Woodland Heights Assisted Living

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) whose initial evaluation was reviewed. Findings include, but are not limited to:

Resident 3 moved into the facility in 09/2024 with diagnoses including chronic obstructive pulmonary disease, protein calorie malnutrition and breast carcinoma.

The initial evaluation was reviewed and failed to address the following required elements:

* Customary routines including sleeping, eating and bathing;
* Spiritual, cultural preferences and traditions;
* Physical health status including list of medications and PRN use, visit to health practitioner, ER, hospital or nursing facility;
* Mental health issues including history of treatment and effective non-drug interventions;
* Personality including how the person copes with change or challenging situations;
* Pain including pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;
* Complex medication regimen;
* History of dehydration or unexplained weight loss or gain;
* Recent losses;
* Unsuccessful prior placements;
* Elopement risk or history;
* Smoking, ability to smoke safely; and
* Alcohol and drug use, not prescribed by a physician must be evaluated and addressed.

The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (Administrator), Staff 3 (RCC) and Staff 22 (Contract RN Consultant) on 11/22/24 at 10:11 am. Staff acknowledged the findings.

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were updated quarterly, reflective of residents' current care needs, provided clear direction regarding the delivery of services and was implemented for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 09/2024 with diagnoses including chronic obstructive pulmonary disease, protein calorie malnutrition and breast carcinoma.

Observations of the resident, interviews with staff and the resident and the 10/28/24 service plan and Resident Care Interim Service, from 09/22/24 thru 11/18/24, reviewed during the survey, revealed Resident 3's service plan was not reflective of his/her status and did not provide clear direction regarding the delivery of services in the following areas:

* Medication management status;
* Oxygen treatment including care instruction;
* Mobility assistance;
* Bathing assistance;
* Conflicting information on dressing assistance;
* Grooming assistance;
* Toileting assistance;
* Pain including location of pain and non-drug interventions;
* Evacuation assistance;
* Use of a side rail;
* Personality with coping skills;
* History of dehydration or unexplained weight loss or gain; and
* Transfer assistance.

On 11/22/24 at 10:11 am, the service plan was discussed with Staff 1 (Administrator), Staff 3 (RCC) and Staff 22 (Contract RN Consultant). Staff acknowledged the service plan was not reflective of the resident's status and lacked clear direction to staff.

2. Resident 6 moved into the facility in 12/2022 with diagnoses including essential primary hypertension.

Observations of the resident, interviews with staff and the 11/09/24 service plan reviewed during the survey, revealed Resident 6's service plan did not provide clear direction regarding the delivery of services in the following areas:

* Use of bilateral side rails.

On 11/22/24 at 10:48 am, the service plan was discussed with Staff 1 (Administrator), Staff 3 (RCC) and Staff 22 (Contract RN Consultant). Staff acknowledged the service plan lacked clear direction to staff for the use of side rails.

3. Resident 1 moved into the facility in 03/2022 with diagnoses including anorexia and dementia.

The resident's service plan, dated 09/30/24, and Interim Service Plans were reviewed. Resident 1 and staff were interviewed. The service plan lacked information relating to the resident's current needs and/or clear direction regarding the delivery of services, in the following areas:

* Meal specific information and where the resident preferred to eat;
* Leisure and facility activity preferences;
* Skin monitoring and current skin issues;
* Nightly checks;
* What to monitor for relating to cognition changes;
* Interventions relating to anger in the late afternoon or early evening;
* Staff to assist with television and cell phone use;
* Going out into the community for church services; and
* Weight loss interventions.

The need to ensure service plans were reflective of the resident's current needs and provided clear direction regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) on 11/22/24 at 11:11 am. They acknowledged the findings.

4. Resident 2 moved into the facility in 11/2021 with diagnoses including congestive heart failure.

The resident's service plan, dated 07/30/24, and Interim Service Plans and Alert Charting documents, dated 08/30/24 through 09/16/24, were reviewed and staff were interviewed.

There was no documented evidence the service plan had been completed quarterly.

The need to ensure service plans were completed quarterly was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) on 11/22/24 at 11:29 am. They acknowledged the findings.

5. Resident 4 moved into the facility in 07/2024 with diagnoses including vertigo and major depression.

The resident's service plan, dated 11/05/24, and Interim Service Plans, dated 07/31/24 through 11/20/24, were reviewed, observations were made, and interviews with the resident and staff were conducted. Resident 4's service plan lacked clear direction regarding the delivery of services and/or was not implemented in the following areas:

* Mental health status including resident specific interventions for the recent loss of his/her spouse;
* Frequency of check-ins with the resident;
* Level of shower assistance required, including resident preferences;
* Current pain including pain in the right shoulder; and
* Dress assistance required including use of an arm sling.

The need to ensure the service plan provided clear direction regarding the delivery of services and implementing these services was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) on 11/22/24 at 1:05 pm. They acknowledged the findings.

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

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

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

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

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

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, referred to the RN for an assessment and service plan updated as needed and/or failed to determine and document what action or intervention was needed for residents, communicate actions to staff on each shift and document weekly progress through resolution for 3 of 4 sampled residents (#s 1, 3, and 4) reviewed with changes of condition. Resident 1 experienced ongoing weight loss. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 03/2022 with diagnoses including anorexia and dementia.

a. During the acuity interview on 11/19/24 at 9:20 am, Resident 1 was identified to have experienced weight fluctuations.

The resident's weight records, Alert Charting Notes, 09/30/24 service plan, and Interim Service Plans were reviewed. Resident 1 and staff were interviewed.

The service plan indicated the resident enjoyed “all kinds of food” and although was not a “breakfast person”, preferred “to eat something lite around mid-morning (coffee, fresh fruit, and a piece of toast).” The service plan reflected that his/her favorite meal was dinner, that the resident ate breakfast and lunch in his/her apartment but preferred to eat in the dining room for dinner in which s/he enjoyed “a glass of wine with dinner.”

Resident 1's weight records were reviewed during the survey and revealed the following:

* 06/15/24: 91.8 pounds;
* 07/15/24: 91.12 pounds;
* 08/15/24: no weight documented;
* 09/16/24: 84 pounds;
* 10/15/24: 77.12 pounds; and
* 11/15/24: 70.8 pounds.

Between 06/15/24 and 09/16/24 the resident experienced a loss of 7.8 pounds, or 8.49% of his/her total body weight, in approximately three months. This constituted a severe loss and was considered a significant change of condition. There was no documented evidence the facility evaluated the resident, referred the significant weight loss to the facility nurse for assessment, or updated the service plan.

Weights documented on 10/15/24 revealed the resident experienced another severe weight loss of 6.88 pounds, or 8.19% of his/her body weight in one month, and again on 11/15/24 with a severe weight loss of 6.32 pounds, or an additional 8.19% of his/her total body weight in one month.

Between 06/15/24 and 11/15/24 the resident experienced a loss of 21 pounds, or 22.87% of his/her body weight in six months.

On 10/25/24, Staff 2 (RN) faxed Resident 1’s physician stating, “Sending you monthly weights on [the resident]. I did let [family] know as well. For now our staff will encourage oral intake. Please advise.” The physician responded on 10/30/24 with, “Noted, thanks for the update, agree with encouraging [oral] intake.”

On 10/30/24, an Interim Service Plan was created and directed staff to “Encourage and/or remind food intake.”

A document entitled, Encourage Food Intake, was reviewed. Staff signed three times a day from 10/30/24 through 11/19/24 that they encouraged Resident 1 to eat. The following was noted:

* 10/31/24 at 11:30 am: resident refused;
* 10/31/24 at 8:51 pm: staff was unsure if the resident ate that day, encouraged him/her to “come down [to the dining room] or at least have a snack.” The resident declined to do either;
* 11/06/24 at 9:14 pm: “ate about 1/3 of the whole main entrée”;
* 11/08/24 at 1:05 pm: staff reported the resident vomited “all [his/her] lunch; and
* 11/18/24 at 8:08 am: “[S/he] was sleeping, [s/he] said [they’ll] be down to breakfast soon”.

Observations of the resident on 11/19/24 and 11/20/24 at approximately 11:45 am on both days, revealed that Resident 1 would go to the dining room, pick up a room tray, and leave.

In an interview with Staff 2 on 11/19/24 at 3:48 pm, she stated Resident 1 was on “meal monitoring.” The resident had been having some difficulty with swallowing and had a swallow study scheduled in 12/2024. Staff 2 reported she “was not looking” at the resident’s weights in 09/2024 and that the resident “looked the same” to her at that time.

No documented evidence of meal monitoring was provided during survey.

In an interview with Resident 1 on 11/20/24 at 10:49 am, s/he reported that the food was “Generally pretty good. I like things plain so I can taste what flavors go with the food. I don't want breakfast, just black coffee. I eat lunch and dinner usually. Sometimes my sister sends me a bottle of wine to have with dinner.”

While in the resident’s apartment, a small container of vanilla yogurt and a half of a sandwich were observed, still sealed and uneaten.

Resident 1 was observed eating lunch with Staff 16 (Community Relations Director) on 11/21/24 at 11:50 am. At 12:47 pm, Staff 16 reported the resident at “90% of [his/her] meal; all of the fish, a couple bites of the wild rice, all of the watermelon, and a cup of clam chowder.”

In an interview with Staff 10 (Resident Assistant) on 11/21/24 at 11:59 am, it was confirmed that encouraging Resident 1 to eat more food worked “sometimes but not always.” Staff 10 stated that the resident goes to the dining room “most of the time” for breakfast, s/he would order black coffee and the entrée. The staff member confirmed Resident 1 “usually” ate most of the entrée and drank 100% of the coffee during their workdays. Staff 10 reported the resident would usually go to the dining room to pick up his/her lunch, then take it back to their apartment.

The facility’s failure to evaluate the resident’s significant weight loss, refer to the RN for an assessment and update the service plan as needed, and/or failure to determine and document what action or intervention was needed for the resident, communicate those actions or interventions to staff on each shift and document weekly progress through resolution resulted in a serious risk of harm to the resident.

On 11/21/24 at 11:10 am, an immediate plan of correction was requested. An acceptable plan of correction was received from the facility at 4:28 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

Resident 1's weight loss was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (RCC), and Staff 21 (Regional Operations) on 11/21/24 during the survey. They acknowledged the findings.

b. Resident 1's Alert Charting Notes, MARs, dated 10/01/24 through 11/19/24, and Interim Service Plans were reviewed. Staff were interviewed and the following changes of condition were identified:

* 10/09/24: Resident 1's diastolic blood pressure (DBP) was documented as 57. The resident had an order to contact the physician if the DBP was under 60;
* 11/02/24: The resident started antibiotics for a urinary tract infection;
* 11/08/24: Resident 1 went to the Emergency Room for nausea, vomiting, and a swollen tongue, returning to the facility on the same day;
* 11/09/24: The resident's DBP was documented as 56; and
* 11/16/24: Staff documented Resident 1 was not able to swallow two medications: venlafaxine (for depression) and cerovite (supplement).

There was no documented evidence the changes of condition were evaluated, actions or interventions were determined, the actions or interventions were communicated to staff on each shift, or the changes of condition had documentation of weekly progress noted through resolution.

The need to ensure the facility monitored changes of condition through evaluation, determine actions or interventions needed, those actions or interventions were communicated to staff on each shift, and weekly progress was noted through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) on 11/22/24 at 11:11 am. They acknowledged the findings.

2. Resident 3 moved into the facility in 09/2024 with diagnoses including chronic obstructive pulmonary disease and breast carcinoma.

Resident 3's alert charting notes, dated 09/22/24 through 11/13/24 and the Resident Care Interim Service, from 09/22/24 thru 11/18/24, were reviewed during the survey and the following was noted:

* 09/22/24: New environment;
* 09/27/24: Skin tear on the right leg; and
* 09/27/24: Multiple medications changes including inhalers for chronic obstructive pulmonary disease.

11/20/24 at 9:26 am, Staff 2 (RCC) confirmed there was no additional information.

There was no documented evidence the resident’s short-term changes of condition were monitored and documented at least weekly until the conditions resolved.

On 11/22/24 at 10:11 am, the above information was discussed with Staff 1 (Administrator), Staff 3 (RCC) and Staff 22 (Contract RN Consultant). Staff acknowledged the findings.

3. Resident 4 moved into the facility in 07/2024 with diagnoses including vertigo and major depression.

The resident's 11/05/24 service plan, 07/31/24 through 11/20/24 Interim Service Plans, Alert Charting Notes, and incident reports were reviewed. Observations were made and interviews with Resident 4 and staff were conducted. The following changes of condition were identified:

* 08/26/24: COVID positive;
* 09/10/24: Spouse passed;
* 11/03/24: Unwitnessed fall; and
* 11/09/24: Comfort – ice pack for right shoulder.

The facility lacked documented evidence the above changes of condition were monitored at least weekly, through resolution.

On 11/22/24 at 8:12 am, Staff 3 (RCC) confirmed there was no additional documentation the above referenced changes of condition were monitored at least weekly through resolution.

The need to ensure changes of condition had documentation of weekly progress until resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3, and Staff 22 (Contract RN Consultant) on 11/22/24 at 1:05 pm. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (# 1) who experienced a significant change of condition with weight. Resident 1 experienced on-going weight loss. Findings include, but are not limited to:

Resident 1 moved into the facility in 03/2022 with diagnoses including anorexia and dementia.

During the acuity interview on 11/19/24 at 9:20 am, the resident was identified to have experienced weight fluctuations.

Resident 1's weight records were reviewed during the survey and revealed the following:

* 06/15/24: 91.8 pounds;
* 07/15/24: 91.12 pounds;
* 08/15/24: no weight documented;
* 09/16/24: 84 pounds;
* 10/15/24: 77.12 pounds; and
* 11/15/24: 70.8 pounds.

During the six-month period between 06/2024 and 11/2024, Resident 1 lost 21 pounds or 22.87% his/her body weight resulting in a severe weight loss and significant change of condition. There was no documented evidence the significant change of condition had been evaluated or referred to the facility RN for an assessment which included findings, resident status, and interventions made as a result of the assessment. This resulted in a serious risk of harm to the resident.

On 11/21/24 at 11:10 am, an immediate plan of correction was requested. An acceptable plan of correction was received from the facility at 4:05 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

The need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment, as well as ensuring they were completed in a timely manner, was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 21 (Regional Operations) on 11/21/24 during the survey. They acknowledged the findings.

Refer to C 270, example 1a.

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.

This Rule is not met as evidenced by:

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 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 03/2022 with diagnoses including anorexia and dementia.

The resident's 10/01/24 through 11/19/24 MARs and physician’s orders were reviewed, and the following was identified:

a. The following medications were not administered per physician's orders:

* Cephalexin (for infection) – once;
* Cefuroxime (for infection) – once;
* Melatonin (for insomnia) – twice;
* Simvastatin (for high cholesterol) – twice;
* Refresh liquid gel (for dry eyes) – three times; and
* Refresh eye drops (for dry eyes) – three times.

b. Resident 1 had a physician’s order for the facility to check his/her blood pressure and to notify the physician if the PCP if the diastolic blood pressure (DBP) was “more than 90 or less than 60 after re-check”.

On 10/09/24 the resident’s DBP was documented as 57 and on 11/09/24 the DBP was documented as 56.

There was no documented evidence the blood pressure was re-checked or that the physician was notified.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) on 11/22/24 at 11:11 am. They acknowledged the findings. No additional information was received.
2. Resident 2 moved into the facility in 11/2021 with diagnoses including congestive heart failure.

The resident's 10/01/24 through 11/19/24 MARs and physician’s orders were reviewed, and the following was identified:

The following medications were not administered per physician's orders:

* Midodrine (for chronic diastolic heart failure); and
* Fluticasone (for postnasal drip).

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) on 11/22/24 at 11:29 am. They acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 3) who had documented medication refusals. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 09/2024 with diagnoses including chronic obstructive pulmonary disease and breast carcinoma.

Resident 3’s 10/03/24 through 11/19/24 MARs were reviewed during the survey and showed staff documented the resident refused physician-ordered, the following scheduled medications:

* Amiodarone (to maintain heart rhythm) on 10 occasions;
* Acetaminophen (for pain) and Sennoside (for constipation) on 22 occasions;
* Apixaban (for irregular heart rate) and Magnesium oxide (for bowel care) on 14 occasions;
* Calcium (for supplement) on seven occasions;
* Furosemide (for fluid retention) and Montelukast (for allergy/hyper reactivity) on six occasions;
* Melatonin (for sleep), Vitamin B12 (for supplement) and Zinc (for supplement) on five occasions;
* Milk of Magnesia (for constipation) on eight occasions;
* Morphine (for pain) on 11 occasions;
* “Multiple Vitamin” (for supplement) on nine occasions;
* MiraLAX (for constipation) on 13 occasions; and
* Potassium Chloride (for supplement) on four occasions.

There was no documented evidence the facility notified Resident 3's physician of the refusals.

On 11/22/24 at 10:11 am, the refusals were reviewed with Staff 1 (Administrator), Staff 3 (RCC) and Staff 22 (Contract RN Consultant). Staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure MARs were kept accurate, included a reason for use, resident-specific parameters for PRN medications and medication-specific instruction to instruct non-licensed staff for 3 of 4 sampled residents (#s 1, 2 and 3) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 09/2024 with diagnoses including chronic obstructive pulmonary disease and breast carcinoma.

a. Resident 3's 10/03/24 through 11/19/24 MARs were reviewed and identified the following medications lacked clear instructions for the sequential use:

* Oxycodone, every 4 hours as needed for pain;
* Morphine, every 2 hours as needed for pain;
* Morphine every 2 hours as needed for shortness of breath; and
* Albuterol Sulfate as needed for shortness of breath.

There were no clear instructions or parameters for the sequential use for PRN bowel and PRN shortness of breath medications.

b. The MAR lacked resident specific parameters and clear instructions for unlicensed staff with the following medications:

* Sennoside 2 tablets twice daily as needed for constipation lacked clear parameters on when to administer;
* Oxygen via nasal 2 to 4 L/min lacked clear parameters on when to administer 2 L/min versus 4L/min oxygen; and
* Albuterol Sulfate every 4 to 6 hours as needed regarding 4 hours versus 6 hours.

The need to ensure the MAR was kept accurate and included resident-specific parameters and clear instructions for unlicensed staff to follow was reviewed with Staff 1 (Administrator), Staff 3 (RCC) and Staff 22 (Contract RN Consultant) on 11/22/24 at 10:11 am. Staff acknowledged the findings.

2. Resident 1 moved into the facility in 03/2022 with diagnoses including anorexia and dementia.

The resident’s 10/01/24 through 11/19/24 MARs were reviewed, and the following was identified:

a. Two medications, azithromycin and cefuroxime, were missing a reason for use.

b. The order for azithromycin directed staff to administer the medication once daily for three days. Staff initialed the MAR as administering the medication for four days.

c. The following medications lacked clear instructions for the sequential use for PRN bowel medications:

* Docusate; and
* Milk of magnesia.

The need to ensure resident MARs included a reason for use, were accurate, and had resident-specific parameters for PRN medications was reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) on 11/22/24 at 11:11 am. They acknowledged the findings.

3. Resident 2 moved into the facility in 11/2021 with diagnoses including congestive heart failure.

The resident’s 10/01/24 through 11/19/24 MARs were reviewed, and the following was identified:

a. Scheduled quetiapine was missing a reason for use.

b. The following medications lacked clear instructions for the sequential use for PRN nausea medications:

* Ondansetron;
* Prochlorperazine maleate; and
* Promethazine.

The need to ensure resident MARs included a reason for use and had resident-specific parameters for PRN medications was reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) on 11/22/24 at 11:29 am. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer medications had an evaluation completed at least quarterly to determine their ability to self-administer medications and obtained a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 2 sampled residents (# 3) reviewed for self-administration. Findings include, but are not limited to:

Resident 3 moved into the facility in 09/2024 with diagnoses including chronic obstructive pulmonary disease.

Resident 3's 10/03/24 through 11/19/24 MARs were reviewed and identified the resident administered his/her own prescription inhalers.

On 11/22/24 at 9:27 am, Albuterol (for wheezing) and Incruse (for chronic obstructive pulmonary disease) inhalers were observed to be attached to the spacer in his/her room and Resident 3 reported s/he used the inhalers.

The last signed physician orders in the resident’s record dated 09/26/24. There was no indication in the signed orders that the resident could self-administer his/her own inhalers. Additionally, there was no evaluation of the resident’s ability to safely administer his/her medications in the record.

The need to ensure residents who self-administered their medications were evaluated at least quarterly and obtained a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications, was discussed with Staff 1 (Administrator), Staff 3 (RCC) and Staff 22 (Contract RN Consultant) on 11/22/24 at 10:11 am. Staff acknowledged the findings.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds

(5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 1 of 1 sampled resident (# 3) who was prescribed PRN medications to address behaviors. Findings include, but are not limited to:

Resident 3 moved into the facility in 09/2024 with diagnoses including chronic obstructive pulmonary disease and breast carcinoma.

Review of the resident's 10/03/24 through 11/19/24 MARs, 09/22/24 through 11/13/24 alert charting notes and 10/28/24 physician orders showed the following:

* Lorazepam 0.25 mg to 0.5 mg tablet, every four hours PRN for anxiety.

The Lorazepam PRN dose was administered 18 times in November 2024 and there was no administration of the PRN Lorazepam in October 2024.

The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety. Additionally, there was no documentation of what non-drug interventions were attempted and ineffective, prior to administration of the medication.

The need to ensure resident-specific information on how the resident expressed anxiety and non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 3 (RCC) and Staff 22 (Contract RN Consultant) on 11/22/24 at 10:11 am. Staff acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to have a sufficient number of direct-care staff to meet the 24-hour scheduled and unscheduled needs of each resident. The following was revealed:

The facility’s ABST entries, staff schedule, calculated staffing hours, and posted staffing plan were reviewed and interviews were conducted. The following was revealed:

The ABST entries determined the facility required a minimum of 75.5 hours of direct care staff a day.

The posted staffing plan and staff schedule reviewed from 11/12/24 through 11/18/24 identified direct care staff were scheduled for 71.5 - 73.5 hours a day.

On 11/20/24 at 10:40 am, Staff 1 (Administrator), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) confirmed they were unaware the posted staffing plan and staff schedule did not meet the calculated ABST time.

The need to ensure the facility had a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident was discussed with Staff 1, Staff 2 (RN), Staff 3, and Staff 22 on 11/22/24 at 1:05 pm. They acknowledged the findings.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

(Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to accurately capture care time for the care elements that staff provided as outlined in each individual service plan for 3 of 4 sampled residents (#s 1, 3, and 4) whose ABST minutes were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 07/2024 with diagnoses including vertigo and major depression.

The resident's service plan dated 11/05/24, Interim Service Plans (ISPs) and alert charting documentation dated 07/31/24 through 11/20/24, and the resident’s ABST data was reviewed. The resident and staff were interviewed and observations were made.

The following areas were not reflective of the resident's current ADL assistance:

* Safety checks, fall prevention;
* Responding to call lights;
* Monitoring physical conditions or symptoms;
* Providing non-drug interventions for pain management;
* Supervising, cueing, or supporting while eating;
* Ambulation, escorting to and from meals or activities;
* Bathing;
* Dressing and undressing; and
* Resident specific laundry services performed by care staff.

On 11/22/24 at 8:51 am, Staff 1 (Administrator) and Staff 3 (RCC) reviewed the residents ABST record with this surveyor and acknowledged the inaccuracy of time documented.

The need to ensure the ABST care elements accurately captured the care time that staff provided as outlined in each individual service plan was discussed with Staff 1, Staff 2 (RN), Staff 3, and Staff 22 (Contract RN Consultant) on 11/22/24 at 1:05 pm. They acknowledged the findings.

2. Resident 1 moved into the facility in 03/2022 with diagnoses including anorexia and dementia.

The resident's service plan, dated 09/30/24, and Interim Service Plans were reviewed. Resident 1 and staff were interviewed. The facility failed to capture resident specific care time on the ABST in the following areas:

* Monitoring behavioral conditions or symptoms;
* Assisting in leisure activities; and
* Supervising, cueing, or supporting while eating.

The need to capture resident specific care time on the facility’s ABST was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) on 11/22/24 at 11:11 am. They acknowledged the findings.

3. Resident 3 moved into the facility in 09/2024 with diagnoses including chronic obstructive pulmonary disease, protein calorie malnutrition and breast carcinoma.

Observations of the resident, interviews with the resident and staff, the 10/28/24 service plan and the Resident Care Interim Service, from 09/22/24 thru 11/18/24, and Resident 3’s ABST data was reviewed.

The following areas were not reflective of the residents current ADL assistance:

* Personal hygiene such as shaving and mouth care;
* Monitoring physical conditions or symptoms;
* Providing non-drug interventions for pain management;
* Repositioning in bed or chair; and
* How much time is spent helping with bowel and bladder management.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (Administrator), Staff 3 (RCC) and Staff 22 (Contract RN Consultant) on 11/22/24 at 10:11 am. Staff acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review the facility failed to complete or update and review the ABST evaluation for each resident before a resident moved in, whenever there was a significant change of condition, and/or at least quarterly for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose ABST data was reviewed and for 33 of 43 unsampled residents whose ABST update data was reviewed. Findings include, but are not limited to:

On 11/19/24 at 1:28 pm, the facility’s ABST data and posted staffing plan were reviewed. The following was identified:

There was no documented evidence that Residents 1, 2, 3, and 4’s ABST data was reviewed and updated at least quarterly and/or with significant changes of condition. Additionally, there were 33 unsampled residents who lacked documented evidence the ABST data was reviewed and updated at least quarterly. Therefore, the ABST did not generate an accurate staffing plan.

The need to ensure ABST evaluations for each resident were updated with significant changes of condition, and/or quarterly at the same time the resident’s service plan was updated was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) on 11/22/24 at 1:05 pm. They acknowledged the findings.

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.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months and to conduct unannounced fire drills according to the Oregon Fire Code. Findings include, but are not limited to:

On 11/19/24, fire drill and fire and life safety records for the previous six months were requested.

Review of the documentation provided showed the following:

1. There was no documented evidence the facility provided fire and life safety training on alternating months for staff consistently as required.

2. Review of fire drill records between 05/2024 and 10/2024, showed the facility failed to document the following required components:

* Escape route used;
* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time-period needed;
* Number of occupants evacuated; and
* Evidence alternate routes were used during the fire drills.

On 11/22/24 at 10:11 am, the need to provide fire and life safety instruction to staff on alternate months and to conduct and document fire drills every other month with all required components was discussed with Staff 1 (Administrator), Staff 3 (RCC) and Staff 22 (Contract RN Consultant). Staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed, at least annually, on fire and life safety procedures according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 11/19/24 and 11/21/24.

There was no documented evidence residents were re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

The need for residents to be re-instructed about fire and life safety procedures at least annually per the OFC was discussed with Staff 1 (Administrator), Staff 3 (RCC) and Staff 22 (Contract RN Consultant). Staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

The facility was toured on 11/19/24 and 11/20/24. Second floor resident unit windowsills were observed to be lower than 36 inches and lacked a system which limited how much the windows could open to prevent accidental falls.

The need to ensure operable windows were designed to prevent accidental falls was discussed with Staff 1 (Administrator) on 11/20/24 at 12:25 pm. He acknowledged the findings.

OAR 411-054-0300 (5) Resident Units

(5) RESIDENT UNITS. All resident units must be accessible per building codes. These apartments must have a lockable entry door with lever type handle, a private bathroom, and kitchenette facilities. Adaptable units are not acceptable.(a) UNIT DIMENSIONS. New construction units must have a minimum of 220 net square feet, not including the bathroom. Units in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.(b) RESIDENT STORAGE SPACE.(A) Each unit must provide usable space totaling at least 100 cubic feet for resident clothing and belongings and include one clothes closet with a minimum of four linear feet of hanging space.(B) The rod must be adjustable for reach ranges per building codes. In calculating useable space, closet height may not exceed eight feet and a depth of two feet.(C) Kitchen cabinets must not be included when measuring storage space.(D) A lockable storage space (e.g., drawer, cabinet, or closet) must be provided for the safekeeping of a resident ' s small valuable items and funds. Both the administrator and resident may have keys.(c) WINDOWS.(A) Each resident's living room and bedroom must have an exterior window that has an area at least one-tenth of the floor area of the room.(B) Unit windows must be equipped with curtains or blinds for privacy and control of sunlight.(C) Operable windows must be designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor.(d) DOORS. Each unit must have an entry door that does not swing into the exit corridor.(A) A locking device must be included that is released with action of the inside lever. Locks for the entry door must be individually keyed, master keyed, and a key supplied to the resident.(B) The unit exit door must open to an indoor, temperature controlled, common-use area or common corridor.(e) BATHROOM. The unit bathroom must be a separate room with a toilet, sink, a roll-in curbless shower, towel bar, toilet paper holder, mirror, and storage for toiletry items.(A) The door to the bathroom must open outward or slide into the wall.(B) Showers must have a slip-resistant floor surface in front of roll-in showers, a hand-held showerhead, cleanable shower curtains, and appropriate grab bar.(f) KITCHENS OR KITCHENETTES. Each unit must have a kitchen area equipped with the following:(A) A sink, refrigerator, and cooking appliance that may be removed or disconnected. A microwave is considered a cooking appliance.(B) Adequate space for food preparation.(C) Storage space for utensils and supplies.(D) Counter heights may not be higher than 34 inches.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents had the freedom and support to control their own schedule for 4 of 4 unsampled residents. Findings include, but are not limited to:

On 11/20/24 at 1:30 pm, during a group interview with unsampled residents a surveyor was informed they were not able to control or determine their own shower schedule if they required any assistance.

On 11/21/24 at 8:39 am, Staff 1 (Administrator) was informed the facility failed to support residents in choosing their own shower schedule.

The need to ensure residents had the freedom and support to control their own schedule was discussed with Staff 1, Staff 2 (RN), Staff 3 (RCC), and Staff 22 (Contract RN Consultant) on 11/22/24 at 1:05 pm. They acknowledged the findings.

OAR411-004-0020(2)(i) Individual freedom & Support: Activities

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

This Rule is not met as evidenced by:

The findings of the re-licensure survey conducted 6/28/21 through 6/30/21 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 6/30/21, conducted 10/13/21, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to thoroughly investigate incidents to reasonably conclude the incident was not the result of suspected abuse or neglect and failed to report to the local SPD's office for 1 of 2 sampled residents (#4) who had an injury of unknown cause. Findings include, but are not limited to:During the entrance interview on 6/28/21, Resident 4 was identified as a fall risk with high care needs. An interim Service plan and RN progress note dated 4/3/21 included the following fall interventions: * Frequent safety checks; * Staff to keep the resident's door opened as much as possible if the resident allowed; * Staff to ensure the resident had everything s/he needed prior to leaving the apartment; and* Ensure the TV remote, food or drinks were placed near the resident so s/he could easily reach them.On 5/22/21, staff documented in an incident report that Resident 4 was found on the floor with a laceration on the head and eyebrow. The resident was unable to state how the injury occurred. The facility completed an incident report which stated abuse had been ruled out based on the resident having no "ill feelings" toward staff.The facility failed to conduct an investigation which reasonably concluded the injury was not the result of abuse/neglect. There was no documented evidence the facility investigated whether the service-planned fall interventions were in place at the time of the fall, when the resident was last checked on and whether staff were following the resident's service plan.The need to ensure all incidents were thoroughly investigated and reported to the local APS office if abuse or neglect could not be reasonably ruled out was discussed with Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) on 6/30/21. They acknowledged the findings.The facility was directed to self-report the incident to the local APS office. Confirmation of the report was received on 6/30/21 prior to survey exit.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 6/29/21 at 9:40 am, the facility's kitchen was toured with Staff 5 (Food Services Director). The following areas were in need of cleaning or repair:* Black residue along the edges of the kitchen and hand washing sinks and countertops; * Black debris and peeling paint on the wall of the warewashing area; * Inoperative paper towel dispenser;* Stains and chipped paint on kitchen doors;* Ceiling vents had an accumulation of dirt and dust; * Walls throughout the kitchen had multiple spills, smears and stains; * The upright refrigerator by the stove had a missing back panel with exposed electrical wiring; * Buildup of burnt food debris and grease was inside the oven and grease was leaking from the bottom right corner of the oven onto the kitchen floor;* Cracked ceiling around the stove exhaust hood; * Particle board cabinets and drawers throughout the kitchen were chipped, dinged and flaking; and * The beverage station located in the dining room had chipped wood and paint on the cabinets, drawers and baseboards.On 6/30/21 at 9:50 am, the above findings were reviewed with Staff 1 (Administrator). She 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 for 2 of 3 sampled residents (#s 3 and 4) whose physician orders were reviewed. Findings include, but are not limited to:Resident 3 and 4's signed physician orders and 6/1/21 through 6/27/21 MAR and TAR were reviewed during the survey. The following deficiencies were identified:1a. Resident 3's MAR or TAR was not signed to indicate the following medications had been administered as ordered:* Torsemide (to reduce edema) 5:00 pm dose on 6/15/21;* Tylenol (for pain) 8:00 pm dose on 6/18/21; and* Miconozole cream (to treat fungal skin conditions) evening application on 6/21/21.Torsemide and Tylenol pills were dispensed from bottles rather than unit dose packages, and because the cream was dispensed from a tube, the facility could not provide evidence the medications were administered as ordered.b. The MAR indicated the facility did not administer Resident 3 once daily Pepcid (to treat acid reflux) on 6/21/21 and 6/22/21. Documentation on the MAR read "Out of stock, waiting for pharmacy."The need to ensure medications and treatments were administered as ordered was reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 4 (Regional Nurse Consultant) on 6/29/21. They acknowledged the findings.
2. Resident 4's orders were not carried out as prescribed:* The resident was prescribed Ensure twice daily to address weight loss. The MAR indicated the Ensure was not provided as ordered on 17 occasions. The MAR read "Not available." * The resident was prescribed Acetaminophen 500 mg two tablets three times daily. The MAR lacked documented evidence the medication was administered as ordered on two occasions. The need to ensure physician orders were carried out as prescribed was discussed Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) on 6/30/21. They acknowledged the findings.

2. Resident 3's 6/1/21 through 6/27/21 MAR and TAR contained the following inaccuracies:a. The following medications or treatments lacked a reason for use:* Routine Senna;* Nasacort nasal spray; and* Atrovent nasal spray.b. The following topical creams/gels did not indicate where or for what condition the medication should be administered:* Miconozole cream TID;* Volaren gel BID; and* PRN Baza antifungal cream.c. Resident 3 was prescribed four PRN medications to treat constipation: Milk of Magnesia, bisacodyl suppository, docusate sodium tablets, and Senna tablets. The MAR lacked parameters as to when unlicensed staff should administer the docusate sodium and Senna, in relation to the other bowel medications.The need to ensure MARs and TARs were accurate was reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 4 (Regional Nurse Consultant) on 6/29/21. They acknowledged the findings.
3. Resident 4's 6/1/21 through 6/28/21 MAR was reviewed and identified the following:* Multiple medications lacked reasons for use; and* Two PRN bowel care medications lacked clear direction and instruction for order of administration.The need to ensure all medications on the MAR included reasons for use and PRN medications included specific instructions for administration was discussed with Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) on 6/30/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication-specific instructions and had specific parameters for PRN medications for 3 of 3 sampled residents (#s 1, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 1's 5/1/21 through 6/28/21 MARs were reviewed and revealed the following: a. Multiple medications lacked reasons for use, both for routine and PRN administration. b. Resident 1 had more than one PRN bowel medication without parameters on when to initiate treatment and what medication to administer first. c. Hydrocodone (for pain) was logged out on the facility's narcotics log but was not initialed as administered on the MAR on four separate occasions, 6/3/21 at 8:00 pm, 6/4/21 at 8:00 pm, 6/24/21 at 12:00 pm, and 6/27/21 at 8:00 pm. The need for an accurate MAR and resident specific parameters was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 4 (Regional Nurse Consultant) on 6/29/21 and 6/30/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with operational alarming devices or other acceptable systems to alert staff when residents exited the building. Findings include, but are not limited to: A tour of the facility on 6/29/21 revealed the following: Exit door alarms were not in place to alert staff when the doors were opened. All external doors except for the front entrance and dining hall courtyard did not have door handles to re-enter the building upon exit. The front entrance and dining hall courtyard doors were manually locked at 10:00 pm. In an interview on 6/29/21, Staff 1 (Administrator) stated the facility had video cameras on all exit doors that were displayed in the administrator's office, but the facility had no plan for monitoring the cameras in the absence of the administrator. During a walk-through of the environment on 6/29/21 at 8:45 am, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) verified there were no exit door alarms. They acknowledged the findings.