurate MAR related to insulin administration. The need for accurate records was discussed with Staff 1 (Executive Director), Staff 2 (RN)and Staff 4 (Operations Director) on 8/4/21. They acknowledged the findings.

C310 Resident 2: the incorrect entry on the medication administration record (MAR) for Lexapro was corrected. (The staff checked the PCP order and the pharmacy delivery records and determined that the resident received the correct dosage - there was no medication error.) Resident 1: At an 8/6/21 PCP appointment, orders for furosemide and potassium were changed from PRN to routine. This was entered correctly on the MAR. Resident 3: PCP was contacted for instructions on when to administer bumetanide. As a result, the medication was discontinued, and the MAR was updated on 8/11/21. Resident 5: The MAR software requires that, when entering provider instructions for sliding scale insulin, a value be entered, which results in a 1 being pre-populated in the insulin administered box. After administering sliding scale insulin, med techs must change that value. The correct way to do this was addressed to all med techs in a group text and at a med tech meeting on 7/28/21. 1:1 reminder by RN have also occurred. Corrective actions: 1. All med techs have had additional training on the correct way to document on the MAR how much insulin was administered. 2. A triple check system for entering new medications has been implemented and staff involved in this process have been trained. 3. The triple check system is being reviewed 5 days a week at the clinical team meeting. 4. A medication review will occur quarterly during the interdisciplinary team meeting. This will also be done when a significant change of condition is documented. 5. A weekly audit of all sliding scale insulin administered during the previous week will ensure that values have been correctly documented. If audit results find an error, the med tech will be required to correct it immediately to ensure an accurate MAR. 6. Every 90 days updated medication orders will be requested of the PCP for all residents. These will be reviewed by clinical team members to ensure these have been correctly implemented.

The findings of the Change of Owner re-licensure survey conducted 08/2/21 through 8/04/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the revisit to the re-licensure survey of 08/04/2021, conducted 11/23/21, 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.